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Lithotripsy with the pulsed-dye laser has been shown to be a safe and effective method of intracorporeal urinary stone fragmentation. Recently, a new device, the holmium: YAG laser, has been developed with both soft tissue and lithotripsy applications. We present our preliminary experience with the Ho:YAG laser for lithotripsy of urinary calculi. Ureteroscopy and lasertripsy resulted in successful fragmentation of ureteral stones in 92% of 21 patients when the laser was used alone or in combination with electrohydraulic lithotripsy. One complication directly related to the use of the laser occurred, a ureteral perforation, when the device was utilized under fluoroscopic control. In four patients undergoing percutaneous flexible nephrolithotripsy, the laser demonstrated utility in fragmenting caliceal stones remote from the nephrostomy tract. In summary, the Ho:YAG laser has demonstrated its efficacy as a method of intracorporeal lithotripsy. The tissue effects of this device, as well as the optimal energy/pulse and frequency settings, need further evaluation in order to minimize the risks of tissue injury.

A variety of devices are currently available for intracorporeal stone fragmentation. Recently a new wavelength of laser, the Holmium:YAG, has demonstrated a variety of potential urologic applications including ablation of soft tissue lesions as well as stone fragmentation. This laser has a wavelength of 2100 nm and operates in a pulsed mode. Energy is delivered through a 400 um quartz end-firing fiber. In this presentation we review our clinical experience with the Holmium:YAG laser for the treatment of renal and ureteral calculi. Over a 23 month period, 63 patients underwent 67 procedures. Seven procedures consisted of percutaneous nephrolithotripsy for large or staghorn renal calculi. Sixty procedures were performed for ureteral stones. Procedures for proximal ureteral stones (6) employed a retrograde approach using flexible ureteroscopes (8.5 or 9.8). Stones in the mid ureter (12) and distal ureter (42) were approached transurethrally using a 6.9 rigid ureteroscope. Complete stone fragmentation without the need for additional procedures was achieved in 82% of cases. Treatment failures included 1 stone migration into the renal pelvis during laser activation, 6 patients who had incomplete fragmentation and 3 patients in which laser malfunction precluded complete fragmentation. Stone analysis available in 23 patients revealed calcium oxalate monohydrate (15), calcium oxalate dihydrate (2), cystine (2), uric acid (3) and calcium phosphate (1). A single complication of ureteral perforation occurred when the laser was fired without direct visual guidance. Radiographic follow-up at an average of 16 weeks is available in 22 patients and has identified 2 patients with ureteral strictures that are not believed to be related to laser lithotripsy. In summary, we have found the Holmium:YAG laser to be a reliable and versatile device for intracorporeal lithotripsy. Its safety and efficacy make it a suitable alternative for performing intracorporeal lithotripsy of urinary calculi.

A new percutaneous approach for the management of stone-containing caliceal diverticula is described that was used successfully in three patients with symptomatic calculi. Access to the stones was achieved via transdiverticular puncture into the renal collecting system, allowing a guidewire to be manipulated down the ureter to provide secure access for the stone-removal procedure. Prolonged probing with a wire for the neck of the diverticulum was avoided and secure access to the diverticulum quickly achieved.

The ideal surgical laser for the treatment of soft tissue pathology should possess both ablative and hemostatic abilities. As well, for use in urologic conditions the laser must also be suitable for endoscopic use. The Holmium:YAG laser possesses these qualities and in preliminary clinical use has demonstrated a variety of potential urologic applications. In this study we review our initial experience with the Holmium:YAG laser over a 18 month period. A total of 51 patients underwent 53 procedures for a variety of soft tissue conditions including: bladder tumor ablation (25), incision of ureteral stricture (15), incision of urethral stricture (6), treatment of ureteropelvic junction obstruction (3), incision of bladder neck contracture (2), and ablation of a ureteral tumor (2). Satisfactory hemostasis was achieved in all cases. Procedures were considered successful (no further intervention being required to treat the condition) in 81% of the cases. Two patients with dense bladder neck contractures required electroincision under the same anesthetic for completion of the procedure. A single complication, that of urinary extravasation following incision of a urethral stricture resolved with conservative management. In summary, the Holmium:YAG laser has demonstrated safety and proficiency in the treatment of a variety of urologic soft tissue conditions.

We report a ease of malignant melanoma metastatic to the bladder. The unusual features of this case include the long quiescent period following the primary melanoma, the size of the tumor and the unexpected findings at laparotomy. We believe that this is the first report of the intraoperative finding of contiguous involvement of the bladder and small bowel by metastatic melanoma.