Laser Lithotripsy

This card explains laser lithotripsy, the use of a laser to break up stones in the urinary tract. It is general education for patients, families and students, and the treating urologist decides which approach suits a given stone. The laser is a tool used within other procedures, so it is best read alongside ureteroscopy and the stone procedures overview.

What it is

Lithotripsy (see the glossary) means breaking up a stone so that it can be removed or passed. In laser lithotripsy the energy comes from a laser fiber placed against the stone. Cleveland Clinic says it is a procedure that uses a laser to break up stones in the kidney, bladder, ureter or urethra, and that it is often done during a ureteroscopy.

A published review of the technique describes the holmium laser, which is strongly absorbed by water and produces a thermal effect that vaporizes the stone when the fiber touches its surface. The sources opened for this card describe the holmium laser, so it is the one covered here.

Why it is done

Cleveland Clinic contrasts laser lithotripsy with shock wave lithotripsy. Shock waves act from outside the body, while the laser works directly on the stone from inside. The same source says the laser can be more effective on stones that shock waves cannot manage because of their size, location or hardness, and that it can be used in people who take blood thinners or are pregnant. It also lists a lower chance of fragments blocking the ureter. Because an instrument goes inside the body, it carries some risks that shock wave treatment does not.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) notes that for larger kidney stones, the surgeon may also use a laser during percutaneous nephrolithotomy to break the stone into smaller pieces.

How it is done, in outline

With ureteroscopy, Cleveland Clinic describes general anesthesia, a scope passed through the urethra, and a laser fiber threaded through the scope to the stone. The stone is broken up and the pieces may be collected in a basket. A temporary ureteral stent is often placed so that urine and small fragments can leave the body, and the procedure usually takes one to two hours. During percutaneous nephrolithotomy, the laser is used through a nephroscope, a viewing tool inserted through a small cut in the back, according to NIDDK.

The review describes two broad strategies for the laser step. In fragmentation with basket retrieval, the stone is broken into pieces that are then removed. In dusting, the laser is set to high frequency and low pulse energy to create very fine, submillimeter fragments that are left to pass on their own. The same review lists reported trade-offs. Dusting may shorten operating time and can reduce the need for some accessories, but it needs a high-power laser, may not suit very hard stones, and results may vary with the surgeon's skill. Basket retrieval can suit hard stones but takes longer and produces larger fragments. Centers differ in which they use, and the choice depends on the stone.

The review also notes that heat must be managed in the confined space of the ureter, which is why the laser power and the flow of irrigating fluid are adjusted carefully.

Recovery

Cleveland Clinic says people are monitored until it is safe to go home, need someone to drive them, and may receive pain medicine, medicine for stent discomfort and a few days of antibiotics. Most people return to usual activities in about a week, though some activities may cause discomfort or blood in the urine while a stent is in. Drinking plenty of fluids is the main self-care step it names. Stone pieces can take weeks to clear completely, with Cleveland Clinic citing eight weeks or longer after ureteroscopy.

The same source advises contacting a healthcare provider about fever, burning on urination that lasts longer than a day or two, or heavy bleeding or pink-tinged urine that lasts longer than two to three days.

Risks

Common effects after laser lithotripsy include pain, difficulty urinating, blood in the urine, and nausea and tiredness from anesthesia. Cleveland Clinic lists injury to the ureter, urinary tract infection and stone fragments blocking the urinary tract as complications. If fragments remain, further treatment may be needed. For risks of stents specifically, see the stent card.

Questions to ask your clinician

• Will the laser be used through a ureteroscope or a nephroscope for my stone?
• Will the stone be broken into pieces that are removed, or into fine dust that I pass?
• Is my stone likely to be a hard one, and does that change the plan?
• Will a stent be placed, and for how long?
• How long might it take for all the fragments to clear?
• Could I need a second procedure if pieces are left behind?
• Which symptoms should make me contact you or seek urgent care?