Holmium laser advances help propel progress in BPH, urinary stones

Bhaskar Somani, MRCS, FEBU, DM

During the 2020 European Association of Urology (EAU) Virtual Congress, urology experts shared their personal experiences with groundbreaking technologies revolutionizing urology practice.

In one session, experts discussed advances in minimally invasive techniques for treating benign prostate hyperplasia (BPH) and urinary stones, specifically focusing on the recently launched Moses 2.0 platform for holmium laser enucleation of the prostate (HoLEP).¹

Holmium laser lithotripsy with Moses 2.0 is intended to enhance precision and versatility by optimizing laser energy transmission. With ultra-speed stone dusting at 120 Hz, the platform has demonstrated enhanced stone ablation rates. For patients with BPH, the platform’s speed and efficiency enables a catheter-free procedure with same-day discharge for most patients.

In a panel discussion during the EAU virtual meeting, Khurshid Ghani, MD, Amy E. Krambeck MD, and Tevita Aho, MD, answered questions from moderator Bhaskar Somani, MRCS, FEBU, DM, on their personal experience with the Moses 2.0 platform.

Where are we at with the technology for holmium laser lithotripsy and thulium fiber laser (TFL) for urinary stones?

Khurshid Ghani, MD

Ghani: To start, photothermal ablation has been shown to be the predominant mechanism of laser fragmentation used for holmium laser lithotripsy, where the goal is to maximize energy transfer to the stone through the process of contact laser lithotripsy.

For all lasers, excessive pulse duration and photothermal effect may lead to collateral damage. Multi-pulse sequencing and pulse shaping with Moses 1.0 has improved the quality and speed of fragmentation and is superior to long pulse. Moses 2.0 provides 120 Hz for faster lithotripsy.

At this point, clinical data comparing the holmium YAG (HoYag) Moses 2.0 laser with TFL is needed with end points including lasting time, OR time, energy, stone-free outcomes, and complications. That being said, I submit to you that HoYag has just the right balance of water and stone absorption, pulse duration, and peak power for effective and safe fragmentation.

Do you think everybody needs to have a power of 120 Hz or at least 100-120 Hz?

Ghani: I think it’s dependent on your own clinical environment and your own health economic system, and what you can afford in a reasonable manner. What we have definitely seen here in Michigan is that when we transitioned to the high-powered lasers, we have been able to be much faster in the operating room, and we get through the stones much more quickly.

We have also seen that our threshold for flexible ureteroscopy to treat renal stones is being challenged. I’m finding it hard to schedule patients with stones larger than 2 cm for a percutaneous nephrolithotomy (PCNL). For larger stones—the staghorn stones—we do PCNL on those. But definitely for the kidney stones, I think high frequency has helped us. Urethral stones are a different beast. I think with those, effective fragmentation using the simple settings that we all trained with and know using low-powered systems is very effective, and you don’t necessarily need high-power settings; in fact high-powered settings in the urethra can be injurious. But definitely for kidney stone surgery, I think the new lasers with the high frequency, and now with the pulse modulation to actually increase the fragmentation, have been revolutionary.

The BPH landscape has changed with so many new technologies. How do you choose among all of these techniques?

Tevita Aho, MD

Aho: If you are after a surgical technique—a true technique where you are going to get an immediate response because you are immediately debulking the prostate—I would go HoLEP or “MoLEP,” as I call it now, with Moses technology.

The advantage of the minimally invasive techniques, and there is a whole range of those, is that, if you have a man whose sexual function is very important to them (they still want to ejaculate) and their prostate is not particularly large, maybe things like UroLift or Rezum are also options. I personally also offer those 2 techniques because I want to be able to offer something to every single patient. I want to be able to tailor the BPH treatment to the individual person. And it’s not for us to necessarily decide for the patient what’s important to them. It’s up to us to tease out what their priorities are and then tailor the treatment to their requirements.

But just going back to the surgical treatments, if you want to disobstruct somebody because they have got a catheter in place—and no man wants to live with a catheter any longer than they absolutely need to—then HoLEP is by far the best procedure, with 99% catheter-free rates for any type of urinary retention, whether it be acute or chronic.

When treating patients with BPH, how has the Moses 2.0 platform impacted your practice?

Amy E. Krambeck, MD

Krambeck: Moses 2.0 has so vastly changed our practice, that we send all patients home. The only time they would stay is if they already started in the hospital because they are very sick and are in the hospital for another reason—otherwise we try to send everyone home.

And the same-day catheter is usually the first 2 cases of the day—we have time to watch them and then we can remove their catheter later that day. And there’s really no limitation to this—anticoagulated or not anticoagulated, they just really need to have the support at home to help them that first night.

What is your recommendation for a urologist considering incorporating HoLEP or MoLEP into their practice?

Krambeck: The most important thing to do is to number one, go watch someone, and when you go to observe an individual doing HoLEP, take someone from your OR crew with you so that they can look at the setup, they can look at how the bags are changed, where the laser is sitting, and take note of all the equipment so that you can focus on the surgical technique. The last thing you want to do is to try to be doing a new surgery that you are not familiar with and simultaneously trying to make sure the room understands the flow of the case and how to set up the instruments. The second thing is to watch a lot of videos and the third is to hook up with a mentor. I have a lot of people who come to watch me and then they send me texts and video clips and we can talk about it.

Amy E. Krambeck, MD, is a professor of urology at Indiana University School of Medicine. Khurshid Ghani, MD, is an associate professor of urology at the University of Michigan Medical School. Tevita Aho, MD, is from the Cambridge University Hospitals NHS Trust. Bhaskar Somani, MRCS, FEBU, DM, is from the University Hospital Southampton NHS Foundation Trust.

The above discussion took place during a session sponsored by Lumenis.

Reference

1. Somani B, Ghani K, Krambeck AE, Aho T. MOSES 2.0 – New levels of versatility and precision. 2020 European Association of Urology Virtual Congress. July 17-26, 2020.

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