Matlaga Brian R, Chew Ben, Eisner Brian, Humphreys Mitchell, Knudsen Bodo, Krambeck Amy, Lange Dirk, Lipkin Michael, Miller Nicole L, Monga Manoj, Pais Vernon, Sur Roger L, Shah Ojas
1 James Buchanan Brady Urological Institute , Johns Hopkins Medical Institutions, Baltimore, Maryland.
2 Department of Urologic Sciences, University of British Columbia , Vancouver, British Columbia.
J Endourol. 2018 Jan;32(1):1-6. doi: 10.1089/end.2017.0641. Epub 2017 Nov 27.
Ureteroscopic laser lithotripsy is becoming the most commonly utilized treatment for patients with urinary calculi. The Holmium:YAG (yttrium aluminum garnet) laser is integral to the operation and is the preferred flexible intracorporeal lithotrite. In recent years, there has been increasing interest in examining the effect of varying the laser settings on the effectiveness of stone treatment. Herein, we review the two primary laser treatment approaches: dusting and fragmentation with extraction.
We reviewed PubMed and MEDLINE databases from January 1976 through January 2017. All authors participated in the development of consensus definitions of dusting and fragmentation with extraction. The review protocol adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology.
When the Holmium:YAG laser is used to treat stones, there are two parameters that can be adjusted: power (J) and frequency (Hz). In one treatment paradigm, which became termed "fragmentation with extraction," laser settings that relied on high energy and low frequency were used. Another paradigm, which became termed "dusting," utilized low energy and high frequency settings, which had the effect of breaking off exceedingly small fragments from the stone.
Both dusting and fragmentation with extraction approaches to ureteroscopic stone treatment are effective. In fact, there is little evidence that one approach is better than the other. However, each does have relative advantages and disadvantages, which should be considered. Although dusting tends to be associated with shorter procedure times and a lower risk of ureteral damage, this approach may place the patient at increased risk for future stone events should all of the resultant debris not be expelled from the collecting system. The active removal associated with fragmentation with extraction, in contrast, may provide for a more complete initial stone clearance.
输尿管镜激光碎石术正成为治疗尿路结石患者最常用的方法。钬：钇铝石榴石（Ho:YAG）激光是该手术不可或缺的部分，是首选的软性体内碎石器。近年来，人们越来越关注改变激光参数设置对结石治疗效果的影响。在此，我们回顾两种主要的激光治疗方法：粉末化和碎块取出法。
我们检索了1976年1月至2017年1月的PubMed和MEDLINE数据库。所有作者参与了粉末化和碎块取出法共识定义的制定。本综述方案遵循系统评价和Meta分析的首选报告项目（PRISMA）方法。
使用钬：钇铝石榴石激光治疗结石时，有两个参数可以调整：功率（焦耳）和频率（赫兹）。在一种治疗模式中，即后来被称为“碎块取出法”，采用了依赖高能量和低频率的激光设置。另一种模式，即后来被称为“粉末化”，采用低能量和高频率设置，其效果是从结石上剥落极小的碎块。
输尿管镜结石治疗的粉末化和碎块取出法均有效。事实上，几乎没有证据表明一种方法优于另一种方法。然而，每种方法都有相对的优缺点，应予以考虑。虽然粉末化往往与较短的手术时间和较低的输尿管损伤风险相关，但如果所有产生的碎片未从集合系统中排出，这种方法可能会使患者未来发生结石事件的风险增加。相比之下，碎块取出法相关的主动清除可能会实现更彻底的初始结石清除。
