Abstract
I
Considering the average stone size of 12.5 mm, and the average operative time of 53 minutes reported in this article, one noticeable characteristic is that of the mean laser usage, which was only 5.2 kJ per case (mainly with dusting settings), which corresponds to only 5 minutes of laser lithotripsy time. It is a considerable achievement, being able to ablate that average stone size in such a short time, thus occupying only 10% of the surgical time with pure laser lithotripsy, leaving the remaining 90% of theater time for auxiliary surgical steps. Obviously, one must consider that this new technology might be indeed a breakthrough, shortening the average lithotripsy time substantially. This might also be related to the fact that this series was based on the work of a single and experienced high-volume surgeon. In addition, by scrutinizing the work of a single surgeon, the authors were able to exclude interuser variability bias, which further enhances the quality of this article.
Despite this excellent performance, the average stone-free rate (SFR) was only 67.4%, sometimes even as low as 39%, depending on the patient group. This could be considered a low value in comparison with other series. 2 However, the definition of SFR is very variable among articles: although the present article classified patients to be stone free only without any trace of residual fragments on CT, there are publications that even considered patients with residual fragments up to 3 mm to be stone free as well. Thus, the performance herein reported could be considered substantially better, depending on the definition.
As with any surgical procedure, some low-grade postoperative complications were reported, which were easily resolved, deeming this high-frequency dusting technique with this new laser, a safe technology. However, one must bear in mind that such high-power systems deliver much energy, in small enclosed spaces to the surrounding medium and in a very short period of time. Furthermore, recent evidence has emerged that even at low energy settings, very high temperatures are locally achieved, which might pose a danger to the patients' tissues, in particular with low irrigation. 3,4 Hence more attention must be paid whenever a high-power laser is used.
Considering the ever faster technological advances and increasing availability of newer and more powerful laser lithotripters, these and other issues will surely pose future challenges for us urologists. Therefore, what applies for kings, rulers, and other leaders also applies to us: “With greater power comes greater responsibility…”