Abstract
This interesting study helps to draw focus toward one of the continued issues with laser lithotripsy, even in the face of more powerful lasers and modified pulse profiles. 1 No matter how much energy we can deliver toward the stone, if a majority of those energy pulses are being absorbed by the irrigation fluid, then there is a significant time and energy waste during the procedure. The technique utilized in this study is a remarkably accurate (>85% per the pilot) method for evaluating per-pulse fiber-to-stone distance and, as has been shown in other studies, can be used as a gating method for laser activation only when stones are close enough for adequate lithotripsy. Although the fragmentation and dusting data discussed in this study may potentially be operator dependent (as other urologists may have significantly higher or lower strike rates than the study participants), it is clear that the popcorn data delineate a genuine drawback of this lithotripsy technique. With a combined 1 mm strike rate across all popcorn settings of 12%, this technique has substantial room for improvement with regard to efficiency—potentially through laser-based gating or other methods to direct a higher percentage of pulses fired into the target stones.