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Glossary of pre-settings given by laser companies: no consensus!

Article in World Journal of Urology · August 2022

DOI: 10.1007/s00345-022-04090-4

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World Journal of Urology
https://doi.org/10.1007/s00345-022-04090-4

ORIGINAL ARTICLE

Glossary of pre‑settings given by laser companies: no consensus!

Alba Sierra1,2 · Mariela Corrales1,2 · Adrià Piñero1,2 · Merkourios Kolvatzis1,2 · Bhaskar Somani3 · Olivier Traxer1,2

Received: 16 February 2022 / Accepted: 30 June 2022

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
Introduction Since the construction of the first laser, many companies around the world have contributed to the development
of new lasers technologies. To be user-friendly, some companies have developed a pre-setting mode in their laser devices.
We aimed to review and compare all laser companies’ pre-settings (PS) already established in the market.
Materials and methods An online search of holmium:YAG (Ho:YAG) and thulium fiber laser (TFL) devices was carried out.
Manual and PS mode, pulse width and pulse modulation technology data were collected. The PS parameters were collected
directly from the brochure devices or by asking the companies consulting agents.
Results Thirty-nine laser devices were analyzed (33 Ho:YAG and 6 TFL). The power range varies from 15 to 152 W and
35 W to 60 W for Ho:YAG and TFL, respectively. PS are present in 66% of Ho:YAG lasers and the 33% of TFL. Long-pulse
modes can be modified in 12 Ho:YAG and 1 TFL lasers. The median (IQR) PS for dusting stones with Ho:YAG laser is
0.4 J (0.2–1), 21.5 Hz (5–120), and 10 W (1.5–28) for energy, frequency and power, respectively; for Ho:YAG fragmenta-
tion is 0.8 J (0.3–5), 10 (3–15) Hz and 5 (1.5–50) W for energy, frequency, and power, respectively; and for popcorn is 0.8 J
(0.4–1.2), 10 Hz (6–15) and 5 W (4–18) for energy, frequency, and power, respectively. Dusting and fragmentation mode of
Rocamed MH01 and EMS LaserClast 35 are programmed according to the stone type. Most of these settings do not depend
on the size of the fiber being used nor the location and type of stone. For TFL, the pre-sets are divided in bladder stone,
dusting, fine dusting, fragmentation, and ureteral stone.
Conclusion There is a huge variability regarding pre-sets offered by companies because there is no consensus. Pre-sets should
provide a range to work efficacy and safety.

Keywords Laser · Holmium YAG​· Thulium fiber laser · Settings · Kidney calculi · Ureteroscopy · Percutaneous
nephrolithotomy

* Olivier Traxer Introduction

olivier.traxer@aphp.fr
Alba Sierra The first working laser emitter was constructed in the 1960s
asierradelrio@gmail.com
[1] and the first commercial laser lithotripter did not arrive
Mariela Corrales until 1988 [2]. Since its commercialization, this technology
mariela_corrales_a@hotmail.com
has changed and evolved tremendously over the last decade.
Adrià Piñero Urology has always been at the center of the laser litho-
adria.pinero@gmail.com
tripsy evolution. Currently, laser lithotripsy is established
Merkourios Kolvatzis primarily in use as a urological specialty, with 85–90% of
merkolv90@gmail.com
articles published over the last 10 years by urology-affiliated
Bhaskar Somani investigators [3].
bhaskarsomani@yahoo.com
Holmium (Ho:YAG) laser lithotripter was introduced in
1
Sorbonne University GRC Urolithiasis No. 20 Tenon clinical practice in 1993 [4]. Some consider it to be the pin-
Hospital, 75020 Paris, France nacle of evolution of lasers in urology [5]. Its wavelength
2
Department of Urology AP‑HP, Tenon Hospital, Sorbonne of 2100 nm is almost completely absorbed by water within
University, 75020 Paris, France 0.4 mm of the laser fiber tip, making the Ho:YAG laser one
3
University Hospital Southampton NHS Trust, Southampton, of the safest lasers ever being used in endourology [6–8].
UK

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As technology evolves, the pursuit for a safer, more effi- Of the 33 Ho:YAG laser devices, 21 Ho:YAG lasers
cient laser technology, has led to the development of another (66,7%) from 9 different LC are presented with PS. They
type of laser, the thulium fiber laser (TFL). Multiple studies are shown in Table 2, except Hypho Laser from HyperPho-
reported about a 1.5–4 times faster stone ablation rate in tonics where no information was found. The manual mode
favor of the TFL, when lithotripsy was performed on cal- and pulse width modification was an option in all, except
cium oxalate monohydrate or uric acid stones [9, 10]. Other one laser device. Long-pulse modes can be modified in 12
favorable aspects for TFL are integration of smaller fibers Ho:YAG lasers (37.5%). Dusting and fragmentation mode of
with a core diameter as small as 50 μm, lower pulse energy Rocamed MH01 are programmed according to the stone type
and super-high frequency [11, 12]. (Fig. 2), similar to EMS LaserClast 35, which is according to
The current and widespread use of Ho:YAG and TFL the hardness in relation to Hounsfield units (HU).
lithotripsy of urinary stones has produced many debates
[13]. The search for the best laser lithotripter settings and
the best laser fiber is still being defined [14–17]. To be user- Dusting
friendly, most laser companies (LC) have introduced their
own pre-settings (PS) for different endourological proce- For dusting stones with Ho:YAG laser, the median (IQR) PS
dures. However, what is the definition of a pre-set? Where energy is 0.4 (0.2–1) J. Frequencies varies between 20 and
do they obtain this information? Is it from laboratory studies 40 Hz or above 50 Hz, high or very high frequency, respec-
or experts experience? We aim to do a review of the existing tively. Frequencies such us 50 were chosen by Empower
LC’ PS and to evaluate the pulse energy, pulse frequency, (Olympus), Wolf and Quanta; and 80 Hz, by Lumenis.
power levels and pulse modes they recommend. Median (IQR) PS power is 10 (1.5–28) W. Aside from EMS
LaserClast 35, no consideration has been made regarding
the fiber size (i.e., with a 200 µm laser fiber, dusting power
Materials and methods is 4.8 W for all stone types; but, with a 1000 µm laser fiber,
it is 18 W, 22.5 W, 21.6 W, and 22.5 W for soft, medium,
Two authors (AS and AP) independently searched online to hard and super-hard stones, respectively). There is no uni-
list all Ho:YAG and TFL laser devices available today. The formity in pulse selection: four companies chose short pulse,
terms ‘Holmium:YAG’ and ‘thulium fiber laser’ were used three medium pulse, one long pulse and two chose long-
in association with any of the following: ‘lithotripsy’, ‘lithi- modulated pulse.
asis’, ‘lithotripter(s)’, ‘adjustments’ and ‘preset’. The search
was performed in November 2021.
Of each device, data of maximum power, PS and/or man- Fragmentation
ual modes, pulse width and modulation technology was col-
lected by looking the online brochure of the manufacturer’s The median (IQR) PS for Ho:YAG fragmentation is 0.8
website or by asking the companies consulting agents by (0.3–5) J, 10 (3–15) Hz and 5 (1.5–50) W for energy, fre-
e-mail. The PS parameters of the laser machines available in quency, and power, respectively. Based on the laser fiber
our center were collected directly from the hospital. size, EMS designed pre-sets such that for a medium hardness
stone, the pre-sets are 4 W, 9.6 W, 14.4 W, 30 W, 30 W and
30 W for 200, 275, 365, 550, 800 and 1000 µm laser fibers,
Results respectively. All the companies chose short pulse.

A total of 39 laser devices were analyzed. Of those, 33 were

Ho:YAG laser machines and 6 were TFL laser machines. Popcorning
The total of 18 LC produce those devices, most of them
manufacturing Ho:YAG technology (13 LC) and a few doing 5 Ho:YAG companies establish popcorning PS. The median
TFL technology (5 LC). The power range varies from 15 to (IQR) is 0.8 (0.4–1.2) J, 10 (6–15) Hz and 6 (4–18) W for
152 W and 35 W to 60 W for Ho:YAG and TFL, respectively energy, frequency, and power, respectively. Short pulse was
(Table 1). chosen by Quanta company, medium for Olympus and long
All TFL machines had a manual mode and choices for modulated for Dornier MedTech, EMS and Storz companies.
pulse width. Only Urolase (IPG medical) offers pulse mod- The EMS LaserClast 35 pre-sets for popcorning differed
ulation. Olympus Company had established pre-settings based on laser size and stone hardness.
options for both of their TFL machines, Soltive Premium Boxplot with Ho:YAG companies’ energy, frequency, and
and Soltive Pro lasers (Fig. 1), pre-sets for the new Laser- power pre-settings for dusting, fragmenting and popcorning
Clast Thulium Power from EMS are not available yet. are represented in Fig. 3.

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Table 1  Lithotripter options from holmium:YAG (Ho:YAG) lasers and thulium fiber laser (TFL) according to the existence of pre-setting, man-
ual mode, pulse width choosing and newly developed long-pulse modes (switch the waveform into a modulated wave—split or sequenced)
Company Laser name Power (W) Pre-setting Manual mode Pulse width Pulse
choosing modula-
tion

Ho:YAG​ COOK Rhapsody 30 No Yes Yes No

Lumenis VersaPulse PowerSuite 60 No Yes No No
100 No Yes No No
Pulse 30 No Yes No No
50 No Yes Yes No
100 No Yes Yes No
Moses Pulse 120 Yes Yes Yes Yes
Boston Scientific StoneLight 15 Yes Yes No No
Auriga 30 Yes Yes No No
Auriga XL 50 Yes Yes No No
Olympus Empower 35 Yes No No No
65 Yes Yes Yes Yes
105 Yes Yes Yes Yes
Dornier MedTech Medilas 20 Yes Yes No Yes
100 No Yes Yes No
140 No Yes Yes No
Medilas Solvo 35 Yes Yes No Yes
Quanta System Cyber Ho 60 Yes Yes No Yes
105 Yes Yes Yes Yes
152 Yes Yes Yes Yes
DK30 30 Yes Yes No No
Litho 35 Yes Yes No No
LithoEVO 35 Yes Yes Yes Yes
Hyper Photonics Hypo 35 Yes NA NA NA
Richard Wolf MegaPulse 70 Yes Yes Yes No
EMS Swiss LaserClast 20 No Yes Yes No
LaserClast 35 Yes Yes Yes Yes
Convergent Laser Odyssey 30 No Yes Yes No
Technologies
Storz Calculase II 20 Yes Yes No No
Calculase III 35 Yes Yes Yes Yes
Rocamed MH01 30 Yes Yes Yes No
LisaLaser Sphinx Jr 30 No Yes Yes Yes
LisaLaser Sphinx 45 Litho 45 No Yes Yes Yes
TFL IPG medical Urolase 60 No Yes Yes Yes
Quanta Fiberdust 60 No Yes Yes No
Rocamed Sirus 60 No Yes Yes No
Olympus Soltive Premium 60 Yes Yes Yes No
Soltive Pro 35 Yes Yes Yes No
EMS LaserClast 35 NA NA NA NA

NA Not available

Discussion and popcorning [18–29]. Nevertheless, the precise defini-

tion of PS is largely unknown. It is unclear on whether they
To increase their user-friendliness, most of the LC cur- are parameters looking for the optimal ablation laser effi-
rently available on the market use PS according to the three ciency or if they are acceptable settings to proceed safely
well-known lithotripsy techniques: dusting, fragmentation, and efficiently.

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Fig. 1  Pre-setting options:

Olympus Soltive Premium and Bladder stone 4J/14Hz
Soltive Pro Bladder stone
Hemostasis 1J/20Hz

Dusng 0,2J/100Hz
Dusng
Fragmentaon 0,6J/30Hz

So stone 0,05J/400Hz

Lithotripsy Fine dusng
Hardcore stone 0,1J/200Hz

So stone 0,4J/40Hz

Fragmentaon
Hardcore stone 1J/20Hz

So stone 0,2J/40Hz

Ureter stone
Hardcore stone 0,6J/14Hz

Solve
Ablaon 2J/10Hz
Premium/Pro
Ablaon/excision
Excision 1J/30Hz
So ssue
Incision 1J/20Hz
Incision
Hemostasis 1J/20Hz

Enucleaon 1J/60Hz
Enucleaon
Hemostasis 1J/20Hz
HBP
Vaporisaon 2J/30Hz
Vaporisaon
Hemostasis 1J/20Hz

Regarding our results, each Ho:YAG LC has chosen dif- by low-power (LP) and high-power (HP) Ho:YAG systems.
ferent PS, with a huge variability between them. All this However, a recent systematic review found that, in labora-
could be explained due to the lack of knowledge about the tory studies, neither HP nor LP provided an advantage based
appropriate PS and, therefore, the lack of consensus. For on stone burden [16].
dusting, they tend to include low energies on the PS, with The same variability is found concerning fragmentation
a mean < 0.5 J. However, regarding frequency, the range PS, were the energy’s IQR goes from 0.3 to 5 J and power’s
between companies is very wide (IQR 5–80 Hz) due to two IQR varies between 2 and 50 W. Power levels higher than
clear trends: high and very high frequencies. It is well known 30 W are rarely used for endocorporeal laser lithotripsy due
that very high frequencies (i.e., > 50 Hz) are related not only to the significant risk of collateral tissue damage arising
to a faster lithotripsy but to an impaired vision due to a pro- from the locally high temperatures associated with HP litho-
nounced “snowstorm effect”, resulting in less effective dust- tripsy [31–33]. Furthermore, if the pulse duration is greater
ing [30]. Besides, if we consider that PS are designed for than 1000 µsec (which is easily achieved with TFL settings),
trainees, a bad vision could lead to more ureteral or renal there is a risk of direct thermal transfer to soft tissue [34].
injury, so high frequencies cannot always be recommended. In terms of pulse width values, they are confidential and are
In addition, the frequency variation could also be explained not fixed values, i.e., when selecting “long pulse”, each laser

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 World Journal of Urology

Table 2  Ho:YAG laser companies with lithotripsy pre-settings

Company Laser name Dusting Fragmentation Popcorn

Energy (J) Frequency (Hz) Power (W) Pulse Energy (J) Frequency (Hz) Power (W) Pulse Energy (J) Frequency (Hz) Power (W) Pulse

Lumenis Moses Pulse™ 120H 0.3 120 36 Short 0.8 10 8 Short

0.8 10 8 1 15 15
Boston Scientific Auriga 30 0.3 6 1.8 Short
Auriga XL 0.3 5 1.5
Olympus EMPOWER H35 0.5 5 2.5 Long 0.5 3 1.5 Short
EMPOWER H65 0.2 50 10 Short 1.5 12 18 1.2 15 18 Medium
EMPOWER H100 0.2 50 10 Short 1.5 12 18 1.2 15 18
Dornier MedTech Medilas SOLVO H35 0.4 (0.2–08) 18 (18–22) 7.2 Medium 0.4 (0.4–2.5) 5 (5–10) 2 Short 0.8 (0.8–1.8) 8 (5–10) 6.4 Modulate
Quanta Cyber Ho 0.2 50 10 Medium 0.8 10 8 Short 1.2 15 18 Short
1 12 12 Modu-
late
Richard Wolf MegaPulse 70 + 0.7 40 28 Medium 2.5 15 37.5 Short
0.4 50 20 5 10 50
EMS LaserClast 35* Soft 0.4 12 4.8 Long 0.3 10 3 Short 0.4 10 4 Long
Medium 0.4 4 0.4 4
Hard 0.5 5 0.5 5
Super 0.5 5 0.5 5
Hard
Storz Calculase III 0.4 25 10 Short 0.8 6 4.8 Short 1 6 6 Burst mode
0.4 6 2.4 Short

*
Laser fiber 200 µm pre-sets

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 World Journal of Urology

Fig. 2  Pre-settings options:

Rocamed MH01 Vaporisaon-
1J/15Hz
Long Pulse
CaOx
MonoHydrate
Fragmentaon-
1.5J/5Hz
Short Pulse

Vaporisaon-
0.6J/15Hz
Long Pulse
CaOx
DiHydrate
Fragmentaon-
1.2J/5Hz
Short Pulse

Vaporisaon-
0.8J/15Hz
Long Pulse
Cysne
Fragmentaon-
1.5J/5Hz
Short Pulse
Rocamed MH01
(Lithotripsy)
Vaporisaon-
0.7J/15Hz
Long Pulse
Uric Acid
Fragmentaon-
1.2J/5Hz
Short Pulse

Vaporisaon-
0.6J/15Hz
Long Pulse
Struvite /
Infecons
Fragmentaon-
1J/5Hz
Short Pulse

Vaporisaon-
0.5J/15Hz
Long Pulse
Others
Fragmentaon-
1.2J/5Hz
Short Pulse

device recalculates the pulse according to the pre-set to give not depend on laser settings only, but also, on a wide variety
the best pulse width possible. of factors such as the patient’s anatomy, endoscopic vision,
The LC’ PS are based on bench studies, limited marked irrigation, technique and endourological skills.
clinical evaluations, advisory boards meetings, among oth- Referring to the TFL, to date we have no consensus on
ers, but there is no solid data to confirm the best PS. The the ideal clinical PS. We count with a small number of pre-
search for optimal Ho:YAG laser settings goes a long way clinical and clinical TFL publications [10, 35]. Nonetheless,
back, since 1993 and still continues today. We tend to know Olympus proposed some PS that should be used with caution
the appropriate range to proceed according to the lithotripter because there is no strong clinical evidence to support these
mode, based mostly on in vitro studies. However, it is impor- affirmations. Concerning Olympus PS, i.e., for dusting, they
tant to remember that the laboratory is always a controlled recommend frequencies up to 400 Hz [29] with the safety
medium, most of the results from the laboratory are not concerns detailed above.
yet validated in real life, so we cannot always extrapolate On the other hand, it is important to highlight that all these
those results [14–16]. In vivo, lithotripsy efficiency does mentioned PS, except those from EMS, are not associated with

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World Journal of Urology

the size of the fiber being used. This concerns “energy density”
which is the amount of energy that is delivered per stone sur-
face area. Compared to the 200 µm core fiber, a 50 µm one, has
16 times less cross-sectional area, meaning that it will deliver
a laser beam 16 times more intense that would be capable of
performing a more efficient lithotripsy with lower lithotripsy
settings, including very low pulse energies (as low as 0.025 J)
[11, 17]. Even if nowadays, we are using the 150 µm core fiber
diameter laser fiber of the TFL, those benefits are already play-
ing a role in the endocorporeal lithotripsy. Therefore, consider-
ing all these amazing properties of small fibers, it is unclear
why the proposed PS from different LC are so high. Perhaps
the laser device manufacturers should take this into account
when proposing PS on their machines.
Moreover, stone localization is crucial while choosing set-
tings. Regarding Ho:YAG and TFL power, suggested settings
for the dusting/fragmentation of ureteral stones are 10–15 W,
for dusting of kidney stones it is 15–30 W, and for fragmenta-
tion of bladder stones, it is 30–50 W in other to avoid tissue
damage [10, 35]. We found that few companies consider a
classification regarding the stone location which is fundamen-
tal when choosing the laser settings to avoid thermal damage.
For instance, Olympus is one of them, dividing PS according
the ureteral or bladder location; however, we found that some
of them include high frequencies with no evidence to back
these up.
Stone type or hardness also plays a major role at the time of
choosing our laser settings. The ablation thresholds for differ-
ent urinary stone compositions, such as harder calcium oxalate
monohydrate or softer uric acid stones, varies. Therefore, we
should also adjust our settings in every “stone composition
scenario” [36]. Having this in mind, there are some compa-
nies, like Rocamend or EMS LaserClast, that developed PS
according to the nature of the stone. Rocamed MH01 [37]
programs their pre-sets according to the stone composition, but
Sampogna et al. demonstrated that even expert endourological
surgeons may not be able to recognize the stone composition
[38]. In line with Rocamed, EMS LaserClast [28] classifies
them in function of their hardness according to HU.
The main limitation of this publication is that we assume
that if experts cannot agree on what settings should be used,
it is difficult to claim the laser companies for their variabil-
ity. However, the goal of PS should be a safe departure point,
to orientate the surgeon towards an optimal procedure range,
and a fix parameter should not be considered. Hence, a sin-
gle value cannot be optimal in every situation.

Conclusion

There is a huge variability regarding pre-sets offered by

Fig. 3  Boxplot with companies’ energy, frequency and power of companies. A PS must be not only effective, but safe too.
Ho:YAG pre-settings for dusting, fragmenting and popcorning Laser efficiency is obtained as a result of the whole surgical

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 World Journal of Urology

technique and it is a dynamic parameter that varies depend- 11. Traxer O, Keller EX (2020) Thulium fiber laser: the new player
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