To evaluate the ablation capacity using two Thulium fiber lasers (TFL) in a porcine kidney model. All tissue samples were mounted on a motorized stage for a precise speed of cutting. A continuous wave (cw) TFL and a super pulsed (SP) TFL were used at power settings of 60 and 120 W with 200 and 600 µm laser fibers. After lactate dehydrogenase staining, histological evaluation was performed to measure the vaporization volume (VV), ablation depth (AD), thermo-mechanical damage zones (TMZ), coagulation zones (CZ) and the carbonization grade (CG). At 120 W, no significant differences were seen between 200 and 600 µm fibers utilizing the cw TFL regarding VV (24.6 vs. 28.2 mm3/s), AD (5.6 vs. 5.7 mm), TMZ (0 vs. 0 mm2) and CZ (18.1 vs. 12.3 mm2). Using the SP TFL, no significant differences between both fiber diameters with regard to VV (4 vs. 6.2 mm3/s), AD (2.7 vs. 3.4 mm), TMZ (1 vs. 2.6 mm2) and CZ (3.1 vs. 2.2 mm2) at 120 W were found, respectively. However, the VV of the cw TFL at 60 W was significantly less compared to 120 W using 200 and 600 µm fibers, respectively, whereas the SP TFL did not show significant differences between 60 and 120 W with regard to VV. SP TFL showed a consistently lower CG compared to cw TFL. This experiment suggests that there is no significant difference using 200 or 600 µm laser fibers in cw or SP TFLs. However, the cw TFL produces a coagulation zone three to five times larger than the SP TFL regardless of the fiber diameter.

Effect of optical fiber diameter and laser emission mode (cw vs pulse) on tissue damage profile using 1.94 µm Tm:fiber lasers in a porcine kidney model.

To evaluate the impact of the fiber–tissue distance on histological parameters in a porcine kidney model.
 Four lasers were tested at 60 W using a 600-µm bare-ended fiber: a continuous wave (cw) thulium fiber laser (TFL), a super pulsed (SP) TFL, a Ho:YAG laser, and a blue diode laser (BDL). All tissue samples were mounted on a motorized XY-translation stage. The fiber–tissue distance was changed within a range from 0to 6 mm. Ten incisions were made with each laser at each distance. Afterwards, the tissue samples were sliced with a microtome for lactate dehydrogenase staining to determine zones of thermal damage.
 In contact mode, the largest incision depth was found for the cw TFL (1.7 ± 0.1 mm) compared to the SP TFL (1.0 ± 0.1 mm), BDL (0.9 ± 0.1 mm) and HoYAG laser (1.1 ± 0.1 mm), respectively. With regard to the coagulative properties, the SP TFL and the Ho:YAG laser showed comparable coagulation depths with 0.7 ± 0.1 and 0.6 ± 0.1 mm, respectively. At 2 mm fiber–tissue distance, the Ho:YAG laser was the only laser that vaporized tissue (incision depth: 0.2 ± 0.1 mm). The BDL was the only laser that caused coagulation at a distance of 3–5 mm. Our results support the clinical observation that cw TFL must be defocused for best coagulation, while the coagulation depth of the SP TFL remains nearly constant within the range of 0–3 mm. Increasing the distance of the laser fiber to the tissue up to 5 mm did not cause significant differences with regard to coagulation depth using the BDL.

The impact of the laser fiber-tissue distance on histological parameters in a porcine kidney model.

Background and objectives To evaluate the feasibility of using a novel blue diode laser (blue laser), a thulium fiber laser (Tm laser), and their combination as a directed-energy surgical tool in laparoscopic partial nephrectomy (LPN). Study design/materials and methods The blue laser emitting at 442 nm, the Tm laser emitting at 1,940 nm wavelengths, and the combination of them were tested. First, cutting and coagulative abilities of the lasers were characterized ex vivo on porcine kidney in air and CO2 . Histological staining was performed to assess the efficiency of ablation and coagulation. Next, experimental LPN was performed on a porcine model at zero ischemia. Upper and lower segments of both kidneys were resected. Total operation time and resection time were measured; bleeding and carbonization were evaluated. Results Ex vivo data show that laser-induced ablation and coagulation processes do not differ substantially between CO2 and air environments. Histological analysis of ex vivo incisions demonstrates that the blue laser produced deep ablation with relatively narrow coagulation zone, whereas Tm laser was less efficient in terms of ablation but possessed excellent coagulative properties. Experimental LPN revealed that the blue laser provided fast cutting with minimal carbonization, whereas Tm laser induced slow cutting with strong carbonization. The combination of the blue and Tm lasers provided the most promising results demonstrating the highest resection rate, almost carbonization free resection surface and clinically acceptable hemostasis enabling LPN without the need for vessel clamping. Conclusions The blue laser can be efficiently utilized in LPN. Furthermore, the combination of the blue and Tm lasers into a single modality may be beneficial for further development of successful laser-assisted LPN. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Ex vivo and animal study of the blue diode laser, Tm fiber laser, and their combination for laparoscopic partial nephrectomy

Endoscopic submucosal dissection (ESD) is clinically used to remove early gastric cancer in stomach. The aim of the current study is to examine a therapeutic capacity of pulsed Ho:YAG laser for the development of laser-assisted ESD under various surgical parameters. Ex vivo porcine stomach tissue was ablated with 1-J Ho:YAG pulses at 10 Hz at different number of treatments (NT = 1, 2, and 3) and treatment speeds (TS = 0.5, 1, and 2 mm/s) without and with saline injection. Regardless of saline injection, straight tissue ablation showed that ablation depth increased with increasing NT and decreasing TS. At NT = 3 and TS = 0.5 mm/s, no saline injection yielded the maximum ablation depth (3.4 ± 0.3 mm), partially removing muscularis propria. However, saline injection confined the tissue ablation within a submucosal layer (2.1 ± 0.3 mm). Thermal injury was found to be 0.7~1.1 mm in the adjacent tissue with superficial carbonization. Circular tissue ablation (2 cm in diameter) at NT = 3 and TS = 0.5 mm/s presented that no saline injection yielded a reduction in the lesion area, whereas saline injection maintained the ablated lesion area. Histological analysis revealed that unlike no saline injection, saline injection ablated the entire mucosal layer without perforation in the muscular propria. The pulsed Ho:YAG laser can be a potential surgical tool for clinical ESD to incise a target lesion without adverse perforation. Further investigations will validate the efficacy and safety of the Ho:YAG laser-assisted ESD in in vivo porcine stomach models for clinical translation.

Evaluations on laser ablation of ex vivo porcine stomach tissue for development of Ho:YAG-assisted endoscopic submucosal dissection (ESD)

A 450-nm blue laser may be suitable to treat benign prostate hyperplasia (BPH) due to its haemoglobin absorption characteristic. The present study compared a novel high-power 450-nm semiconductor blue laser with other lasers marketed for in vitro soft tissue ablation, to evaluate the safety and efficacy of the 450-nm laser in BPH surgery. With the in vitro tissues on an experimental platform in water, the vaporization efficiency and coagulation layer thickness of the novel 450-nm laser and commercially available 532-nm, 980-nm, and 1470-nm lasers were measured at the same power (120 W). The damage to the adjacent tissue and the working noise were also measured. The vaporization efficiency was proved to be 450-nm laser > 532-nm laser > 1470-nm laser > 980-nm laser. Comparison of coagulation layer thickness was as follow: 980-nm laser > 1470-nm laser > 532-nm laser > 450-nm laser. The degree of tissue damage caused by the 450-nm and 532-nm lasers increased with the decrease in distance and increase in time (these are safe when a sufficient distance and short irradiation time are maintained). The heating ability of 980-nm and 1470-nm lasers was much greater than that of 450-nm and 532-nm lasers. The working noise was lower in 450-nm and 1470-nm lasers. The novel 450-nm laser has the advantages of highly efficient tissue vaporization, creating a thin coagulation layer, and low working noise. These characteristics suggest that the novel 450-nm laser may be a promising choice for the surgical treatment of BPH.

In vitro evaluation of the safety and efficacy of a high-power 450-nm semiconductor blue laser in the treatment of benign prostate hyperplasia

Three lasers were directly compared, including the Ho:YAG laser (λ = 2100 nm), Tm fiber laser (λ = 1940 nm) operating in 3 different modes (CW, regular pulse, and super pulse), and blue diode laser (λ = 442 nm) for vaporization and coagulation efficiency for treating blood-rich soft tissues, ex vivo, in a porcine kidney model at quasi-contact cutting in water. In addition, experimental results were compared with published data on performance of KTP laser (λ = 532 nm) at similar experimental settings (Power = 60 W and cutting speed = 2 mm/s). Tm fiber laser in pulsed mode and blue laser produced highest vaporization rates of 3.7 and 3.4 mm3/s, respectively. Tm fiber laser (in both CW and pulsed modes) also produced the largest coagulation zone among the laser sources tested. A carbonization zone was observed for Tm fiber laser in CW and pulsed modes, as well as for the blue diode laser. Tm fiber laser in super-pulse mode and Ho:YAG laser both resulted in irregular coagulation zones without carbonization. Comparison with known data for KTP laser revealed that tissue effects of the blue laser are similar to that of the KTP laser. These results suggest that the combination of the two lasers (Tm fiber and blue diode) in one system may achieve high cutting efficiency and optimal coagulation for hemostasis during surgical treatment. Ex vivo testing of the combined system revealed feasibility of this approach. The combination of the CW Tm fiber laser (120W) and the blue diode laser (60W) emitting through a combination tip were compared with CW 120 W Tm fiber laser alone and 120 W Ho:YAG laser. Vaporization rates measured 34, 28, and 6 mm3/s, and coagulation zones measured 0.6, 1.3, and 1.7 mm, respectively. A carbonization zone was only observed with CW Tm fiber laser. The vaporization rate of combined CW Tm fiber laser / blue diode laser was comparable to published data for KTP laser for equivalent total power. Thus, high-power blue diode laser, Tm fiber laser, and their combination may provide an alternative to conventional Ho:YAG and KTP lasers for applications in urology and other surgical fields.

Anastasiya Kovalenko

Papers

Comparison of a novel 450-nm laser with Ho:YAG (2100 nm), Tm fiber (1940 nm), and KTP (532 nm) lasers for soft-tissue ablation