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May 25th, 2017

There’s more than one way to lase a stone.

Dusting and busting (basketing) are two techniques for treating kidney stones with laser lithotripsy. Choosing which technique to use often depends on the situation—the composition of the stone, its size and location in the kidney, and a variety of other factors. But one technique isn’t necessarily better than the other. Sometimes both techniques are employed during a single procedure.

A basket case

Often, basketing procedures use high-pulse energy and low-frequency laser settings to fracture stones into large (2-4 mm) fragments, which can then be removed with an extractor. Basketing is often a suitable approach for hard stones that are likely to break into discrete fragments and that are in a location that can be accessed with an extractor. By breaking the stone into manageable fragments for extraction, a basketing procedure theoretically allows for complete stone removal, leaving behind few or no fragments.1 A notable disadvantage to basketing is the added cost of having to use additional products in the procedure: a ureteral access sheath (UAS) and the necessary extractor(s).

“Additional potential downsides to the basketing technique include the added cost of retrieval devices, increased technical challenge to manually remove stones…and surgeon frustration due to the tedium of sequentially basketing many fragments. None of these factors have been studied.”1

When the dust settles

Breaking a stone apart is not the only option. By changing the laser’s settings, a physician can dust the stone instead, pulverizing it into small dust-like fragments that can be washed out with irrigation or left to pass on their own.

“[Dusting] eliminates the need for multiple passes of the ureteroscope in and out of the ureter to remove multiple fragments and may lessen the need for UAS placement. Dusting may decrease the tedium of extracting a large number of stone fragments, possibly reducing operative time.”1

Dusting may not be best suited for treating stones in the lower pole of the kidney because the stone particulates may be less likely to pass from that location. And then there’s the issue of those residual fragments that are left behind. One school of thought argues that the fragments left behind in dusting are too small to cause problems or are likely to dissolve.2 However, another argues that any fragment left behind can be problematic. “Proponents of basket retrieval of stone fragments commonly hold the premise that ensuring that all stone fragments are removed is the most sure way of maximizing SFRs.”2

Put your finger on the pulse

The exact settings used to dust or bust a stone will vary depending on the specific laser. High-powered lasers use high energy (joules) and low frequency (hertz) to bust and the opposite to dust. However, Cook Medical’s H-30® Holmium Laser System features a variable pulse width option that can be adjusted for the desired effect. The short pulse is recommended for breaking apart dense or large stones for basketing. The long pulse is appropriate for dusting. The long pulse width has the additional benefit of reducing retropulsion, or stone migration.3,4 (This video shows a side-by-side comparison of the short and long pulse widths.) At the touch of a button, the H-30 laser system can go from a short pulse to a long pulse in order to adapt to the needs of the case.

We know that many physicians may vary their approach as the situation dictates. However you lase, we applaud your efforts to make a difference—one stone at a time.

  1. Santiago JE, Hollander AB, Soni SD, et al. To dust or not to dust: a systematic review of ureteroscopic laser lithotripsy techniques. Curr Urol Rep. 2017;18(4):32.
  2. Rizkala E, Monga M. Controversies in ureteroscopy: wire, basket, and sheath. Indian J Urol. 2013;29(3):244-248.
  3. Kang HW, Lee H, Teichman JM, et al. Dependence of calculus retropulsion on pulse duration during Ho: YAG laser lithotripsy. Lasers Surg Med. 2006;38(8):762-772.
  4. Finley DS, Petersen J, Abdelshehid C, et al. Effect of holmium:YAG laser pulse width on lithotripsy retropulsion in vitro. J Endourol. 2005;19(8):1041-1044.