Holmium Laser Lithotripsy: Procedure, Benefits, Risks, Recovery and Alternatives

Holmium laser lithotripsy has emerged as a leading minimally invasive technique for breaking up stones in the urinary tract, bile ducts, and even salivary glands. With technological advances and decades of clinical experience, it has become a mainstay for treating stones that are otherwise challenging to manage. This article offers a comprehensive, evidence-based look at holmium laser lithotripsy—how it works, its benefits, potential risks, what recovery looks like, and how it compares to alternative treatments.

Holmium Laser Lithotripsy: The Procedure

Holmium laser lithotripsy is a minimally invasive procedure that uses a highly specialized laser to fragment stones within the urinary tract, bile ducts, or other ducts of the body. The laser’s energy is delivered via a fine fiber through an endoscope, allowing precise targeting and effective fragmentation of stones of various sizes and compositions. This technique can be performed through flexible or rigid scopes, depending on the stone's location and patient anatomy, and is typically done under anesthesia.

Step	Approach	Key Features	Sources
Access	Endoscopic (flexible or rigid), percutaneous, or transhepatic	Minimally invasive, enables direct visualization	4, 6, 10, 17, 18
Energy	Holmium:YAG laser	Adjustable pulse energy, frequency, and width; new “Moses” technology	2, 5, 7, 8
Fragmentation	Contact or dusting	Stones broken into extractable pieces or fine “dust” for natural passage	8, 18
Monitoring	Real-time imaging	Fluoroscopy, ultrasound, or endoscopic view for precision and safety	10, 17, 18

Table 1: Holmium Laser Lithotripsy Procedure Overview

Endoscopic Access: Routes and Techniques

Holmium laser lithotripsy is most commonly used in urology for kidney, ureter, and bladder stones, but it is also applied in biliary and even salivary ducts. The stone’s location determines the approach:

• Urinary tract: A semirigid or flexible ureteroscope is passed via the urethra into the bladder, ureter, or kidney to visualize and treat stones 4, 6, 17, 18.
• Biliary tract: Endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic approaches allow stone access in bile ducts 1, 10.
• Salivary glands: Sialoendoscopy enables access for ductal stones 16.

Laser Technology and Settings

The holmium:YAG laser emits pulsed energy, which is transmitted through a fiber to the stone. Surgeons can adjust:

• Pulse energy and frequency: Higher energy breaks stones faster but may cause more retropulsion (stone movement); higher frequency with lower energy allows “dusting,” creating tiny fragments 2, 8.
• Pulse width: Longer pulse widths reduce stone retropulsion and potential tissue injury 2, 8.
• Fiber diameter: Thin fibers (as small as 200 μm) allow navigation through narrow ducts and flexible scopes 2.

Advanced technologies like "Moses" mode split the laser pulse, significantly reducing stone retropulsion and improving fragmentation efficiency 5, 7.

The Fragmentation Process

Two main techniques are used:

• Fragmentation: Stones are broken into extractable pieces using baskets or forceps.
• Dusting: Stones are pulverized into submillimeter particles that can pass naturally in urine 8, 18.

The choice depends on stone size, location, and surgeon preference.

Safety and Monitoring

Continuous irrigation maintains a clear field and cools the area to prevent thermal injury, as temperature can rise with prolonged lasing 3, 12. Real-time imaging confirms complete stone clearance and monitors for complications.

Benefits and Effectiveness of Holmium Laser Lithotripsy

Holmium laser lithotripsy is considered one of the most effective and versatile options for stone management. Its high success rates, broad applicability, and minimally invasive nature make it a preferred choice for many patients and clinicians.

Benefit	Outcome	Effectiveness/Stats	Sources
Success Rate	Stone clearance	90–98% for most locations; lower for large kidney stones	4, 6, 11, 10, 16, 18
Versatility	Multiple stone types and locations	Urinary, biliary, salivary stones treated	1, 6, 10, 16
Safety	Low complication rate	1.9–14% (mostly minor or transient)	4, 6, 10, 11, 16
Recovery	Outpatient possible	Short hospital stays, fast return to normal activity	6, 11, 18

Table 2: Effectiveness and Benefits of Holmium Laser Lithotripsy

High Success and Stone-Free Rates

Multiple studies demonstrate impressive stone-free rates:

• Ureteral stones: 92–100% clearance after a single session, depending on location 4, 6.
• Kidney stones: 84–97% clearance, with slightly lower rates for larger stones or complex intrarenal calculi 6, 18.
• Biliary stones: 83–98% clearance, especially for stones not amenable to standard techniques 1, 10.
• Salivary stones: Success rates around 90%, even for midsize stones 16.
• Bladder stones: High removal rates and lower adverse events compared to conventional approaches 11.

Applicability Across Multiple Organs

The holmium laser’s wavelength is highly absorbed by water, making it effective for stones of all compositions and safe for surrounding tissue. Its use spans:

• Urinary tract (ureter, bladder, kidney)
• Bile ducts (intrahepatic and extrahepatic)
• Salivary glands

It is particularly valuable for “difficult” or previously failed cases 1, 6, 10, 16.

Safety and Minimally Invasive Nature

• Most procedures are outpatient or require short hospital stays 6, 18.
• Complications are typically mild and transient (fever, pain), with severe complications being rare 4, 6, 10, 11.
• The risk of tissue injury is minimized by precise energy delivery and real-time monitoring.

Technological Advances Improve Outcomes

• Newer laser modes (like Moses) reduce stone retropulsion and procedural times 5, 7.
• Both contact and dusting techniques can be tailored to stone size and patient needs 8.

Risks and Side Effects of Holmium Laser Lithotripsy

While holmium laser lithotripsy is generally safe, like all medical procedures, it carries certain risks and potential side effects. Understanding these helps prepare patients and guides clinicians in minimizing complications.

Risk	Incidence/Type	Severity/Management	Sources
Infection	9–14% (fever, SIRS)	Usually mild, treatable with antibiotics	4, 9, 10, 12
Tissue Injury	Ureteral/biliary stricture, mucosal damage	Rare (<1%), may require surgery	4, 6, 14, 16
Pain	Mild/transient	Analgesics usually sufficient	1, 4, 10
Retropulsion	Stone migration	Decreased with long pulse/Moses tech	5, 7, 8

Table 3: Risks and Side Effects of Holmium Laser Lithotripsy

Infectious Complications

• Fever and Systemic Inflammatory Response Syndrome (SIRS): Incidence ranges from 9–14%, often related to preexisting infection, stone size, surgery duration, and use of ureteral access sheaths 9, 10, 12.
• Prevention: Careful preoperative evaluation, sterile technique, and proper irrigation can reduce risk. Warming irrigation fluid may also lower the incidence of postoperative fever and shivering 12.

Tissue Injury and Stricture Formation

• Ureteral or biliary strictures: Rare but serious, affecting <1% of patients. More common in upper ureter; may require reconstructive surgery 4, 6, 14, 16.
• Mucosal injury, perforation, or ductal stenosis: Occur infrequently; most are mild or resolve with conservative management 4, 6, 11, 16.

Pain and Minor Complications

• Abdominal/flank pain: Usually mild and transient, managed with analgesics 1, 4, 10.
• Hematuria (blood in urine): Often self-limited.

Stone Retropulsion

• The stone can move away from the laser during fragmentation, especially with higher-energy settings.
• Mitigation: Use of long-pulse or Moses technology significantly reduces retropulsion, leading to more efficient procedures 5, 7, 8.

Thermal Effects

• High-power settings and low irrigation rates can raise local temperatures, risking thermal injury.
• Prevention: Use intermittent laser activation and adequate irrigation flow 3.

Recovery and Aftercare of Holmium Laser Lithotripsy

Recovery after holmium laser lithotripsy is typically rapid, with most patients resuming normal activities within days. However, aftercare is crucial to ensure complete stone clearance, prevent complications, and support healing.

Aspect	Timeframe/Advice	Outcome	Sources
Hospital Stay	Outpatient or 1–2 days	Quick discharge	6, 11, 18
Pain Management	Short-term analgesics	Mild discomfort	1, 4
Fragment Clearance	Position therapy, activity	Improved stone-free rates	15
Follow-up	Imaging, stent removal	Confirms clearance	4, 15, 18

Table 4: Recovery and Aftercare Summary

Postoperative Care and Return to Activity

• Hospital stay: Most patients go home the same day or after 1–2 days of observation 6, 11.
• Pain: Discomfort is generally mild and controlled with oral pain medications 1, 4.
• Hydration: Encouraged to help flush out residual fragments.

Facilitating Stone Fragment Clearance

• Self-help position therapy (SHPT): Patients adopting certain positions postoperatively improve the passage of stone fragments, decrease hydronephrosis, and increase stone-free rates at follow-up 15.
• Activity: Light mobility and hydration can also promote fragment clearance.

Follow-up and Monitoring

• Imaging: X-ray, ultrasound, or CT scan at 2, 4, and 12 weeks to confirm stone clearance and monitor for complications 4, 15, 18.
• Stent management: Temporary ureteral stents may be placed to maintain drainage; these are removed within a few weeks.

Preventing and Managing Complications

• Infection: Monitor for fever or urinary symptoms; antibiotics may be prescribed if necessary 9, 12.
• Stricture surveillance: Especially for patients with difficult stones or prolonged procedures 14.

Alternatives of Holmium Laser Lithotripsy

While holmium laser lithotripsy is highly effective, alternative treatments exist and may be preferred based on stone size, location, patient health, or resource availability.

Alternative	Indication/Use	Pros and Cons	Sources
ESWL	Small to medium stones, non-obstructive	Non-invasive; less effective for hard/large stones	17, 18
PCNL	Large/complex renal stones (>2–3 cm)	High stone clearance; more invasive	18, 13
Thulium Fiber Laser	All urinary stones	Faster ablation, less retropulsion; new technology	19, 20
Open/Robotic Surgery	Rare, for complex or failed cases	Most invasive, highest risk	1, 10, 16, 14

Table 5: Key Alternatives to Holmium Laser Lithotripsy

Extracorporeal Shock Wave Lithotripsy (ESWL)

• Best for: Small to medium, uncomplicated stones.
• Advantages: Non-invasive, no anesthesia required.
• Limitations: Less effective for hard, large, or lower-pole stones; may require multiple sessions 17, 18.

Percutaneous Nephrolithotomy (PCNL)

• Best for: Large or complex kidney stones (>2–3 cm).
• Advantages: Highest stone-free rates for large stones.
• Drawbacks: More invasive, longer hospital stay, higher risk of bleeding and complications 18, 13.

Thulium Fiber Laser Lithotripsy

• Emerging alternative: Offers faster stone ablation, less stone retropulsion, and the ability to use finer fibers for improved scope flexibility 19, 20.
• Status: Promising early results; may challenge holmium laser as the gold standard in the future.

Open or Robotic Surgery

• Reserved for: Rare, complex cases where endoscopic or percutaneous approaches fail or are contraindicated 1, 10, 14, 16.
• Risks: Higher morbidity, longer recovery, greater risk of complications.

Conclusion

Holmium laser lithotripsy stands as a versatile, highly effective, and minimally invasive option for managing stones in diverse anatomical locations. It continues to evolve with technological advances, offering patients faster recovery and high success rates.

Key Takeaways:

• Holmium laser lithotripsy uses flexible, precise laser energy to fragment urinary, biliary, and salivary stones 1, 4, 6, 10, 16.
• The procedure is minimally invasive, with high stone clearance rates and low complication rates 4, 6, 10, 11, 16, 18.
• Risks include infection, tissue injury, and rare strictures; most side effects are mild and manageable 4, 6, 9, 10, 11, 12, 14.
• Recovery is rapid, with outpatient care and simple measures enhancing fragment passage and outcomes 6, 11, 15, 18.
• Alternatives like ESWL, PCNL, and thulium fiber lasers are available; choice depends on stone characteristics and patient factors 17, 18, 19, 20.

With ongoing innovations and strong clinical evidence, holmium laser lithotripsy remains a cornerstone in stone management, offering hope and relief to patients worldwide.