Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : PC05 - PC08 Full Version

Transurethral Holmium Laser Cystolithotripsy Under Local Anaesthesia in Adult Patients: A Prospective Observational Study at a Tertiary Care Centre in North-east India


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/54858.16453
Stephen Lalfakzuala Sailo, Laltanpuii Sailo, Cornerstone Wann

1. Professor, Department of Urology, North-Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India. 2. Assistant Professor, Department of Anaesthesiology, Zoram Medical College, Aizawl, Mizoram, India. 3. Associate Professor, Department of Urology, North-Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India.

Correspondence Address :
Dr. Stephen Lalfakzuala Sailo,
A-19, Faculty Quarters, Neigrihms, Mawdiangdiang, Shillong, Meghalaya, India.
E-mail: stephensailo@gmail.com

Abstract

Introduction: Urinary bladder stones comprise 5% of all urinary stones. Various modalities for the treatment of symptomatic bladder stones are available. They are open cystolithotomy, extra corporeal shock wave lithotripsy, cystolitholapaxy, suprapubic or transurethral cystolithotripsy using various energy sources. Presently transurethral Holmium laser cystolithotripsy is considered as the treatment of choice for symptomatic bladder stones.

Aim: To report the experience of holmium laser cystolithotripsy for the treatment of symptomatic urinary bladder stones under local anaesthesia in adult patients.

Materials and Methods: This prospective observational study was conducted on 86 patients at Department of Urology, North-Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India, between June 2016 and August 2019. It included consecutive adult patients with symptomatic bladder stones of size upto 4 cm who underwent transurethral holmium laser cystolithotripsy under local anaesthesia during the study period. Laser energy was delivered through a 9.5F semi rigid ureteroscope using 365 μm or 550 μm end-firing fibre. Pain during the procedure was assessed using Visual Analogue Scale (VAS). Descriptive statistics was used for analysis of the results.

Results: During the study period, 86 patients (84 men, 2 women) underwent transurethral Holmium laser cystolithotripsy under local anaesthesia. Complete fragmentation of the stones was achieved in all patients. The mean stone size was 15.04 mm and the mean operating time was 23.81 minutes. The procedure was well tolerated by the patients and the mean pain score was 3.26. It was associated with minor complications only. There was no major complication or mortality during the study.

Conclusion: Transurethral holmium laser cystolithotripsy under local anaesthesia is a safe procedure. It is well tolerated by adult patients and it can be used for the treatment of bladder stones of size upto 4 cm.

Keywords

Complications, Pain, Ureteroscope, Visual analogue scale

Urinary bladder stones comprise 5% of all urinary stones and they commonly form as a result of foreign bodies, obstruction, or infection (1). They cause lower urinary tract symptoms, infections, pain and haematuria and they may be associated with bladder cancer (2),(3). They are more common in developing countries and in male patients (4),(5). Open suprapubic cystolithotomy, the traditional method of treatment of bladder stones, has high success rate but this procedure requires postoperative catherization and hospitalisation (6). Extracorporeal shock wave lithotripsy, the least invasive procedure for treatment of bladder stones, has low success rate (7),(8). Percutaneous cystolithotripsy is associated with shorter duration of operation, catheterisation and less blood loss compared to open cystolithotomy (9). But this procedure requires making a small suprapubic incision into the bladder. Now-a-days transurethral cystolithotripsy is considered to be the treatment of choice for symptomatic bladder stones (6). In this procedure, various energy sources (electrohydraulic, ultrasonic, mechanical, laser), passed via an instrument through the urethra, are used to fragment the stones. Normally these procedures are performed under regional or general anaesthesia and require hospitalisation (3). Transurethral cystolithotripsy using holmium laser was reported to be highly effective and safe (10),(11),(12). It was also reported that the operation could be performed under local anaesthesia as the procedure was associated with minimal pain (11),(12). The aim of this study is to report the experience of transurethral cystolithotripsy of bladder stones using holmium laser under local anaesthesia in adult patients.

Material and Methods

This was a prospective observational study conducted in the Department of Urology, North-Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India, from June 2016 to August 2019. The study was approved by the Institute’s Ethics Committee (NEIGR/IEC/M13/F13/2020). The sample included all patients presenting with symptomatic bladder stones who underwent transurethral holmium laser cystolithotripsy under local anaesthesia during the study period.

Inclusion criteria: Inclusion criteria for laser cystolithotripsy were adult patients (age more than 18 years) and bladder stone of size upto 4 cm.

Exclusion criteria: Exclusion criteria were patients not willing for operation under local anaesthesia, paraplegia, stricture urethra, concomitant ureteric stone and benign prostatic hyperplasia.

Informed consent for operation was taken from all patients. Though the patients who gave consent for the operation to be conducted under local anaesthesia were recruited for the study, during any stage of the operation, if any patient found the operation under local anaesthesia to be too painful, they were given the choice of stopping the operation and converting the operation to be performed under general or regional anaesthesia in the next operating day. So, the patients underwent complete blood count, kidney function test, serum electrolytes {serum creatinine, Sodium (Na), and Potassium (K)}, random blood sugar and Glysated Haemoglobin (HbA1c), coagulation studies like Prothrombin Time (PT), Partial Thromboplastin Time (PTT), International Normalised Ratio (INR) and platelets, urine analysis and culture. These investigations were performed to assess the fitness of the patients to undergo operation for the stone either under general or regional anaesthesia. So, during the study, fitness for operation under general or regional anaesthesia was taken for each patient before the operation.

Study Procedure

X-ray and ultrasound of Kidney, Ureter and Bladder (KUB) region was done to look for concomitant renal or ureteric stones. The patients with concomitant renal or ureteric stones also underwent Intravenous Urogram (IVU) to assess the functional status of the kidneys. Few patients with poorly opaque or radioluscent bladder stones underwent non contrast Computed Tomography (CT) scan of KUB region for better evaluation of the stones. Maximum diameter of the stones in millimeter was measured on KUB x-ray/ultrasound/CT scan. They were started on appropriate antibiotics if culture was positive or given single dose of Ceftriaxone (1gm, intravenous) one hour before the operation if culture was sterile. All patients underwent transurethral holmium laser (VersaPulse PowerSuite, Lumenis, Israel) cystolithotripsy under local anesthesia. The operations were performed in the operating theatre with monitoring of Electrocardiography (ECG), blood pressure, heart rate, and peripheral oxygen saturation (SpO2). Patients were set up for operation in lithotomy position and 10 ml of 2% lignocaine jelly was instilled into the urethra. Ten minutes after local anaesthetic instillation, 7F infant feeding tube was inserted to drain the urinary bladder during the procedure. Semi rigid ureteroscope (9.5F, Karl Storz, Germany) was then inserted into the bladder through which holmium laser energy (0.6-1.5 J/Pulse at 5-20 Hz) was applied using 365 μm or 550 μm end-firing fibre with video monitoring. The stones were fragmented to the smallest size possible so that the patients could pass the fragments through the urethra. Once the operation was over, the bladder was filled with saline. Then the patients were instructed to pass the stone fragments. Patients were not catheterized after completion of the procedure.

The pain score during operation was assessed by VAS. VAS is a validated pain rating scale for subjective measure of pain (13). The patients were asked to rate the pain experienced during the operation and they were asked to mark a point on a 10 cm line (scale) in a paper. The score varies between 0, on the right end of the scale. The duration of the operation was assessed from the start of laser firing till complete fragmentation was achieved. Analgesic injection (Inj. Diclofenac 75 mg, im) was given on demand. Tablet Aceclofenac (100 mg) was given on request in the postoperative period. Postoperative KUB x-ray was done on the day of operation or the day after operation to check for residual stones. Complete clearance was defined as absence of any stone fragments in the x-ray. Patients were discharged if they passed urine well and no residual stones were detected on postoperative KUB x-ray. Patients were asked to come for follow up after one, six and 12 months. At each follow up, urine analysis and culture, uroflowmetry and x-ray of the kidney, ureter and bladder region were done.

Statistical Analysis

Continuous variables were presented as mean and range while categorical variables were expressed as frequencies and percentages.

Results

A total of 102 patients were treated during the study period (Table/Fig 1). Out of these 102 patients, 16 patients were excluded from the study based on exclusion criteria (concomitant ureteric stone-5, children-3, BPH-2, not willing for operation -2, stone bigger than 4 cm-1, stricture urethra-1, paraplegia-1, laser not working-1). Eighty-six adult patients (84 men, 2 women) underwent transurethral holmium laser cystolithotripsy during the study period. Their mean age was 36.44 years (range 18-72 years). The common presenting symptoms were acute urinary retention in 56 (65.12%); dysuria in 43 (50%) and suprapubic pain in 40 (46.51%) patients respectively. The mean serum creatinine concentration was 1.1 mg% (range, 0.6-3.3 mg %). Ultrasound was done in 50 patients, IVU in 18 patients and CT scan in four patients. All bladder stones were visible on KUB x-ray except stones in four patients for which CT scan was done. Urine culture was positive in 17 patients (Escherichia coli-10, Pseudomonas aeruginosa-3, Staphylococcus aureus-2, Enterococcus faecalis-1, Klebsiella pneumoniae-1). The mean stone size was 15.04 mm (range, 5-40 mm).

Complete fragmentation of the stones was achieved in all patients ((Table/Fig 2)a,b and (Table/Fig 3)a,b). The procedure was well tolerated with mean VAS score of 3.26. Only four patients (with pain score of 3, 3, 7 and 8) wanted analgesic injection during the operation and they were given Injection Diclofenac (75 mg, intramuscular). The procedure could be completed successfully in all patients under local anesthesia. No patient opted to convert the operation under spinal or general anaesthesia because of pain. In the postoperative period, 12 patients received Tablet Aceclofenac (100 mg) and three patients received Diclofenac injection. The mean operating time was 23.81 minutes (range, 10-120 minutes).

All patients except one could pass urine well after the operation. This patient was catheterised for one day and he passed urine well after removal of the catheter. Small residual stone fragments were detected in one patient in the postoperative KUB x- ray. This patient passed urine well and no residual stone was seen on KUB x-ray done after one month. All patients, except one patient who had retention of urine after the operation, were discharged the day after the operation.

Twelve patients had mild haematuria in the immediate postoperative period. The haematuria resolved with increased fluid intake. Three patients developed mild fever which subsided with antipyretics and antibiotics within a day. There was no major complication (e.g., bladder perforation or gross haematuria) or mortality. Eleven patients came for follow-up. All of them had normal urinary flow rate, normal urine analysis and normal KUB x-ray.

Discussion

Holmium laser has transformed the treatment of urinary bladder stones as it can fragment stones satisfactorily with minimal trauma to the bladder mucosa (10),(11),(12). Fragmentation of the stone using Holmium laser is associated with mild pain and so the procedure can be performed under local anaesthesia (10),(11). In this study, complete fragmentation of bladder stones was achieved in all patients. The procedure was well tolerated with a mean VAS score of 3.26.

The rate of successful fragmentation of bladder stones in this study is comparable to those reported by other studies (10),(14),(15),(17). Thirty-seven men with bladder stones (mean size, 2.1 cm) underwent transurethral laser cystolithotripsy under local anaesthesia (15). All the stones were completely fragmented and the mean VAS score was 2.8. Kara C et al., performed Holmium laser cystolithotripsy in 13 patients with bladder stones ≥3 cm using flexible cystoscope (10). They reported 100% success rate with mean VAS score of 2.15. Sixteen patients with mean bladder stone size of 2.15 cm underwent holmium laser cystolithotripsy under local anaesthesia and sedoanalgesia (16). Clearance rate was 89% and mean pain VAS score was 1.75. Similarly, holmium laser cystolithotrippsy was performed in 85 patients with bladder stones (mean size, 3 cm) as a day care procedure (14). Complete stone clearance was achieved in all patients with mild VAS score in 50 patients. Forty-eight patients with bladder stones (mean size, 3.7 cm) underwent Holmium laser cystolithotripsy as outpatient (17). The procedure was successful in 98.5% of patients with mean VAS score of 4.2. The average size of the stones (1.5 cm) in the present study was smaller than those reported by other studies because other studies excluded smaller stones in their study while we included all stones upto 4 cm in the present study (14),(16),(17) (Table/Fig 4).

The mean VAS score in our study was lower than that of the study by Karami et al., who used cystoscope (19F) to provide laser energy (17). The lower pain score in the present study may be due to the use of smaller calibre (9.5F) ureteroscope in comparison to the cystoscope. The mean VAS score (3.26) in the study was higher than those of the studies by Kara C et al., and D’Souza N et al., in which mean VAS scores were 2.15 and 2.8 respectively (10),(15). In these two studies, flexible cystoscope was used to provide laser energy. Although we used the same instrument (ureteroscope, 9.5F) as Uzun H et al., the mean VAS score in their study was lower than that of our study (16). This may be because of sedoanalgesia (medazolam and alfentanil) used by them, in addition to local anaesthesia.

The mean duration of operation in the present study was 23.81 minutes, which is less than those of other studies (10),(15),(16),(18). Smaller stones were excluded in these studies. Therefore, the duration of operation was longer. Although Uzun H et al., excluded stones smaller than 1 cm, the mean duration of operation was only 19.2 minutes (16). This may be due to the sedoanalgesia (medazolam and alfentanil) used by them so that there is no interruption of fragmentation. In the present study, occasionally the procedure had to be interrupted because of pain.

Holmium laser also produces tiny fragments, which are smaller than the fragments produced by other lithotripters (12). During Holmium laser cystolithotripsy, the bladder stones are fragmented to the smallest size possible so that they may be spontaneously passed or washed out using aspirator, ellik evacuator, or with irrigation (10),(14),(15).

The use of local anaesthesia avoids many complications associated with spinal or general anaesthesia. It also reduced the cost of treatment of the stone (10). Moreover, patients who are unfit and who are not willing for operation under spinal or general anaesthesia can be treated by this procedure under local anaesthesia (15). Holmium laser cystolithotripsy can be performed as a day care procedure (14),(17). However, most of our patients were from distant villages, so they were admitted one day before the operation and discharged the day after the operation.

The thermal injury associated with holmium laser is superficial and it is only 0.5 to 1 mm deep (19). The stone can be focussed accurately because holmium laser has aiming beam and stone vibration is minimal (2). So, holmium laser cystolithotripsy is quite safe and is usually associated with minimal complications like mild haematuria due to mucosal abrasion. In the present study, in the immediate postoperative period, 12 patients had mild haematuria, three patients developed mild fever and one patient developed acute urinary retention. The haematuria and fever subsided within 24 hours with increased fluid intake and antibiotics. Other studies also reported minor complications like mild haematuria and transient fever (10),(15),(17). None of these studies reported any major complications. In our study, all patients (except one patient who developed urinary retention) were discharged on the first postoperative day.

The follow-up in the present study was not satisfactory. Only 11 patients came for follow-up at one, six and 12 months. This could be due to our patients residing in distant villages and many of them being illiterate. The patients who came for follow up had no recurrent stones and no urethral stricture. Since in the present study a small calibre (9.5F ureteroscope) was used, the patients were unlikely to develop urethral strictures.

Limitation(s)

The present study was limited by the absence of a comparative group treated under spinal or general anaesthesia and poor follow-up.

Conclusion

Transurethral cystolithotripsy of bladder stones using Holmium laser under local anaesthesia was a safe technique. It was well tolerated by adult patients and it can be used for the treatment of bladder stones of size upto 4 cm.

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DOI and Others

DOI: 10.7860/JCDR/2022/54858.16453

Date of Submission: Jan 09, 2022
Date of Peer Review: Feb 08, 2022
Date of Acceptance: Apr 12, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 13, 2022
• Manual Googling: Apr 11, 2022
• iThenticate Software: Apr 19, 2022 (7%)

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