Purpose: We tested the hypothesis that holmium:YAG laser lithotripsy speed is best maximized by using low pulse energy at high pulse frequency. Materials and Methods: To demonstrate that optical fiber damage increases with pulse energy and irradiation, the 365-μm optical fiber irradiated calcium hydrogen phosphate dihydrate (CHPD), calcium oxalate monohydrate (COM), cystine, magnesium ammonium phosphate hexahydrate (MAPH), and uric acid calculi at pulse energies of 0.5 to 2.0 J. Optical energy output was measured with an energy detector after 10 J to 200 J of total energy. To demonstrate that lithotripsy efficiency varies with power, fragmentation was measured at constant power settings at total energies of 200 J and 1 kJ with the 365-μm optical fiber. Fragmentation was measured for the 272-μm optical fiber at pulse energies of 0.5 J to 1.5 J at 10 Hz. To demonstrate that low pulse energy produces smaller fragments than high pulse energy, fragment size was characterized for COM and uric acid calculi after 0.25 kJ of irradiation using the 272-μm to 940-μm optical fibers at 0.5 J to 1.5 J. Results: Damage to the 365-μm optical fiber was greatest for irradiation of CHPD, followed by MAPH, and COM (P < 0.001). There was no significant optical fiber damage after cystine and uric acid lithotripsy. For the 365-μm optical fiber and CHPD, fragmentation after 200 J was greatest for pulse energies ≤1.0 J (P < 0.001). For other compositions, fragmentation was not statistically different among the power settings for constant irradiation. No significant difference was noted in fragmentation for any composition at different pulse energies (1.0 v 2.0 J) for 1-kJ irradiation. However, for all compositions, the calculated lithotripsy speed was greatest at high power settings (P < 0.001). For the 272-μm optical fiber, CHPD fragmentation was greatest for the 1.0-J pulse energy. The mean fragment size and relative quantity of fragments ≥2 mm both increased as pulse energy increased. Conclusions: Optical fiber degradation varies with stone composition, irradiation, and pulse-energy. Holmium:YAG lithotripsy speed is maximized with higher power (either increased pulse energy or higher pulse frequency). Because low pulse energy may be safer and yields smaller fragments than high pulse energy, holmium:YAG lithotripsy speed is best increased by using pulse energies ≤1.0 J at a high repetition rate.
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