A review of the Moses effect and its applications in endourology

Abstract

The holmium:yttrium aluminum garnet laser, the gold standard for lithotripsy, is widely used in various endourological fields. Their physical characteristics contribute to the Moses effect. This narrative review aimed to analyze the current knowledge of the Moses effect and its applications in endourology. The Moses effect involves the rapid formation of a vapor bubble that allows the remaining energy to reach the target with less attenuation. Lumenis® developed pulse modulation technology, the MOSES™ technology, that harnesses the Moses effect to optimize holmium energy. Preclinical studies concluded that the new technology improves stone retropulsion, allowing for reduced lithotripsy duration. However, the heterogeneity of clinical studies and the lack of randomized controlled trials do not allow definitive conclusions. The MOSES™ technology has also been applied in holmium laser enucleation of the prostate, reducing enucleation and hemostasis times, leading to improved enucleation efficiency. However, minimal changes occurred in hemoglobin or hematocrit levels and no significant differences were noted in complications or functional outcomes. Further research is needed to fully evaluate the benefits and limitations of MOSES™ technology in clinical practice.

Keywords

Moses effect / Holmium:yttrium aluminum garnet / Lithotripsy / Benign prostatic hyperplasia / Holmium laser enucleation of the prostate

Acknowledgments

None.

Statement of ethics

Not applicable.

Conflict of interest statement

The authors declare no conflicts of interest.

Funding source

None.

Author contributions

AP, AN, JP, ET, JM: Participated in project development;

AP, AN: Participated in data collection;

AP, AN, ET, JM: Participated in the manuscript writing;

AP, EM, ET, JM: Participated in data analysis;

AP, AN, JP, EM, ET, JM: Participated in manuscript reviewing and editing.

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

References

[1] Robert G, de la Taille A, Descazeaud A. Surgical treatment of BPO: Standard and innovations. Prog Urol 2018; 28(15):856-867.

[2] Enikeev D, Shariat SF, Taratkin M, Glybochko P. The changing role of lasers in urologic surgery. Curr Opin Urol 2020; 30(1):24-29.

[3] Kronenberg P, Somani B. Advances in lasers for the treatment of stones—A systematic review. Curr Urol Rep 2018; 19(6):45.

[4] Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol 2008; 53(1):160-166.

[5] van Leeuwen TG, van der Veen MJ, Verdaasdonk RM, Borst C. Noncontact tissue ablation by holmium:YSGG laser pulses in blood. Lasers Surg Med 1991; 11(1):26-34.

[6] The Bible:Old Testament - Exodus. 13:17-14:2.

[7] Jansen ED, Asshauer T, Frenz M, Motamedi M, Delacrétaz G, Welch AJ. Effect of pulse duration on bubble formation and laser-induced pressure waves during holmium laser ablation. Lasers Surg Med 1996; 18(3):278-293.

[8] Traxer O, Keller EX. Thulium fiber laser: The new player for kidney stone treatment? A comparison with holmium:YAG laser. World J Urol 2020; 38(8):1883-1894.

[9] Isner J, Clarke R, Katzir A, Gal D, DeJesus S, Halaburka K. Transmission characteristics of individual wavelengths in blood do not predict ability to accomplish laser ablation in a blood field: Inferential evidence for the “Moses effect.”. Circulation 1986; 74(11):361.

[10] Isner JM, DeJesus SR, Clarke RH, Gal D, Rongione AJ, Donaldson RF. Mechanism of laser ablation in an absorbing fluid field. Lasers Surg Med 1988; 8(6):543-554.

[11] Royston DD, Waynant RW, Banks AK, Ramee SR. Laser transmission characteristics in blood-saline solutions. In: ProcSPIE [Internet]. 1989. doi: 10.1117/12.951955.

[12] Blomley MJ, Nicholson DA, Bartal G, Bradley A, Myers M, Allison DJ. Penetration of the holmium:YAG laser through fluid. J Vasc Interv Radiol 1995; 6(6):903-910.

[13] Fuh E, Haleblian GE, Norris RD, et al. The effect of frequency doubled double pulse Nd:YAG laser fiber proximity to the target stone on transient cavitation and acoustic emission. J Urol 2007; 177(4):1542-1545.

[14] Bader MJ, Gratzke C, Hecht V, et al. Impact of collateral damage to endourologic tools during laser lithotripsy—In vitro comparison of three different clinical laser systems. J Endourol 2011; 25(4):667-672.

[15] Dushinski JW, Lingeman JE. High-speed photographic evaluation of holmium laser. J Endourol 1998; 12(2):177-181.

[16] Zhong P, Tong HL, Cocks FH, Pearle MS, Preminger GM. Transient cavitation and acoustic emission produced by different laser lithotripters. J Endourol 1998; 12(4):371-378.

[17] Lumenis®. Moses™ Pulse 120H [Internet]. Available at: https://lumenis.com/medical/holmium-products/lumenis-Moses-pulse-120h/. Accessed January 14, 2021.

[18] Jansen ED, Motamedi M, Welch AJ, Borst C. Bubble formation during pulsed laser ablation: Mechanism and implications. Laser-Tissue Interact IV 1882;1993:13-22.

[19] Trost D. Laser pulse format for penetrating an absorbing fluid. Inventor; Lumenis Ltd., assignee. United States Patent 5, 321, 715. 1994.

[20] Ventimiglia E, Traxer O. What is Moses effect: A historical perspective. J Endourol 2019; 33(5):353-357.

[21] Ventimiglia E, Doizi S, Kovalenko A, Andreeva V, Traxer O. Effect of temporal pulse shape on urinary stone phantom retropulsion rate and ablation efficiency using holmium:YAG and super-pulse thulium fibre lasers. BJU Int 2020; 126(1):159-167.

[22] Elhilali MM, Badaan S, Ibrahim A, Andonian S. Use of the Moses technology to improve holmium laser lithotripsy outcomes: A preclinical study. J Endourol 2017; 31(6):598-604.

[23] Becker B, Gross AJ, Netsch C. Ho: YaG laser lithotripsy: Recent innovations. Curr Opin Urol 2019; 29(2):103-107.

[24] Aldoukhi AH, Roberts WW, Hall TL, Ghani KR. Watch your distance: The role of laser fiber working distance on fragmentation when altering pulse width or modulation. J Endourol 2019; 33(2):120-126.

[25] Aldoukhi AH, Black KM, Ghani KR. Emerging laser techniques for the management of stones. Urol Clin North Am 2019; 46(2):193-205.

[26] Terry RS, Whelan PS, Lipkin ME. New devices for kidney stone management. Curr Opin Urol 2020; 30(2):144-148.

[27] Kronenberg P, Traxer O. The laser of the future: Reality and expectations about the new thulium fiber laser—A systematic review. Transl Androl Urol 2019; 8(Suppl 4):S398-S417.

[28] Hiller SC, Ghani KR. Frontiers of stone management. Curr Opin Urol 2020; 30(1):17-23.

[29] Hardy LA, Kennedy JD, Wilson CR, Irby PB, Fried NM. Analysis of thulium fiber laser induced bubble dynamics for ablation of kidney stones. J Biophotonics 2017; 10(10):1240-1249.

[30] Fried NM. Recent advances in infrared laser lithotripsy [invited]. Biomed Opt Express 2018; 9(9):4552-4568.

[31] Mullerad M, Aguinaga JRA, Aro T, et al. Initial clinical experience with a modulated holmium laser pulse-Moses technology: Does it enhance laser lithotripsy efficacy? Rambam Maimonides Med J 2017; 8(4):e0038.

[32] Aldoukhi AH, Roberts WW, Hall TL, Ghani KR. Holmium laser lithotripsy in the new stone age: Dust or bust? Front Surg 2017;4:57.

[33] Keller EX, de Coninck V, Audouin M, et al. Fragments and dust after holmium laser lithotripsy with or without “Moses technology”: How are they different? J Biophotonics 2019; 12(4):e201800227.

[34] 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.

[35] Ibrahim A, Badaan S, Elhilali MM, Andonian S. Moses technology in a stone simulator. Can Urol Assoc J 2018; 12(4):127-130.

[36] Winship B, Wollin D, Carlos E, et al. Dusting efficiency of the Moses holmium laser: An automated in vitro assessment. J Endourol 2018; 32(12):1131-1135.

[37] Black KM, Aldoukhi AH, Teichman JMH, et al. Pulse modulation with Moses technology improves popcorn laser lithotripsy. World J Urol 2021; 39(6):1699-1705.

[38] Ibrahim A, Elhilali MM, Fahmy N, Carrier S, Andonian S. Double-blinded prospective randomized clinical trial comparing regular and Moses modes of holmium laser lithotripsy. J Endourol 2020; 34(5):624-628.

[39] Pietropaolo A, Hughes T, Mani M, Somani B. Outcomes of ureteroscopy and laser stone fragmentation (URSL) for kidney stone disease (KSD): Comparative cohort study using MOSES technology 60 W laser system versus regular holmium 20 W laser. J Clin Med 2021; 10(13):2742.

[40] Wang M, Shao Q, Zhu X, Wang Z, Zheng A. Efficiency and clinical outcomes of Moses technology with flexible ureteroscopic laser lithotripsy for treatment of renal calculus. Urol Int 2021; 105(7-8):587-593.

[41] Knoedler MA, Li S, Best SL, Hedican SP, Penniston KL, Nakada SY. Clinical impact of the institution of Moses technology on efficiency during retrograde ureteroscopy for stone disease: Single-center experience. J Endourol 2022; 36(1):65-70.

[42] Stern KL, Monga M. The Moses holmium system—Time is money. Can J Urol 2018; 25(3):9313-9316.

[43] Winship B, Terry R, Boydston K, et al. Holmium:Yttrium-aluminum-garnet laser pulse type affects irrigation temperatures in a benchtop ureteral model. J Endourol 2019; 33(11):896-901.

[44] Whiles B, Martin A, Brevik K, Glavin K, Thurmon K. MP03-19 improved efficiency of holmium laser enucleation of the prostate utilizing a modulated pulse platform. J Endourol 2019; 33(S1):A51-A52.

[45] Yasser Hussein MI, Petrelli F, Ceresoli F, et al. MoLEP is better than HoLEP, evidence from the first prospective randomized study involving 140 patients. Eur Urol Open Sci 2020;20:S83-S84.

[46] Large T, Nottingham C, Stoughton C, Williams J Jr., Krambeck A. Comparative study of holmium laser enucleation of the prostate with MOSES enabled pulsed laser modulation. Urology 2020;136:196-201.

[47] Assmus MA, Ganesh MB, Lee MS, Large T, Krambeck AE. Contemporary outcomes for patients undergoing concurrent surgeries at the time of holmium laser enucleation of the prostate before and after Moses 2.0 BPH mode. J Endourol 2021; 35(S3):S8-S13.

[48] Kavoussi NL, Nimmagadda N, Robles J, et al. MOSES^TM technology for holmium laser enucleation of the prostate: A prospective double-blind randomized controlled trial. J Urol 2021; 206(1):104-108.

[49] Klett DE, Baird B, Ball CT, Dora CD. Does MOSES pulse modulation reduce short-term catheter reinsertion following holmium laser enucleation of the prostate? Investig Clin Urol 2021; 62(6):666-671.

[50] Lee MS, Assmus M, Agarwal D, Large T, Krambeck A. A cost comparison of holmium laser enucleation of the prostate with and without Moses™. Urol Pract 2021; 8(6):624-629.

[51] Nevo A, Faraj KS, Cheney SM, et al. Holmium laser enucleation of the prostate using Moses 2.0 vs non-Moses: A randomised controlled trial. BJU Int 2021; 127(5):553-559.

[52] Nottingham CU, Large T, Agarwal DK, Rivera ME, Krambeck AE. Comparison of newly optimized Moses technology vs standard holmium:YAG for endoscopic laser enucleation of the prostate. J Endourol 2021; 35(9):1393-1399.

[53] Rodríguez Socarras M, Fernandez del Alamo J, Esposito F, et al. MP09-14 En-bloc enucleation technique using Moses laser (en-bloc MoLEP) vs en-bloc HoLEP: Comparing intra and post-operative outcomes for en-bloc enucleation technique with early apical release, to treat patients affected by benign prostatic enlargement. J Urol 2021;206:e165-e165.

[54] Noureldin Y, Gupta A, Hodhod A, et al. Same-day trial of void and discharge following standard vs. MOSES^TM holmium laser enucleation of the prostate: A single-center experience. Can Urol Assoc J 2023; 17(1):E23-E28.

[55] Mohamed Ismail YH, Petrelli F, Ceresoli F, et al. MoLEP is better than HoLEP, evidence from the first prospective randomized study involving 140 patients. Eur Urol Open Sci 2020; 20(S2):S83-S84.

[56] Whiles BB, Martin AJ, Brevik A, et al. Utilization of MOSES modulated pulse mode results in improved efficiency in holmium:YAG laser ablation of the prostate. Urology 2021;149:187-192.