Harry
There is good evidence of fibre tips breaking/ falling off, see Rockwell laser accident data base http://www.rli.com/resources/accident.aspx
We haven't come across this yet
Might this procedure have been recorded on a video stack.
What have the clinical team said.
What part of the bladder was damaged, bladder neck ( eg did clinician push fibre too far forward ?) or did it appear the beam was fired from the end
How big is the damaged area ?
Be useful to build up a probability of events.
How many of these devices used in UK in year, how many fibre failures, near misses, how many real events
Not seen one of these in our centres
Best Wishes
Matt
Matt Williamson
Head of Physiological Sciences
Medical Physics & Engineering
Leeds Teaching Hospitals NHS Trust
Tel 01924 541640
mob 07768 987956
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Note: I work across sites and so e-mail may come from
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-----Original Message-----
From: British Medical Laser Association [mailto:[log in to unmask]] On Behalf Of BMLA automatic digest system
Sent: 24 June 2015 00:01
To: [log in to unmask]
Subject: BMLA Digest - 22 Jun 2015 to 23 Jun 2015 (#2015-10)
There is 1 message totaling 277 lines in this issue.
Topics of the day:
1. laser fibres
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Date: Tue, 23 Jun 2015 06:41:26 +0000
From: "Swift Colin (RBV) NHS Christie Tr" <[log in to unmask]>
Subject: Re: laser fibres
Hi Harry,
I would say the fibre end sustained damage, broke off or possibly was defective (a fracture?) - as to how likely this is I guess only the manufacturer will know. The power densities these fibres have to cope with is rather high....
Regards
Colin
Dr Colin Swift
Christie Medical Physics and Engineering (CMPE) Radiation Protection (Non-ionising) The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX
01614463553
From: British Medical Laser Association [mailto:[log in to unmask]] On Behalf Of Harry Moseley (Staff)
Sent: 22 June 2015 17:06
To: [log in to unmask]
Subject: laser fibres
Dear list,
I am investigating a case in which a patient who was undergoing KTP laser prostatectomy using a side-firing fibre sustained thermal damage to the bladder. One possible explanation is that the fibre end-fired as well as side-fired. How likely is this? Unfortunately, the fibre was not kept.
Regards
Harry
Professor Harry Moseley
Head of Scientific Services
The Photobiology Unit
University of Dundee
Ninewells Hospital & Medical School
Dundee
DD1 9SY
U.K.
Tel. 01382 383272 (Lorraine Malone), 383426 (direct line)
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