Reviews of the Cook Medical Rhapsody H-30 Holmium Laser System | Which Medical Device

User review Rhapsody H-30™ Holmium Laser System

1.    Device features
The Cook Rhapsody laser is made for endourologic lithotripsy of urinary calculus disease. It generates a 2100nm HoYAG pulsed laser beam with up to 30W. It can also be used for endourologic tissue therapy in the form of tumor ablation and stricture incision. It might be usable for other, more adventurous endeavors elsewhere in the human body, yet it was not made for these.

2.    Design/construction
Rhapsody has the industry-standard tower shape. It has a touch-screen for operating the settings. It has a mains switch on the back, an emergency off-switch in the front (which is mandatory in the EC for all laser devices) and a screw-in laser fibre port with sliding shield protection that features instrument recognition (read: you must buy Cook proprietary fibres). Most laser generators have that nowadays, probably for commercial reasons.  The device has a standby/ready mode that is set by touch-screen (usually by the circulator, but you can put a sterile drape on the display), a frequency, power intensity and aiming beam regulator. Moreover, and that is what sets its apart from other HoYAG on the market, the Rhapsody sports a short/long laser pulse firing selector. The actual lazing is done with a foot pedal that is nothing special.

3.    The device in use
The device and its touch screen are straightforward to use.  The touch screen has a good sizing to allow spot-on setting identification from a distance.  I personally do not like aiming beams in HoYAG laser (it’s a contact laser anyway), but the Rhapsody has a green aiming beam, which at least doesn’t eat your endoscopic light the way red beams tend to do. The aiming beam can be decreased in intensity and made to flicker, too. All changes in the setting result in the device going back to standby mode, which then has to be set to ready state again with the touchscreen- a safety feature in all other models, too, It’s a bit irritating if you are the impatient type, of course.
When it comes to stone treatment, this laser doesn’t differ much from his concurring brethren. 30W HoYAG gives you plenty of punch for most stones. The star feature short/long pulse, however, is really quite helpful if you wish to treat calyceal diverticula or the occasional jackstone, as it allows to release the same energy in 0.3 ms instead of the usual 0.8 ms pulse time (that is the time there’s actually laser coming out of the aperture). Roughly speaking, this should give you twice the energy density. This comes in handy for tissue surgery. I am very fond of this feature, and thus far no other device has this currently (10-2014) in the EU. Please refer to the video to see the opening of a calicogenic cyst with impacted purulent material as well as the second movie of stones actual behind the thin epidemial layer in a renal papilla. Both the deroofing parts were done with the short pulse at 0.5J, 10-14Hz. 
The Rhapsody does have a nagging limitation. All current pulsed lasers make a lot of noise when switched on, and  so does the Cook device. The switch between Standby and Ready mode is poorly audible with the Rhapsody in the average endourology suite (with surgeon, anesthesia, C-arm, technician, various students, circulator – some 5-10 people standing around).

4.    Comparisons with similar devices
The previous generation of HoYAG “stone” lasers allowed 20W of energy - the recent ones pretty much all offer 30W. Some high-end machines that can be used for prostate surgery as well go up to 100W, but the cost of the latter (above 100.000€) is pretty prohibitive. Nowadays, 30.000 to 50.000€ should get you a 30W HoYAG laser. Many manufacturers offer smaller, “desktop” versions of generators - I generally do not recommend them as they need to be placed on a trolley (to allow for inspection of device energy setting).  That defies the purpose of having a desktop box, and most desktop - devices do limit the laser setting. More irritating, some have a very small touch-screen (to small for an OR) and all of them feature decreased performance / less versatility in the lazing settings.  I think that’s the wrong way for the industry.
Tobrix, Wolff, Versapulse, Dornier (Olympus) are some of this device’s competitors. Generally speaking, the laser coming out of them is the same. 2100nm makes for great underwater-surgery but renders the device useless when travelling through air. Some devices do offer better fine-tuning of settings at the lower end of the power settings (Rhapsody forces 0.5 J and 5 Hz minimum on you), but that generally is not a problem as stones mostly won’t fragment otherwise anyway. Dornier has a wireless footswitch that is the best the industry currently has to offer, as it can not only switch from standby to ready with the footswitch but does allow manipulation of energy and frequency with the switch as well.  The foot switch is a little fiddly to use, and the laser itself is more expensive than the Cook Laser.  Versapulse is an industry veteran that offers a very wide range of differently-powered lasers and, most importantly, free choice of non-proprietary fibers. The Wolff laser I tested (Megapulse Tower 30+) was by far the quietest of the models.
The Cook laser, however, is at this time the only HoYAG laser that offers variable pulse duration.  I find that very useful. It was very easy to use for the circulator, too.

5.    Conclusion and star rating (out of 5)
The Cook Rhapsody is an excellent lithotriptor laser with a very good secondary mode for fine tissue ablation. It is easy to use and gets the job done. The burst modifier is a step forward for the entire class of these devices.  Future models might want to consider soundproofing of the case, better audio status indicator and maybe a wireless pedal.

6.    References
None given

7.    Conflict of interest statement
My hospital has recently purchased the Rhapsody device. I was involved in the acquisition process. I have not received money in any way from Cook. I am a frequent speaker for medical society teachings and industry trainings in urology for devices and usually receive remuneration, and sometimes Cook sponsors these events, with meaterials or money, among other competitors. 


Picture data
Two videos (subepithelial stone short, calyceal cyst.
One Xray (key caliceal diverticulum)

Author
Dr Thomas Müller,FEBU
t.muller@nijsmellinghe.nl
Urologist, Nij Smellinghe Ziekenhuis Drachten, the Netherlands.