Kidney Stone Treatment System

Abstract

A kidney stone removal system is disclosed having components including a handle mechanism, a nozzle tip, and a guide device. The handle mechanism employs a trigger that allows control of irrigation and aspiration / aspiration. Depression of the trigger communicates the status of aspiration / aspiration and irrigation to the user. When the trigger is in a reference (non-depressed) position, irrigation and aspiration / aspiration are turned off. When the trigger is in a fully depressed position, irrigation and aspiration / aspiration are turned on. When the trigger is in an intermediate position, irrigation is turned on and aspiration / aspiration remains off. The nozzle includes an irrigation port having an irrigation port exit angle of 30-60 degrees for directing irrigation fluid. The guide device is removably configured within the nozzle to receive a debris crushing device. The guide device prevents unintended movement of the crushing device and allows fluid and debris to flow past the crushing device and down the aspiration tube.

Description

[Technical field]

[0001]

[0001] The present invention relates to systems, devices and methods for the guided removal of objects in vivo, and more particularly to mechanisms for the irrigation and removal of objects such as kidney stones. [Background technology]

[0002] Kidney stones are a common medical problem that adversely affects millions of people worldwide. Kidney stones usually include one or more solid masses of material consisting of crystals that form in parts of the urinary tract, including a person's ureter, kidneys, and / or bladder. Kidney stones range in size from small (less than about 1 cm) to very large (greater than 4 cm), which can cause a person significant pain and damage to the kidney. The vast majority of stones treated by surgeons are less than 1 cm.

[0003]

[0003] The treatment recommended for the removal of kidney stones depends on many factors, including the size, number, and location of the kidney stones. The most common treatments for kidney stones are shock wave lithotripsy (using ultrasound to break up stones), ureteroscopy (breaking up and removing stones using an endoscope inserted through the bladder), and percutaneous nephrolithotomy (breaking up and removing stones using an endoscope inserted through a sheath inserted into the kidney through the patient's back).

[0004]

[0004] Most large kidney stones are usually removed by percutaneous nephrolithotomy or kidney lithotripsy. In these procedures, a small incision is made in the patient's back near the kidney and a sheath is passed into the kidney to accommodate a larger endoscope used to break up and remove the stone. The stone may be removed directly through the tube or may be broken into smaller pieces while still in place inside the patient and then removed by suction or other known methods.

[0005]

[0005] There are many disadvantages associated with kidney stone removal, kidney stone lithotripsy, and other invasive procedures that require skin incisions: such surgical techniques may require the administration of significantly larger amounts of anesthesia to the patient, the procedures are more complicated and expose the patient to a higher risk of infection and complications, and the procedures require significant incisions in the patient and may leave scars. Furthermore, given the invasiveness of the procedures, percutaneous procedures are usually not preferred for smaller kidney stones (e.g., less than 1 cm), depending on the size and location of the stone.

[0006] Traditionally, smaller kidney stones have been treated using less invasive techniques, including ureteroscopy. In ureteroscopy, the surgeon typically passes a ureteroscope through the urethra, into the bladder and ureters, allowing direct visualization of the kidney stone that may be present in the ureter or kidney. If the kidney stone is small enough to easily pass through the urinary tract, the surgeon then either directly removes the kidney stone using a basket device, or breaks the kidney stone into smaller pieces using a laser or other breaking device. A laser lithotripsy device is inserted through the ureteroscope and is used to break up larger kidney stones into smaller pieces. After breaking the kidney stone into smaller pieces, the surgeon removes the laser or breaking device and inserts a basket or extraction catheter to capture the kidney stone fragments under the direct visualization of the ureteroscope. After retrieving some of the kidney stone fragments, the surgeon removes the basket from the patient and drains the kidney stone fragments from the basket. This process is repeated until clinically significant kidney stones and kidney stone fragments are broken up and removed from the body.

[0007]

[0007] It is evident that this process is very time-consuming, costly, and inefficient, as the surgeon must repeatedly insert and remove the scope and basket from the patient to completely remove the kidney stones and kidney stone fragments. Another drawback of using a basket removal device to capture kidney stones or kidney stone fragments is that it is difficult to position the basket next to the kidney stone fragments and manipulate it to effectively retrieve the fragments. The training required for such a procedure is not inconsiderable, and the basket removal technique can be difficult even for the most skilled surgeon. Furthermore, the surgeon is subject to hand fatigue due to the long hours required to manipulate the kidney stone retrieval basket. Furthermore, the patient is required to be under local anesthesia and / or remain immobile for long periods of time. Furthermore, repeated insertion and removal of the basket retrieval device causes irritation to the urinary tract.

[0008]

[0008] Thus, there is an unmet need for new devices and methods for minimally invasive removal of kidney stones. Summary of the Invention

[0009]

[0009] According to one aspect of the present invention, a kidney stone removal mechanism is provided. The mechanism includes an irrigation tube, an aspiration tube, and a trigger mechanism. The trigger mechanism includes a trigger operable by a user. The trigger can be located at a proximal end of the kidney stone removal mechanism. The trigger mechanism can be operable to selectively contract, close, and open the irrigation tube to irrigate the treatment area in response to user actuation of the trigger, and to selectively cause suction in the aspiration tube to remove a portion or all of the kidney stone in response to user actuation of the trigger. User depression of the trigger can progressively open the irrigation tube. In one embodiment, the trigger includes a first protrusion, and user actuation of the trigger can cause the first protrusion to selectively contract, close, and open the irrigation tube. User depression of the trigger can cause the first protrusion to progressively open the irrigation tube. In one embodiment, the trigger includes a second protrusion, and user actuation of the trigger can cause the second protrusion to selectively cause suction in the aspiration tube. User depression of the trigger can cause the second protrusion to progressively create suction in the suction tube. The kidney stone removal mechanism comprises: a catheter connected at its proximal end to a distal end of a kidney stone removal mechanism The catheter may further include a distal tip at a distal end of the catheter. A steering mechanism may be located at a proximal end of the kidney stone removal mechanism. The steering mechanism is operable to steer the distal tip to facilitate removal of part or all of the kidney stone. The steering mechanism may include at least one wire connected between the steering mechanism and the catheter for moving the distal tip to a desired location to facilitate removal of part or all of the kidney stone.

[0010]

[0010] The first protrusion can comprise a roller. The second protrusion can comprise a roller. The trigger can comprise a third protrusion, and the trigger mechanism can comprise a first detent selectively engageable with the third protrusion to alert the user to a predetermined amount of depression of the trigger. The first detent can include an edge of a protrusion that is internal to the trigger mechanism, or can include an edge of a recessed portion that is internal to the trigger mechanism. The third protrusion of the trigger can comprise a roller. The kidney stone removal mechanism can further comprise a second detent to alert the user to a full amount of depression of the trigger. The second detent can include a protrusion that is internal to the trigger mechanism. The second detent can include an opposing edge of a recessed portion that is internal to the trigger mechanism. The roller can engage the opposing edge of the recessed portion to alert the user to a full amount of depression of the trigger.

[0011] According to one embodiment, the trigger mechanism can be located at a proximal end of the kidney stone removal mechanism so that it can be operated by a user's thumb. The trigger mechanism can be located at a proximal end of the kidney stone removal mechanism so that it can be operated by a user's finger. The steering mechanism can be located at a proximal end of the kidney stone removal mechanism so that it can be operated by a user's thumb.

[0012] According to one embodiment, the kidney stone removal mechanism further comprises a resilient device that interacts with the trigger mechanism to return the trigger mechanism to a home position in response to a user release of the trigger. The resilient device may comprise a spring.

[0013] According to one embodiment, the kidney stone removal mechanism further comprises a suction actuation tube connected to the suction tube. The second protrusion can pinch and close the suction actuation tube to create suction in the suction tube. The second protrusion can cover a port of the suction actuation tube to create suction in the suction tube.

[0014] According to one aspect of the present invention, there is provided a kidney stone removal mechanism comprising an irrigation tube configured to carry a fluid and having a portion passing through the trigger mechanism, and a bypass structure connected to the irrigation tube at two locations and configured to allow fluid to flow from a first portion of the irrigation tube to a second portion of the irrigation tube without passing through a portion of the irrigation tube within the trigger mechanism. The trigger mechanism includes a trigger operable by a user. The trigger mechanism may be operable to selectively contract, close, and open the first irrigation tube to irrigate the treatment area in response to user actuation of the trigger. The bypass structure may comprise a flow restrictor. User depression of the trigger may cause the irrigation tube to be progressively opened. The kidney stone removal mechanism may further comprise a suction tube configured to be actuated by the trigger mechanism. The kidney stone removal mechanism may comprise a catheter connected at its proximal end to a distal end of the kidney stone removal mechanism, the catheter having a distal tip at the distal end of the catheter; The kidney stone removal mechanism may further include a steering mechanism located at a proximal end of the kidney stone removal mechanism, the steering mechanism operable to steer the distal tip to facilitate removal of some or all of the kidney stone.

[0015] According to another aspect of the present invention, there is provided a kidney stone removal mechanism comprising an irrigation tube, an aspiration tube, and a flow indicator mechanism including a flow indicator connected to the stone capture assembly. In one embodiment, the flow indicator may comprise one or more vanes that move in response to a flow of fluid or air. The kidney stone removal mechanism may further comprise a catheter connected at its proximal end to a distal end of the kidney stone removal mechanism, the catheter having a distal tip at the distal end of the catheter, and a steering mechanism located at the proximal end of the kidney stone removal mechanism, the steering mechanism being operable to steer the distal tip to facilitate removal of part or all of the kidney stone.

[0016] According to one aspect, the kidney stone removal mechanism may further comprise a nozzle. The nozzle may include an aspiration lumen in communication with the aspiration tube and sized to remove kidney stones or kidney stone fragments, and one or more irrigation ports in communication with the irrigation tube, the irrigation ports being disposed at a distal end portion of the nozzle and having an irrigation port exit angle in the range of 30-60 degrees for directing irrigation fluid forward and laterally from the distal end portion of the nozzle. In one embodiment, at least one of the irrigation ports has a shape of a circular arc.

[0017] According to another aspect of the present invention, there is provided a kidney stone removal mechanism comprising a kidney stone removal catheter and a nozzle assembly included at a distal end of the catheter. The nozzle may comprise an aspiration lumen sized to remove a kidney stone or kidney stone fragments, and one or more irrigation ports at a distal end portion of the nozzle. At least one of the irrigation ports has an irrigation port exit angle in the range of 30-60 degrees for directing irrigation fluid forward and sideways from the distal end portion of the nozzle. In one embodiment, the kidney stone removal mechanism comprises a first irrigation port configured to direct irrigation fluid forward but not in a radially expanding direction, and a second irrigation port configured to direct irrigation fluid in a radially expanding direction. In one embodiment, at least two of the irrigation ports have different opening sizes, different shapes, and / or different irrigation port exit angles. In one embodiment, a first one of the perfusion ports is one of a circular, elliptical, or arc shape, and a second one of the perfusion ports has a different shape than the first one and is one of a circular, elliptical, or arc shape. The first perfusion port may be located directly between the second and third perfusion ports, and the arc distance between the first and second perfusion ports is different from the arc distance between the first and third perfusion ports.

[0018] In one embodiment, the kidney stone removal mechanism further comprises an image sensor and a light source. The nozzle can include an upper recess for receiving the image sensor and the light source. The kidney stone removal mechanism can further comprise a distal manifold configured to be inserted into a proximal end of the nozzle, the distal manifold having a conduit for directing irrigation fluid to the irrigation port of the nozzle.

[0019] The kidney stone removal mechanism may further comprise a shaft manifold configured to connect to the distal manifold, the shaft manifold having an irrigation lumen for directing irrigation fluid to the conduits of the distal manifold.

[0020]

[0019] The nozzle may include a distal face having rounded or curved edges. The aspiration lumen may be offset from a center of the nozzle. The nozzle may include at least one conduit for providing a fluid path between the catheter and the irrigation port. The at least one conduit may include a partition for directing fluid to the irrigation port.

[0021] According to one aspect of the present invention, there is provided a kidney stone removal system comprising an aspiration tube and a laser guide configured to be removably inserted into the aspiration tube, the laser guide comprising a tubular body having an inner lumen configured to receive a laser device, and wings extending from the distal end segment of the tubular body for guiding the distal end segment of the tubular body within the aspiration tube and creating a flow gap between the tubular body and the aspiration tube.

[0022] In one embodiment, the tubular body is configured so as not to extend beyond the distal end of the suction tube when the tubular body is fully inserted into the suction tube and placed in the operative position. In one embodiment, the guide comprises two to four wings. In one embodiment, the guide comprises three or four wings, and the circumferential distance is the same between each pair of adjacent wings. In one embodiment, the guide comprises three or four wings, and the circumferential distance between a first pair of adjacent wings is different from the circumferential distance between a second pair of adjacent wings. The first and second pairs of adjacent wings may share a common wing. In some embodiments, at least two of the gaps have different sizes.

[0023] In one embodiment, each wing includes an intermediate segment having a rectangular shape that transitions to a tapered end segment that tapers down into the tubular body. In some embodiments, each wing has a variable thickness that increases along the longitudinal axis from the proximal end of the wing to the distal end of the wing. In some embodiments, each wing has a longitudinal axis that is at an angle relative to the longitudinal axis of the tubular body.

[0024]

[0023] In accordance with another aspect of the present invention, the kidney stone removal system further comprises an actuator for moving the tubular body within the suction tube. In one embodiment, the actuator comprises a biasing element and a shaft coupled to the tubular body, the shaft being adapted to move the tubular body back and forth within the suction tube upon actuation of the biasing element. In one embodiment, the shaft is configured to be removably coupled to the proximal end of the tubular body. In an alternative embodiment, the shaft is permanently attached to the proximal end of the tubular body.

[0025] In one embodiment, the biasing element comprises a band coupled to a distal section of the shaft. The actuator may further comprise a cylindrical housing coupled to the band and configured to receive the shaft, such that inward compression and release of the band telescopically moves a portion of the shaft in and out of the cylindrical housing. The actuator comprises a channel for receiving the laser device. The channel is configured to communicate with the lumen of the tubular body.

[0026] According to another aspect of the present invention, a catheter assembly is provided that includes an aspiration tube and a guide device configured to be removably positioned within the aspiration tube to receive a debris-breaking device. The guide device is configured to allow fluid and debris to pass through the break-up device and through the aspiration tube while preventing unintended movement of the break-up device when the break-up device is positioned at the distal end of the aspiration tube. The catheter system may further include an actuation device for moving the guide device within the aspiration tube to remove debris. The break-up device may be a laser fiber.

[0027] According to another aspect of the present invention, there is provided a method of removing kidney stones using any of the embodiments of the present invention. According to one aspect of the present invention, there is provided a method of removing kidney stones comprising operating a kidney stone removal mechanism as described above and herein.

[0028] Aspects of the present invention will now be described in detail with reference to the accompanying drawings, which are not drawn to scale. [Brief description of the drawings]

[0029] [Figure 1] FIG. 1 is a schematic perspective view of a kidney stone treatment system, according to one embodiment. [Diagram 2] FIG. 1 illustrates a perspective view of a kidney stone removal mechanism, according to one embodiment. [Diagram 3] FIG. 3 is a rear view of the mechanism shown in FIG. 2. [Figure 4] FIG. 3 is a side view of the mechanism shown in FIG. 2. [Diagram 5] FIG. 3 is a front view of the mechanism shown in FIG. 2. [Figure 6] FIG. 13 is an exploded view of a trigger actuation mechanism, according to one embodiment. [Figure 7] FIG. 2 illustrates one position of a trigger, according to one embodiment. [Figure 8] 11A-11C illustrate successive alternative positions of the trigger according to one embodiment. [Figure 9] 11A-11C illustrate further sequential positions of the trigger according to one embodiment. [Figure 10] FIG. 13 is an opposite view of the trigger actuation mechanism, according to one embodiment. [Figure 11] 1A-1C illustrate one position of a trigger in a trigger actuation mechanism according to one embodiment. [Figure 12] 11A-11C illustrate successive alternative positions of a trigger in a trigger actuation mechanism according to one embodiment. [Figure 13] 1A-1C illustrate one position of a trigger in a trigger actuation mechanism according to one embodiment. [Figure 14] 11A-11C illustrate successive alternative positions of a trigger in a trigger actuation mechanism according to one embodiment. [Figure 15] FIG. 1 illustrates a trigger actuation mechanism, according to one embodiment. [Figure 16] FIG. 1 illustrates a front view of a kidney stone removal mechanism of one embodiment. [Figure 17] FIG. 1 illustrates a side view of a kidney stone removal mechanism of one embodiment. [Figure 18] FIG. 13 is a rear view of an embodiment of a kidney stone removal mechanism. [Figure 19] FIG. 2 illustrates one position of a trigger, according to one embodiment. [Figure 20] 11A-11C illustrate successive alternative positions of the trigger according to one embodiment. [Figure 21] 11A-11C illustrate further sequential positions of the trigger according to one embodiment. [Figure 22]FIG. 22 is an enlarged perspective view of the trigger and distal tip control mechanism of FIGS. 16-21. [Diagram 23] FIG. 13 is an exploded view of a trigger mechanism, according to one embodiment. [Figure 24] FIG. 24 is an assembly view of the trigger mechanism of FIG. 23. [Diagram 25] 1A-1C illustrate one position of a trigger mechanism according to one embodiment. [Figure 26] 11A-11C illustrate successive alternative positions of the trigger mechanism according to one embodiment. [Figure 27] 11A-11C illustrate successive alternative positions of the trigger mechanism according to one embodiment. [Figure 28] FIG. 1 illustrates a kidney stone treatment system, according to one embodiment. [Figure 29] FIG. 29 shows a portion of the kidney stone removal mechanism of FIG. 28. [Diagram 30] FIG. 1 illustrates a portion of a kidney stone removal mechanism, according to one embodiment. [Diagram 31] FIG. 31 illustrates one location of a trigger within the structure of FIG. 30, according to one embodiment. [Diagram 32] 31A-31C show successive alternative positions of the trigger within the structure of FIG. 30, according to one embodiment. [Diagram 33] 31A-31C illustrate further sequential positions of the trigger within the structure of FIG. 30, according to one embodiment. [Diagram 34] 31A-31C show further sequential positions of the trigger within the structure of FIG. 30 according to one embodiment. [Diagram 35] FIG. 1 is a schematic diagram of an aspiration / evacuation control system and method, according to one embodiment. [Diagram 36] FIG. 1 is a schematic diagram of an aspiration / evacuation control system and method, according to one embodiment. [Figure 37] 1A-1C illustrate one position of a trigger in a trigger actuation mechanism according to one embodiment. [Figure 38] 11A-11C illustrate successive alternative positions of a trigger in a trigger actuation mechanism according to one embodiment. [Figure 39]FIG. 13 illustrates a flow bypass structure of the mechanism, according to one embodiment. [Diagram 40] 1 is a cross-sectional view of a flow bypass structure of the mechanism according to one embodiment. [Diagram 41] 1 is a cross-sectional view of a flow bypass structure of the mechanism according to one embodiment. [Diagram 42] 1 is a cross-sectional view of a flow bypass structure of the mechanism according to one embodiment. [Diagram 43] FIG. 1 illustrates a kidney stone removal mechanism, according to one embodiment. [Diagram 44] FIG. 13 is a rotated, close-up view of a portion of a kidney stone removal mechanism, according to one embodiment. [Diagram 45] FIG. 1 is an exploded view of a stone capture assembly, according to one embodiment. [Diagram 46] FIG. 1 is a diagram of a flow director mechanism, according to one embodiment. [Figure 47] FIG. 13 is another view of a flow director mechanism, according to one embodiment. [Figure 48A] FIG. 1 is a perspective view of a distal assembly, according to one embodiment. [Figure 48B] FIG. 1 is a perspective view of a distal assembly, according to one embodiment. [Figure 49A] FIG. 1 is a perspective view of a distal assembly, according to one embodiment. [Figure 49B] FIG. 1 is a perspective exploded view of a distal assembly, according to one embodiment. [Figure 50A] FIG. 13 is an end view of a distal assembly, according to one embodiment. [Figure 50B] FIG. 13 is an end view of a distal assembly, according to one embodiment. [Figure 50C] FIG. 13 is an end view of a distal assembly, according to one embodiment. [Figure 51A] FIG. 2 illustrates a nozzle tip according to one embodiment. [Figure 51B] FIG. 13 illustrates a nozzle tip according to another embodiment. [Figure 52A] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 52B]FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 53A] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 53B] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 54A] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 54B] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 55A] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 55B] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 56] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 57] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 58A] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 58B] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 59A] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 59B] FIG. 13 illustrates a nozzle tip according to yet another embodiment. [Figure 60] FIG. 1 illustrates a distal assembly, according to one embodiment. [Figure 61] FIG. 1 illustrates a distal assembly, according to one embodiment. [Figure 62A] FIG. 1 illustrates one embodiment of a nozzle tip of the distal assembly. [Figure 62B] FIG. 1 illustrates one embodiment of a nozzle tip of the distal assembly. [Figure 62C] FIG. 1 illustrates one embodiment of a nozzle tip of the distal assembly. [Figure 63A] FIG. 1 is a schematic diagram of a test apparatus for measuring the affected area of ​​a nozzle tip design. [Figure 63B] 13 is a photograph of test results of nozzle tip designs when measuring affected area. [Figure 64] FIG. 1 is a cross-sectional view of a section of a catheter shaft assembly. [Figure 65] FIG. 2 is a partial perspective view of one embodiment of a guide. [Figure 66] FIG. 13 is a front view of one embodiment of a guide. [Figure 67] FIG. 13 is a schematic front view of one embodiment of a guide disposed inside a suction tube. [Figure 68] FIG. 13 is a schematic diagram of a distal section of one embodiment of a guide. [Figure 69A] FIG. 13 is a top view showing one embodiment of wings or extensions for a guide. [Figure 69B] FIG. 13 is a top view showing another embodiment of wings or extensions for a guide. [Figure 70] FIG. 2 is a partial side view of one embodiment of a guide. [Figure 71A] FIG. 13 is a perspective view of one embodiment of an actuator for actuating a guide. [Figure 71B] FIG. 2 illustrates a top view of one embodiment of an actuator. [Figure 72] FIG. 2 is a perspective view of one embodiment of an actuator. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0030]

[0080] Disclosed herein are systems, devices, and methods for guided removal of objects in vivo. In particular, the systems, devices, and methods may be adapted to pass through a compact area, such as the urinary tract, and remove debris, such as kidney stones or kidney stone fragments, by suction through a suction tube. As used herein, the term "kidney stone" may refer to kidney stone fragments, including fragments resulting from therapeutic fragmentation of a kidney stone, such as with a device described herein or by another device.

[0031]

[0081] FIG. 1 illustrates an embodiment of a treatment system 10 used to remove debris, such as kidney stones. The system 10 includes a handle mechanism 12 from which a catheter 14 extends. The system 10 includes a handle mechanism 12 from which a catheter 14 extends. In the embodiments described below, the handle 12 may be configured to provide a single trigger design that includes or consists of two modes, for example, active perfusion mode only (i.e., active perfusion on / suction off) and active perfusion mode in combination with aspiration mode (i.e., active perfusion on / suction on). In the embodiments described below, the handle 12 may be configured to provide a single trigger design that includes or consists of three modes, for example, passive perfusion on / active perfusion off / suction off, passive perfusion on / active perfusion on / suction off, and passive perfusion on / active perfusion on / suction on. In one embodiment, a minimal amount of negative pressure may be present even in the mode where aspiration is off. In some aspects of the flow design, an uninterrupted conduit between the end of the device and the aspiration source is achieved such that there is high flow when aspiration is activated and minimal or no flow when aspiration is not activated. The catheter 14 can include various ports and lumens, including an aspiration lumen and an irrigation lumen that runs along the length of the catheter 14. The system 10 can also include a camera (digital visualization and illumination, e.g., video chip and LED) located at the end, distal face, or distal portion of the catheter 14 to provide real-time imaging to the physician. A distal assembly 16 is at the distal end of the catheter 14 for irrigation and removal of debris with the aid of negative pressure applied through the aspiration lumen. The handle mechanism 12 allows the physician to hold and manipulate the system 10. The handle mechanism 12 can include features that allow the surgeon to manipulate various functions of the system, including the camera, the aspiration pressure, the amount of irrigation and irrigation pressure, and the ability to manipulate the catheter 14.For example, the handle mechanism 12 may include mechanical and electronic controls that allow the physician to adjust the amount of negative pressure, regulate the drainage of irrigation fluid, and steer the catheter through tortuous anatomical passages using wheels and / or levers attached to a cable, as is well known in the art. The system 10 may be coupled to a control unit 18 via a connector 20. The control unit 18 may control or help control aspects of the operation of the system 10. For example, the control unit 18 may control or help control visualization aspects of the system 10. The connector 20 may be a wired and / or wireless connection.

[0032]

[0082] Handle mechanism FIG. 2 illustrates a handle mechanism 12 for performing kidney stone removal, according to one embodiment. A finger grip portion 22 extends a portion of the length of the mechanism 12. An optional shelf portion 24 is located where a user's hand rests when the user grips the mechanism 12. Above the optional shelf portion 24 is a trigger 26, which is part of a trigger mechanism, described below. The trigger mechanism controls the aspiration (or suction) and airflow, and also controls the irrigation operation of the mechanism 12. A user can operate the trigger 26 with one of the user's fingers. A distal tip steering control 28 is located at a proximal end portion of the mechanism 12. The user's thumb can control the positioning and / or steering of the distal tip of the catheter by manipulating a lever 30. Various types of catheters may be used with the mechanism 12, including, but not limited to, those shown and described in U.S. Pat. No. 11,116,530. The '530 patent shows and describes one or more pull wires that can steer the distal tip of the catheter by manipulation of a lever 30 to which the one or more pull wires can be attached. Figure 2 also shows the suction / aspiration port 32 and irrigation port 34, as well as the catheter strain relief 36. A stone capture receiver 38 receives extracted kidney stones and / or fragments via port 40. An access or working channel port 42 allows access to the catheter (not shown) to allow for insertion of a treatment instrument, such as a laser, into the distal end of the catheter.

[0033]

[0083] FIG. 3 shows a rear view of the handle mechanism 12. In FIG. 3, the suction port 32, irrigation port 34, and catheter strain relief 36 are shown, as is the stone capture receptacle 38 and distal tip steering control 28. FIG. 4 shows a side view of the mechanism 12. In FIG. 4, many of the same elements as in FIG. 2 are shown. The finger grip portion 22 has a shelf portion 24 located above it to accommodate a user's hand over an access or working channel port 42. The suction port 32, irrigation port 34, and catheter strain relief 36 are behind the stone capture receptacle 38 and are located at the bottom of the mechanism 12. Also shown is a port 40 for depositing a kidney stone, or a fragment or portion of a kidney stone, into the stone capture receptacle 38. In FIG. 5, which is a front view of the mechanism 12, many of the same elements as in FIG. 2 are shown. The finger grip portion 22 has a shelf portion 24 located above it to accommodate a user's hand over an access or working channel port 42. The catheter strain relief 36 is behind the stone catch receptacle 38 and is located at the bottom of the mechanism 12. A port 40 is also shown for depositing the kidney stone, or portions of the kidney stone, into the stone catch receptacle 38.

[0034]

[0084] FIG. 6 is an exploded view of a portion of the top of the mechanism 12. The parts in FIG. 6 together form the trigger mechanism assembly 44. From top to bottom in FIG. 6, a screw or bolt 46 passes through a washer 48 and an opening 50 in a trigger mechanism 52. The trigger mechanism 52 includes protrusions 54, 56, and 58. The function of these protrusions during actuation of the trigger mechanism 52 is described in more detail below with reference to FIGS. 7-9. The screw or bolt 46 also passes through a spring 60 or other resilient device and is received by a screw / bolt receiving portion 62. In some examples, the bolt 46 holds the trigger tightly against a base plate boss that captures the spring 60. The spring 60 provides resilience to the trigger mechanism 52 such that when the user releases or removes pressure from the trigger 26, the trigger mechanism 52 returns to its original home position. The spring 60 or other resilient device is located within an opening 64 in a mechanism casing or body 66. The mechanism body 66 also includes a first detent 68 and a second detent 70, the functions of which are described in more detail below with respect to Figures 7-9. In some examples, the mechanism body 66 may include more or fewer detents. When the handle mechanism 12 is assembled, the mechanism casing 66 is not visible. In Figure 6 and subsequent figures, the mechanism casing 66 is exposed to facilitate illustrating the function of the trigger mechanism 52. An irrigation tube (not shown) enters through opening 72, passes under the covered portion 76 through opening 74, and exits through opening 78. An aspiration actuation tube (not shown) is located inside the mechanism casing 66 and exits through opening 80.

[0035]

[0085] Proceeding to Figures 35 and 36, there is shown a schematic diagram of the suction / aspiration control system and method 82. The suction outlet tube 84 includes a suction opening 86 that is connected to a suction / aspiration source (not shown). Flow through the suction outlet tube 84 is in the direction of arrow S. The suction target tube 88 includes a target opening 90 that is connected to a portion of the device near the area that is to be suctioned / aspirationed. Figure 36 shows a configuration in which flow through the suction target tube 88 is in the direction of arrow T. The actuation tube 92 includes an actuation opening 94 that is open to the surrounding atmosphere. An actuation pinch mechanism 96 is disposed next to the actuation tube 92 and is movable in the direction of arrow P from a first position (shown in Figure 35) that allows flow through the actuation tube 92 in the direction of arrow B and a second position (shown in Figure 36) that prevents flow through the actuation opening 94 through the actuation tube 92. The system and method 82 shows that the actuation pinch mechanism 96 allows for control of the suction / aspiration flow. A suction source (not shown) may be positioned to provide a fixed amount of suction (e.g., 200 mmHg), and the actuation pinch mechanism 96 provides on / off control of suction / aspiration by opening or closing the actuation tube 92. In the configuration shown in FIG. 35, the actuation pinch mechanism 96 is positioned so that air flows through the actuation tube 92 in the direction of arrow B, through the suction outlet tube 84 in the direction of arrow S, and is exhausted to the suction / aspiration source. In the configuration shown in FIG. 35, there is little or no flow from the target area through the suction target tube 88 toward the suction outlet tube 84. In the configuration shown in FIG. 35, there is no (or relatively little) suction applied to the target area, and suction is off at the target area. In the configuration shown in FIG. 36, the actuation pinch mechanism 96 is positioned so that no air flows through the actuation tube 92. In the configuration shown in FIG. 36, all flow is from the target area through the suction target tube 88 in the direction of arrow T toward the suction outlet tube 84, and is exhausted out of the suction opening 86 in the direction of arrow S. In the configuration shown in FIG. 36, suction is on in the area of ​​interest.

[0036]

[0086] 7-9 show successive positions of the trigger 26. In FIG. 6, the trigger 26 is in a non-depressed position. When the trigger 26 is in that position, the suction and irrigation in the handle mechanism 12 are turned off. In some examples, an irrigation bypass structure may allow a minimal amount of irrigation to flow even when the trigger 26 is in a non-depressed position. The protrusion 54 pinches the irrigation tube 98. The protrusion 56 is not in contact with the detent 68. The protrusion 58 may contact the suction actuation tube 100 but does not compress the suction actuation tube 100 (see, for example, FIG. 35 and also the actuation tube 92 in FIG. 35). The suction actuation tube 100 is open to the ambient air at one end and is connected at the end 102 to the suction tube tissue that extends from the suction source to the suction lumen that extends to the area to be suctioned. A spring 60 or other resilient device resiliently engages the trigger mechanism 52 such that when the user releases the trigger 26, the trigger 26 returns to its initial position so that irrigation and suction are turned off. In some embodiments, when the trigger 26 returns to its initial position, irrigation is partially on at a minimum level and suction is off. In FIG. 8, the trigger 26 is partially depressed to the point where the protrusion 56 contacts a detent 68 in the mechanism body 66, indicating to the user that the first stopping point in the operation has been reached. When the trigger 26 is in this position, the protrusion 54 partially disengages the irrigation tube 98, opening the irrigation tube 98 slightly and allowing some irrigation (or, in some embodiments, complete irrigation flow). Although the protrusion 58 partially closes the suction activation tube 100, air can still flow through the suction activation tube 100 so that suction in the area of ​​interest is still off. In FIG. 9, the trigger 26 is fully depressed. The protrusion 56 advances past the detent 68 and engages with the detent 70. In this position, the protrusion 58 pinches the suction actuation tube 100, thereby turning on suction in the area of ​​interest. The protrusion 54 further opens the irrigation tube 98 so that irrigation can continue and remove and deposit kidney stones and / or kidney stone fragments in the stone capture receptacle 38 (FIGS. 2-5). FIG. 10 shows a view of the mechanism body 66 from the opposite side to that shown in FIGS. 7-9. The irrigation tube 98 has an inlet 104 and an outlet 106. The actuation tube 100 extends through the mechanism body 66.The trigger 26 has protrusions (not shown) that interact with the irrigation tube 98 and the actuation tube 100 depending on the degree of depression of the trigger 26. In the above description of the kidney stone removal mechanism, the functions of the inlet 104 and outlet 106 can be reversed, so that element 104 acts as an irrigation outlet and element 106 acts as an irrigation inlet.

[0037]

[0087] FIG. 11 shows a portion of a kidney stone removal mechanism 108, according to one embodiment. A mechanism casing or body 110 includes an irrigation tube 112 having an irrigation inlet 114 and an irrigation outlet 116. A trigger 118 has a protrusion 120 that interacts with the irrigation tube 112. When the trigger 118 is not depressed, the protrusion 120 closes or at least contracts the irrigation tube 112, as shown in FIG. 11. A spring 122 or other resilient device moves against the force of a user depression of the trigger 118 to return the trigger 118 to a non-depressed state when the user releases the trigger 118. When depressed, the trigger 118 rotates about a pivot point 124, moving the protrusion 120 away from the irrigation tube 112, opening the tube and allowing irrigation. FIG. 12 shows a structure similar to that of FIG. 11, except that in FIG. 12 the trigger 118 is depressed, resulting in the protrusion 120 moving away from the irrigation tube 112 to open the irrigation tube. FIG. 13 shows a structure similar to that of FIG. 11, but from the opposite side of the mechanism body 110. The trigger 118 is in the same position in FIG. 13 as in FIG. 11. When the trigger 118 is in this position, the suction tube (not shown) at position 126 is not pinched, resulting in the suction or aspiration being turned off. Comparing FIG. 13 to FIG. 11, when the suction or aspiration is off, the irrigation is also off. FIG. 14 shows a structure similar to that of FIG. 13, except that in FIG. 14 the trigger 118 is depressed, resulting in the suction tube (not shown) at position 126 being pinched, resulting in the suction or aspiration being turned on. Comparing FIG. 14 to FIG. 12, when the suction or aspiration is on, the irrigation is also on, as in the other described embodiments.

[0038]

[0088] Unlike the embodiment of Figures 7-9, Figures 11-14 do not show intermediate depression positions of the trigger 118. However, one skilled in the art will appreciate that the kidney stone removal mechanism 108 allows for various depression positions of the trigger 118. Thus, similar to the embodiment of Figures 7-9, there is an intermediate depression of the trigger 118, whereby the irrigation tube 112 is not pinched slightly, allowing irrigation to flow, while the aspiration tube (not shown) is pinched slightly, so that suction or aspiration is still off.

[0039]

[0089] FIG. 15 is a photograph of a portion of a kidney stone removal mechanism 108, similar to the structure in FIG. 11, according to one embodiment. The mechanism body 110 includes an irrigation tube 112 having an irrigation inlet 114 and an irrigation outlet 116. A trigger 118 has a protrusion 120 that interacts with the irrigation tube 112. When the trigger 118 is not depressed, the protrusion 120 closes or at least contracts the irrigation tube 112, as shown in FIG. 15. A spring 122 or other resilient device moves against the force of a user depression of the trigger 118 to return the trigger 118 to a non-depressed state when the user releases the trigger 118. When depressed, the trigger 118 rotates about a pivot point 124, moving the protrusion 120 away from the irrigation tube 112, opening the tube and allowing irrigation. The trigger 118 is in the same position in FIG. 15 as in FIG. 13. When trigger 118 is in this position, the aspiration tube (not shown) at position 126 is not pinched, so that aspiration or suction is off. When aspiration or suction is off, irrigation is also off. In the above description, the functions of inlet 114 and outlet 116 can be reversed, in which case element 114 acts as an irrigation outlet and element 116 acts as an irrigation inlet.

[0040]

[0090] 16-22 show a kidney stone removal mechanism 128 according to one embodiment. A finger grip portion extends a portion of the length of the mechanism. A trigger mechanism 130 is located at the proximal end of the kidney stone removal mechanism 128. A distal tip steering mechanism 132, also located at the proximal end of the kidney stone removal mechanism 128, allows manipulation of the catheter, and in particular the distal end of the catheter, to position the distal end as desired for breaking up and / or removing the kidney stone. The catheter is connected to a catheter strain relief 134. A stone capture receiver 136 receives the removed kidney stone and / or its fragments. A working channel port 138 allows access to the catheter for insertion of devices and instruments. In FIG. 16, which shows a front view of the kidney stone removal mechanism 128, there is a more detailed view of the catheter strain relief 134. There is also a front view of the stone capture receiver 136. An access or working channel port 138 allows access to the catheter to allow a therapeutic tool, such as a laser, to be inserted into the distal end of the catheter. FIG. 16 also shows a front view of the trigger 130 and a side view of the distal tip steering mechanism 132. FIG. 17 shows a side view of the kidney stone removal mechanism 128. The aspiration outlet 140 and irrigation inlet 142 can be seen, as can the catheter strain relief 134, the stone catch receptacle 136, and the finger grip 143. In FIG. 18, which shows a rear view of the kidney stone removal mechanism 128, the aspiration outlet 140 and irrigation inlet 142 can be seen, as can the catheter strain relief 134. The distal tip steering mechanism 132 can also be seen. FIGS. 19-21 show enlarged views of successive positions of the trigger 130 of the kidney stone removal mechanism 132, from an undepressed state in FIG. 19 to a fully depressed state in FIG. 21. FIG. 22 shows a perspective side view of FIGS. 19-21.

[0041]

[0091] FIG. 23 shows an exploded view of the trigger mechanism assembly 144, according to one embodiment. A bolt 146 and a washer 148 pass through a slot 150 in the trigger mechanism 152. An irrigation tube 154 has an irrigation inlet 166 and an irrigation outlet 168. A spring 156 biases the trigger 158 to a non-depressed position. A pivot 160 receives the trigger mechanism 152 by passing through a hole 162 in the trigger mechanism 152. When a user actuates the trigger 158, the trigger mechanism 152 rotates about the pivot 160. An opening 164 leads to an aspiration outlet (not shown). FIG. 24 shows an assembled version of the trigger mechanism of FIG. 23. Elements previously described with respect to FIG. 23 are designated with the same reference numbers in FIG. 24.

[0042]

[0092] 25-27 show successive positions of the trigger 158 for the trigger mechanism 144, from undepressed in FIG. 25 to fully depressed in FIG. 27, along with the corresponding movements of the associated parts. In FIG. 25, the trigger 158 is in a normal position, which results from a bias applied by the spring 156 or other resilient device (shown in the previous figure). A roller 167 is mounted on a pin 169 at one end of a bar or lever 170. At the other end 172 of the bar or lever 170 is a mount 174 to which the bar or lever 170 is attached. In this configuration, the bar or lever 170 pivots about the mount 174 when the trigger 158 is depressed. Also in FIG. 25, the roller 167 is positioned away from the opening 164 leading to the aspiration outlet (not shown). The roller 167 depresses the irrigation tube 154, blocking irrigation. Thus, in the trigger position shown in FIG. 25, both irrigation and suction are turned off. FIG. 25 further shows protrusions 176 and 178, the function of which will be described with reference to FIGS. 26 and 27. FIG. 26 shows an intermediate position of trigger 158, with a corresponding intermediate position of roller 167 closer to opening 164. Depression of trigger 158 causes bar or lever 170 to rotate about mount 174. Depressing trigger 158 to the extent shown in FIG. 26 brings roller 167 into contact with protrusion 178, providing greater resistance and communicating to the user that trigger 158 is in the intermediate position. In this position, roller 167 exerts less pressure on irrigation tube 154. Thus, in the trigger position shown in FIG. 26, suction is still turned off, but irrigation begins to be turned on. FIG. 27 shows the fully depressed position of trigger 158. In this position, the user depresses trigger 158, causing roller 167 to ride over protrusion 178, covering opening 164 and moving further away from irrigation tube 154. Roller 167 moves up against protrusion 176, indicating to the user that trigger 158 is fully depressed. In this position, both suction and irrigation are turned on so that kidney stones and / or kidney stone fragments may be removed.

[0043]

[0093] FIG. 28 illustrates a mechanism 180 for kidney stone removal according to one embodiment. In FIG. 28, a user may employ a distal tip steering control 182 to position and / or steer a catheter 184 to perform the appropriate maneuver to break up and / or remove a kidney stone. One or more pull wires (not shown) facilitate positioning and / or steering of the catheter 184. User control of a trigger 186 controls operation of a trigger mechanism, further described herein, to control aspiration and irrigation through the catheter 184. A handle portion 188 is sized for a user to hold the mechanism 180, with the user's thumb operating the distal tip steering control 182 and one of the user's fingers operating the trigger 186. Alternatively, the user's thumb may operate the trigger 186 and the user's finger may operate the distal tip steering control 182. Also in FIG. 28, a port 190 connects to a suction source (not shown). The catheter 184 is attached to a catheter strain relief 192. In one embodiment, a port 194 provides access to a working channel in the catheter 184 to facilitate insertion of a therapeutic tool, such as a laser, into the distal end of the catheter 184. Figure 29 shows a close-up view of the distal tip steering control 182, trigger 186, and the top of the handle portion 188.

[0044]

[0094] FIG. 30 shows an example of a trigger mechanism that may be used in the embodiments of FIGS. 28 and 29. An irrigation tube 196 has an inlet 198 connected to an irrigation source to irrigate a desired area, and an outlet 200 connected to a distal tip (not shown). A post 202 is positioned and sized to hold the distal tip steering control 182, which may be attached to the post 202 by one or more pins (also not shown) that pass through holes 204 in the post 202. As part of the distal tip steering control 182, pull wires (not shown) may be provided to guide the movement and position of the tip to perform the appropriate actions to steer the distal tip of the catheter to the proper position for a kidney stone removal procedure. Depression of the trigger 186 causes rotation of the trigger 186 about the pivot pin 206, which moves a roller 208 attached via a pin 210 from the position shown to a position covering a port 212 that communicates with ambient air via an actuation tube (not shown). That is, covering the port 212 functions similarly to the actuating pinch mechanism 96 of Figures 35 and 36 in that there is no flow from the ambient air to the suction source when the port 212 is covered. When the port 212 is uncovered, suction is off in the area of ​​interest. When the port 212 is covered, suction is on in the area of ​​interest.

[0045]

[0095] 31-34 show the progressive depression of the trigger 186. In these figures, for ease of illustration, the post 202 remains in the same position, i.e., the distal tip steering control 182 is not manipulated. FIG. 31 shows the trigger 186 in the undepressed position. In this position, the roller 208 closes or at least restricts the irrigation tube 196 while the port 212 is open. The roller 208 is positioned away from the contact edge 214. This position corresponds to both aspiration and irrigation being off. In FIG. 32, the initial depression of the trigger 186 causes the trigger 186 to rotate slightly to the right about the pivot pin 206, causing the roller 208 to move slightly upward and to the right. In this position, the irrigation tube 196 is further opened, allowing irrigation of the area being treated. This positioning of the trigger 186 corresponds to an irrigation only state, where the suction is still off due to the port 212 remaining open. In FIG. 33, further depression of the trigger 186 causes it to rotate slightly more to the right about the pivot pin 206, causing the roller 208 to move slightly more upward and to the right. With the roller 208 in this position, the port 212 remains open, so suction is still off. The irrigation tube 196 is less compressed, allowing further irrigation of the affected area. In this position, the roller 208 contacts the edge 214, which, according to one embodiment, acts as a detent. When the roller 208 contacts the edge 214, the user is alerted by encountering resistance to the depression of the trigger 186. In FIG. 34, when the user overcomes the resistance at the edge 214 and further depresses the trigger 186, the trigger 186 rotates further upward and to the right until the roller 208 covers the port 212. At this point, the roller 208 becomes stuck in the recess 216 and cannot move any further. In this way, the user is aware that the trigger depression is at a maximum. When trigger 186 is in this position, irrigation remains on and suction is turned on by closing port 212 (eg, performing as described in Figures 35 and 36).

[0046]

[0096] 37 and 38 show one embodiment of the mechanism 218 including a perfusion bypass structure 220 that functions to always provide a minimum perfusion flow through the mechanism. The perfusion bypass structure 220 may be implemented in any of the embodiments disclosed above and is not limited to the mechanism 218. FIG. 37 and 38 show a mechanism head 222 having protrusions 224, 226, and 228 that functions as disclosed in other embodiments herein to control irrigation and aspiration / aspiration using a single trigger 230. In some cases, a user may wish to maintain a minimum perfusion flow through the mechanism 218 without actuating the trigger 230. In some embodiments of the mechanism disclosed herein, the protrusions 224 may be implemented such that they do not completely occlude the perfusion tube in which they are placed. While such an implementation may be appropriate in some cases, in other cases, it may not provide a well-defined minimum flow rate. That is, the degree of incomplete occlusion of the perfusion tube may vary more than desired. 37 and 38 provide an embodiment that can provide a more clearly defined minimum perfusion flow via the perfusion bypass structure 220 than partial occlusion of the perfusion tube.

[0047]

[0097] FIG. 37 shows the flow path FP of most of the perfusion fluid flow from the inlet 232 through the perfusion tube 234 until the protrusion 224 pinches the perfusion tube 234 and closes it, stopping its flow. A lower amount of perfusion fluid flows from the inlet 232 through the perfusion bypass structure 220 to the outlet 236 connected to the distal end of the stone removal device. Thus, in this embodiment, at least some perfusion flows to the distal end of the stone removal device at all times. FIG. 38 shows a configuration in which the trigger 230 is depressed, which moves the protrusion 224 away from the perfusion tube 234, opening the perfusion tube 234. When the perfusion tube 234 is open, the perfusion fluid can flow along the flow path FP from the inlet 232 through the mechanism head 222 to the outlet 236. Some small amount of perfusion fluid may still flow through the bypass structure 220, but most of the perfusion fluid flows through the mechanism head 22.

[0048]

[0098] FIG. 39 illustrates a perfusion bypass structure 220 having an inlet tube 238 and an outlet tube 242. The inlet tube 238 defines an inlet lumen 240 that connects the inlet 232 with the supply outlet 236. The outlet tube 242 defines an outlet lumen 244 that connects the return inlet 246 with the outlet 236. Irrigation tubing (not shown) connects the supply outlet 236 with the return inlet 246 and carries perfusion fluid through the mechanism head and trigger actuation mechanism of the various embodiments disclosed herein. The inlet tube 238 is connected to the outlet tube 242 by a bypass 250 that includes a pair of bypass tubes 252 connected by a bypass connector 254. Although FIG. 39 illustrates the bypass tubes 252 as hose barbs and the bypass connector 254 as tubing, other equivalent configurations of similar structures may be used. The bypass 250 includes a flow restriction 256, which is a narrow lumen (narrower than the diameter of the inlet lumen 240) that limits the amount of perfusion fluid that can flow through the bypass 250. In FIG. 39, two flow restriction 256 are shown because, for manufacturing efficiency, it may be desirable to manufacture two of the same parts and connect them via connector 254 to form the perfusion bypass structure 220, but a single flow restriction 256 may be sufficient to provide the functionality of the perfusion bypass structure 220 disclosed herein. In some embodiments, the inner diameter of the flow restriction 256 may be about 5% to about 30% of the inner diameter of the inlet lumen 240, and in some embodiments may be within a range of about 20% of the inner diameter of the inlet 240. For example, when the inner diameter of the inlet lumen 240 is about 2.5 mm, the inner diameter of the flow restriction 256 may be about 0.5 mm. Other specific inner diameters within the disclosed percentage ranges are within the range of the bypass structure. Because flow rate varies as the fourth power of diameter, the ratio of the inner diameter of the flow restriction 256 to the inner diameter of the inlet lumen 240 directly affects the distribution of flow rate through the trigger mechanism and bypass structure. Other factors such as surface tension and pressure drop can affect the degree to which flow rate is governed by this power law relationship.

[0049]

[0099] FIG. 40 illustrates an alternative embodiment perfusion bypass structure 258 in cross section defined by a plane along line C in a similar embodiment of the perfusion bypass structure 220. This bypass structure may be implemented in any of the embodiments disclosed above. The perfusion bypass structure 258 includes an inlet tube 260 defining an inlet lumen 262 and an outlet tube 264 defining an outlet lumen 266. These lumens are connected by an irrigation tube (not shown) that carries irrigation fluid through the mechanism head and trigger actuation system disclosed herein. FIG. 40 illustrates that the inlet lumen 262 and the outlet lumen 266 are also connected by a bypass 268 formed by a first bypass fitting 270 and a second bypass fitting 272. The first bypass fitting 270 and the second bypass fitting 272 connect via complementary features and form a fluid-tight seal via an O-ring 274. When connected, the first bypass fitting 270 and the second bypass fitting 272 form a conduit for fluid bypass that includes a flow restriction 276 having a narrower lumen than the inlet lumen 262. The perfusion bypass structure 258 thus functions to provide a well-defined minimum perfusion flow rate when the perfusion tube in the mechanism head is closed by the trigger mechanism.

[0050]

[0100] FIG. 41 shows another alternative embodiment perfusion bypass structure 278 in cross section defined by a plane along line C in similar perfusion bypass structure 220 and 258 embodiments. This bypass structure may be implemented in any of the above disclosed embodiments. The perfusion bypass structure 278 includes an inlet tube 280 defining an inlet lumen 282 and an outlet tube 284 defining an outlet lumen 286. These lumens are connected by an irrigation tube (not shown) that carries irrigation fluid through the mechanism head and trigger actuation system disclosed herein. FIG. 41 shows that the inlet lumen 282 and the outlet lumen 286 are also connected by a bypass 288 formed by a first bypass fitting 290 and a second bypass fitting 292. The first bypass fitting 290 and the second bypass fitting 292 connect via complementary features and form a fluid tight seal via a compressible member 294, which is formed of a resilient flexible material and includes an internal flow restriction 296. The compressible member 294 is similar in shape or function to an O-ring or grommet in that it provides a fluid tight seal, but the compressible member also provides an internal lumen in the form of the flow restriction 296 that assumes a predetermined diameter when the first bypass fitting 290 and the second bypass fitting 292 are connected. This predetermined diameter of the flow restriction 296 is narrower than the diameter of the inlet lumen 282. The perfusion bypass structure 278 thus functions to provide a well-defined minimum perfusion flow rate when the perfusion tube in the mechanism head is closed by the trigger mechanism.

[0051]

[0101] FIG. 42 shows another alternative embodiment perfusion bypass structure 298 in cross section defined by a plane along line C in similar perfusion bypass structure 220, 258, and 278 embodiments. This bypass structure may be implemented in any of the embodiments disclosed above. The perfusion bypass structure 298 includes an inlet tube 300 defining an inlet lumen 302 and an outlet tube 304 defining an outlet lumen 306. These lumens are connected by an irrigation tube (not shown) that carries irrigation fluid through the mechanism head and trigger actuation system disclosed herein. FIG. 42 shows that the inlet lumen 302 and the outlet lumen 306 are also connected by a bypass 308 formed by a first bypass fitting 310 and a second bypass fitting 312. The first bypass fitting 310 and the second bypass fitting 312 connect via complementary features and form a fluid-tight seal via an O-ring 314, which is formed of a resilient, flexible material. The second bypass fitting 312 also includes an internal flow restriction 316 having a diameter narrower than the diameter of the inlet lumen 300. The perfusion bypass structure 298 therefore functions to provide a well-defined minimum perfusion flow rate when the perfusion tubing in the mechanism head is closed by the trigger mechanism.

[0052]

[0102] Alternatively, the various flow control mechanisms and bypass structures described herein can be in a separate unit from the handle of the device. In this scenario, flexible irrigation tubing and flexible suction lines connect the separate unit to the handle. The separate unit can be controlled by the user via a foot pedal, touch screen, or other similar actuation mechanism. The mechanisms within the separate unit can be controlled mechanically, electromechanically, electromagnetically, or by other similar control methods. In one example, the separate unit is a reusable unit similar to or included with the control unit 18. In this example, the control unit 18 provides irrigation fluid and negative pressure to the system in addition to imaging control.

[0053]

[0103] FIG. 43 shows a mechanism 12 for performing kidney stone removal according to one embodiment. The bottom of the mechanism includes a stone capture receiver 38 in fluid communication with the suction inlet 32. FIG. 44 is a rotated close-up view of the mechanism 12 inside the box W of FIG. 43, showing the location of a flow indicator 318 on the mechanism 12. The flow indicator 318 provides a visual (and optionally audible) indication of whether air and / or fluid is flowing through the mechanism 12 and out to the suction inlet 32. The absence of fluid flow through the mechanism 12 can indicate a clog somewhere in the fluid path within the stone removal device. The clog may be in the catheter compartment or in the mechanism 12, and it may be important to address such a clog to prevent overpressure within the kidney caused by continuing to perfuse the kidney in the presence of a clog.

[0054]

[0104] FIG. 45 is an exploded view of a stone capture assembly 320 that may be configured as part of the mechanism 12 and implemented in any of the embodiments described above. A flow indicator 322 is contained within a flow indicator housing 324 with an O-ring 326 that seals the flow indicator housing 324 with a flow indicator cover 328 that is transparent or translucent so that a user can observe the movement of the flow indicator 322. A stem 330 allows the flow indicator 322 to rotate in the presence of flow. Alternative configurations of the flow indicator are within the scope of this disclosure, such as any configuration that visibly moves in response to flow within the housing. The flow indicator housing 324 is connected to a stone capture receiver cap assembly 332 by a fluid-tight seal, such as an O-ring 334. The stone capture receiver cap assembly 332 is connected to a stone capture receiver 336 via a stone capture receiver seal 338. The stone capture receiver cap assembly 332 is also connected to an inflow assembly 340. In use, the direction of fluid flow (including kidney stone fragments) within the stone capture assembly 320 is through the catheter section of the stone removal device and the inflow assembly 340 connected to the stone capture receptacle 336. Fluid and air are wicked up through the stone capture receptacle filter 342, which retains the debris within the stone capture receptacle 336 and allows the fluid and air to pass through and eventually into the flow indicator housing 324 to interact with the flow indicator 322. Thus, the flow indicator 322 is unlikely to become clogged or blocked with kidney stone fragments. In any embodiment of the flow indicator, the flow indicator should be protected from being stopped in motion by debris interacting with the flow indicator itself.

[0055]

[0105] 46 and 47 are two views of a flow indicator mechanism including a flow indicator 322 disposed within a flow indicator housing 324. Fluid from the stone trap receptacle 336 enters the flow indicator housing 324 via a flow inlet 344, which is connected to an indicator inlet 346 for introducing fluid into the flow indicator housing 324 to interact with the flow indicator 322. The fluid exits the flow indicator housing 324 via an indicator outlet 348, which is connected to a flow outlet 350. The flow indicator 322 includes at least two flow indicator vanes 352 that interact with the fluid as it travels from the indicator inlet 346 to the indicator outlet 348. The movement of the fluid between the indicator inlet 346 and the indicator outlet 348 creates movement of the flow indicator 322 by pushing against the flow indicator vanes 352 and causing the flow indicator vanes to rotate about the mandrel 330. The indicator inlet 346 and indicator outlet 348 may be positioned at various locations within the flow director housing 324 such that the fluid flow interacts with two or more flow director vanes 352 on the path between the indicator inlet 346 and the indicator outlet 350.

[0056]

[0106] The flow indicator embodiments disclosed herein are one approach to prevent overpressure in the device and / or anatomical structures during kidney stone removal procedures.In addition to or instead of a flow indicator, the mechanisms and devices disclosed herein may include a pressure relief valve that can release fluid pressure when the fluid pressure exceeds a certain predefined safety threshold.The pressure relief valve may be included on the mechanism handle, on the catheter, at the junction between the handle and the catheter, on the fluid supply line, and / or at the junction between the fluid supply line and the handle.

[0057]

[0107] Distal Assembly and Nozzle Referring again to FIG. 1 , the distal assembly 16 of the insertable treatment system 10 is flexible and steerable, configured to apply irrigation, configured to allow drainage of irrigation fluid, configured to apply suction (which may be referred to as aspiration and / or aspiration), and includes visualization capabilities such as at least one image sensor and at least one light emitting diode (LED). The catheter 14 includes one or more lumens and / or other elongated structures within the catheter shaft to facilitate manipulation of the distal assembly 16. For example, the catheter 14 may include portions of the steering assembly, such as one or more pull wires. The catheter 14 may include one or more suction lumens in fluid communication with the handle 12 to facilitate suction from the distal assembly 16. The catheter 14 may include one or more irrigation lumens in fluid communication with the handle 12 to facilitate irrigation from the distal assembly 16. Additionally, these elongated structures may extend along the entire length of the catheter 14 or along a partial length of the catheter 14.

[0058]

[0108] 48A and 48B, each shows a perspective view of a distal assembly 400 that is part of the distal section of the insertable treatment system 10. FIG. 48B shows a view of the distal assembly 400 with the outer member 402 retracted as compared to FIG. 48A. The outer member 402 can be one or more layers of a tubular structure, one or more of which can be part of the outer portion of the proximal section of the catheter shaft. The layers of the outer member 402 can include a relatively softer, more flexible outer layer over a relatively stiff inner layer. The distal assembly 400 includes an aspiration lumen 404 defined by an aspiration shaft 406. The distal end of the aspiration shaft 406 terminates at or near the distal end of a nozzle tip 408. The nozzle tip 408 includes one or more irrigation ports 410 and 412. The irrigation ports 410 and 412 have a groove shape and can direct irrigation fluid forward and laterally from the distal end of the nozzle tip 408. The distal assembly further comprises an image sensor 414 and a light source 416 on either side of the image sensor 414. The image sensor 414 can be a semiconductor chip designed for image capture, and the light source 416 can be a light emitting diode or similar light source. The area around the image sensor 414 and the light source 416 can be filled with a potting material of the type commonly used in electronics, provided that the material is biocompatible or suitable for use with medical devices. FIG. 48B shows a printed circuit board 418 connected with the image sensor 414 and the light source 416. The area around the printed circuit board 418 can also be filled with a potting material. FIG. 48B also shows the distal end of a pull wire 420 that can be used to steer the distal assembly 16 of the insertable treatment system 10. Nozzle tip 408 includes a recess into which a ferrule or similar fitting on the end of pull wire 420 can be inserted to provide a distal attachment point for pull wire 420 .

[0059]

[0109] FIG. 49A shows a perspective view of multiple portions of the distal assembly 400, and FIG. 49B shows a perspective exploded view of the portions of FIG. 49A. The nozzle tip 408 is configured to receive a distal manifold 422 therein. The distal manifold 422 includes a conduit 424, although other examples of the distal manifold 422 can include more or less complete conduits. The conduit 424 functions to direct irrigation fluid to the irrigation ports 410 and 412. The distal manifold 422 also includes a top recess 426 for housing an imaging assembly (or components thereof), including, but not limited to, at least one printed circuit board 418, at least one light source 416, and at least one image sensor 414. The distal manifold 422 also includes a proximal flange 428 that provides a structural member for joining and sealing to the nozzle tip 408 on one side and the shaft manifold 430 on the other side. The seals on either side of the proximal flange 428 can be liquid tight. The distal manifold 422 also includes a pull wire recess 432 for attaching steering pull wires to the distal assembly 16 to facilitate steering of the insertable treatment system 10. FIG. 49B shows that the shaft manifold 430 includes a pull wire lumen 434 and multiple perfusion lumens 436 (only one of the five perfusion lumens 436 shown in FIG. 49B is labeled). In some examples of the shaft of the catheter 14, the shaft manifold 430 can extend the entire length of the shaft of the catheter 14, or only a portion of the length of the shaft of the catheter 14. In some examples of the catheter 14, there is no shaft manifold and the lumen defined by the outer member 402 serves as a perfusion lumen and a pathway for steering mechanisms such as pull wires.

[0060]

[0110] Figures 50A, 50B, and 50C show end views of the components of the distal assembly 400. Figure 50A shows a shaft manifold 430 with two pullwire lumens 434 and multiple irrigation lumens 436 (only one of the five irrigation lumens 436 shown in Figure 4A is labeled). Figure 50B shows a distal manifold 422 with a conduit 424, a top recess 426, a proximal flange 428, and a pullwire recess 432. Figure 50C shows a nozzle tip 408 with irrigation ports 410 and 412.

[0061]

[0111] FIG. 51A and FIG. 51B show two different examples of the nozzle tip 408. FIG. 51A shows one example of the nozzle tip 408 in which an image sensor 414 and a light source 416 are mounted on the nozzle tip 408 and there are multiple irrigation ports 410 and 412. This example is conceptually similar to the example shown in the previous figure. The nozzle tip 408 includes a nozzle lumen 438 that can accommodate the aspiration shaft 406 in some examples and can define the aspiration lumen 404 in alternative examples. FIG. 51B shows an alternative example in which the image sensor 414 and the light source 416 are mounted on an elongated insertable member 440 that can be slid relative to the nozzle tip 408, the distal assembly 400, the shaft of the catheter 14, and / or the insertable system 10. The elongated insertable member 440 includes a working lumen 442 through which a therapeutic or diagnostic device can be slid relative to the elongated insertable member 440. Examples of such devices include, but are not limited to, lasers, sensors, and graspers. Additionally, working lumen 442 can allow for the aspiration of fluids and kidney stone fragments while elongated insertable member 440 is in place. The outer diameter of insertable elongated member 440 can be from about 1 mm to about 4 mm, and the inner diameter of working lumen 442 can be from about 0.3 mm to about 1.5 mm.

[0062]

[0112] 52A and 52B show alternative examples of the nozzle tip 408. In FIG. 52A, the nozzle tip 408 includes a single image sensor 414 and a single light source 416, and in FIG. 52B, the nozzle tip 408 includes a single image sensor 414 and three light sources 416 (only one light source 416 is labeled). The arrangement of the light sources 416 in FIG. 52B may be preferred in some instances as it may provide more uniform illumination by placing the light sources 416 on either side of the image sensor 414. FIG. 52A and 52B each show six irrigation ports 410 (only one irrigation port 410 is labeled). These irrigation ports 410 are configured to direct fluid distally and laterally from the nozzle tip 408. In FIG. 52A and 52B, the nozzle tip 408 includes a nozzle lumen 438 that may house the aspiration shaft 406 in some instances and may define the aspiration lumen 404 in alternative instances.

[0063]

[0113] 53A and 53B show alternative examples of the nozzle tip 408. In FIG. 53A and 53B, the nozzle tip 408 includes a nozzle lumen 438 that can accommodate the aspiration shaft 406 in some examples and can define the aspiration lumen 404 in alternative examples. The nozzle tip 408 also includes at least one pull wire recess 444. The nozzle tip 408 includes a tip manifold 446 configured to direct fluid to the irrigation ports. The tip manifold 446 is in fluid communication with one or more irrigation lumens that route irrigation fluid from the handle 12 down the catheter 14 and provides a fluid path to each of the irrigation ports. In FIG. 53A and 53B, the nozzle lumen 438 is offset from the center of the nozzle tip 408. FIG. 53A shows groove-shaped irrigation ports 448 and 450. The irrigation ports 448 are larger than the irrigation ports 450. The interior of each of the irrigation ports 448 and 450 is configured to direct fluid radially from the central axis of the nozzle tip 408. FIG. 53B shows circular irrigation ports 452 and 454 that are similarly sized. Irrigation port 452 is on the front surface of the nozzle tip 408. The opening of irrigation port 454 is on the front surface and extends to the side wall of the nozzle tip 408. The interior of each of the irrigation ports 452 and 454 is configured to direct fluid radially from the central axis of the nozzle tip 408. The configuration of irrigation port 454 allows irrigation port 454 to direct fluid radially outwardly than port 452. In some examples, the direction of the fluid may approximate a spiral away from the central axis of the nozzle tip 408 in both the groove-shaped example and the circular-shaped example.

[0064]

[0114] 54A and 54B show alternative examples of the nozzle tip 408. In FIG. 54A and 54B, the nozzle tip 408 includes a nozzle lumen 438 that can accommodate the aspiration shaft 406 in some examples and can define the aspiration lumen 404 in alternative examples. The nozzle tip 408 also includes at least one pull wire recess 444. The nozzle tip 408 includes a tip manifold 446 configured to direct fluid to the irrigation ports. The tip manifold 446 is in fluid communication with one or more irrigation conduits 456 to provide a fluid path to each of the irrigation ports. In FIG. 54A and 54B, the nozzle lumen 438 is concentric with the outer diameter of the nozzle tip 408. FIG. 54A shows six circular irrigation ports 458. The irrigation ports 458 can be elliptical, groove, or arc shaped. The openings of the irrigation ports 458 extend from the front surface to the sidewall of the nozzle tip 408. Figure 54B shows five circular irrigation ports 458 that are similarly sized. The interior of each of the irrigation ports 458 is configured to direct fluid radially away from the central axis of the nozzle tip 408. The exit angle for the irrigation ports shown in Figures 54A and 54B is approximately 45 degrees relative to the central axis of the nozzle tip 408, and the direction of the irrigation fluid leaving the nozzle tip 408 is radially away from the central axis of the nozzle tip 408.

[0065]

[0115] 55A and 55B show alternative examples of the nozzle tip 408. In FIGS. 55A and 55B, the nozzle tip 408 includes a nozzle lumen 438 that can accommodate the aspiration shaft 406 in some examples and can define the aspiration lumen 404 in alternative examples. The nozzle lumen 438 is offset from the center of the nozzle tip 408. The nozzle tip 408 also includes at least one pullwire recess 444. The nozzle tip 408 includes a tip manifold 446 configured to direct fluid to the irrigation ports. The tip manifold 446 is in fluid communication with one or more irrigation lumens that route irrigation fluid from the handle 12 down the catheter 14 and provides a fluid pathway to each of the irrigation ports. FIG. 55A shows three circular irrigation ports 458 having exit angles of approximately 45 degrees and configured to direct fluid radially from the central axis of the nozzle tip 408, and two elliptical irrigation ports 460 that direct fluid at a 45 degree angle downward from the central axis of the nozzle tip 408 rather than radiating out. The openings of the elliptical irrigation ports 460 are on the front surface of the nozzle tip 408. The openings of the circular irrigation ports 458 encompass both the front surface and the sidewall. FIG. 55B shows five circular irrigation ports 458 having exit angles of approximately 45 degrees and configured to direct fluid radially from the central axis of the nozzle tip 408, and two elliptical irrigation ports 460 that direct fluid at a 45 degree angle downward from the central axis of the nozzle tip rather than radiating out.

[0066]

[0116] 56 shows a rear perspective view of a nozzle tip 408 (which may be, for example, any of the nozzle tips described) having a tip manifold 446 that provides a fluid pathway to various irrigation ports on the distal face of the nozzle tip 408. The nozzle tip 408 also includes a nozzle irrigation lumen 462 that provides a pathway for fluid from the catheter 14 to the tip manifold 446.

[0067]

[0117] FIG. 57 illustrates an alternative embodiment of the nozzle tip 408. The nozzle tip 408 includes a nozzle lumen 438 that can accommodate the aspiration shaft 406 in some embodiments and can define the aspiration lumen 404 in alternative embodiments. The nozzle lumen 438 is offset from the center of the nozzle tip 408. The nozzle tip 408 also includes at least one pull wire recess 444. The nozzle tip 408 includes a tip manifold 446 configured to direct fluid to the irrigation ports. The tip manifold 446 is in fluid communication with one or more irrigation lumens that route irrigation fluid from the handle 12 down the catheter 14 and provides a fluid path to each of the irrigation ports. FIG. 57 illustrates a grooved irrigation port 464 having an exit angle of approximately 45 degrees and configured to direct fluid radially from the central axis of the nozzle tip 408. The irrigation port 464 has a 140 degree arc that provides a substantial sweep of fluid. The nozzle tip 408 includes two elliptical irrigation ports 466 that direct fluid at a 45 degree angle downward from the central axis of the nozzle tip rather than diverging radially.

[0068]

[0118] 58A and 58B show alternative examples of the nozzle tip 408. In FIG. 58A and 58B, the nozzle tip 408 includes a nozzle lumen 438 that can accommodate the aspiration shaft 406 in some examples and can define the aspiration lumen 404 in alternative examples. The nozzle lumen 438 is offset from the center of the nozzle tip 408. The nozzle tip 408 also includes at least one pull wire recess 444. The nozzle tip 408 includes a tip manifold 446 configured to direct fluid to the irrigation ports. The tip manifold 446 is in fluid communication with one or more irrigation lumens that route irrigation fluid from the handle 12 down the catheter 14, providing a fluid path to each of the irrigation ports. FIG. 58A shows two grooved irrigation ports 468, each having an exit angle of about 45 degrees and configured to direct fluid radially from the central axis of the nozzle tip 468. Each irrigation port has an arc of about 70 degrees and is separated by a central region having an arc of about 40 degrees. Together, the irrigation ports 468 can provide a sweep of fluid of about 180 degrees. FIG. 58B shows two grooved irrigation ports 470, each having an exit angle of about 65 degrees and configured to direct fluid radially from the central axis of the nozzle tip 408. Each irrigation port 470 has an arc of about 70 degrees and the irrigation ports 470 are separated by a central region having an arc of about 40 degrees. Together, the irrigation ports 470 can provide a sweep of fluid of about 180 degrees. FIGS. 58A and 58B show that the irrigation ports 468 and 470 are configured to direct fluid both distally and laterally from the distal face of the nozzle tip 408.

[0069]

[0119] 59A and 59B show alternative examples of the nozzle tip 408. In FIG. 59A and 59B, the nozzle tip 408 includes a nozzle lumen 438 that can accommodate the aspiration shaft 406 in some examples and can define the aspiration lumen 404 in alternative examples. The nozzle lumen 438 is offset from the center of the nozzle tip 408. The nozzle tip 408 also includes at least one pull wire recess 444. The nozzle tip 408 includes a tip manifold 446 configured to direct fluid to the irrigation ports. The tip manifold 446 is in fluid communication with one or more irrigation lumens that route irrigation fluid from the handle 12 down the catheter 14, providing a fluid path to each of the irrigation ports. FIG. 59A shows two grooved irrigation ports 472, each having an exit angle of about 45 degrees and configured to direct fluid radially from the central axis of the nozzle tip 408. Each irrigation port 472 has an arc of about 70 degrees, and the irrigation ports 472 are separated by a central region having an arc of about 40 degrees. Together, the irrigation ports 472 can provide a sweep of fluid of about 180 degrees. FIG. 59A shows that the irrigation ports 472 are configured to direct fluid both distally and laterally from the distal face of the nozzle tip 408. FIG. 59B shows four grooved irrigation ports 474 and 476, each having an exit angle of about 45 degrees, and configured to direct fluid radially from the central axis of the nozzle tip 408. Each irrigation port has an arc of about 20 degrees. The irrigation ports 474 are separated by a central region having an arc of about 50 degrees. Adjacent irrigation ports 474 and 476 are separated by a region having an arc of about 40 degrees. Together, the irrigation ports 474 and 476 can provide a sweep of fluid of about 180 degrees. 59A and 59B show that the irrigation ports are configured to direct fluid both distally and laterally from the distal face of the nozzle tip 408.

[0070]

[0120] The various examples of irrigation port configurations presented herein demonstrate that a nozzle tip can achieve a variety of spray patterns by manipulating variables such as the size, shape, and number of irrigation ports, the exit angle of the irrigation ports, the placement of the irrigation ports on the distal face of the nozzle tip (i.e., entirely on the distal face, or, as shown by the figures, partially on the distal face and partially on the outer portion of the nozzle tip). Additionally, one or more of the irrigation ports may be configured the same as or different from the configuration of one or more of the irrigation ports on the same nozzle tip.

[0071]

[0121] 60 and 61 are perspective views of one embodiment of a distal assembly 400 in the distal section of the insertable treatment system 10. Both FIGS. 60 and 61 show an outer member or outer hypotube 402 included in the distal assembly 400. As disclosed herein, the outer member 402 of the distal assembly 400 can include one or more layers of tubular structure. In FIGS. 60 and 61, the outer hypotube 402 can be at least partially covered by a more flexible outer layer (not shown). FIGS. 60 and 61 show an aspiration lumen 404 defined by a nozzle tip 408 in the distal assembly 400 and by an aspiration shaft (not shown) in the portion of the device proximal to the distal assembly 400. The nozzle tip 408 in FIGS. 60 and 61 includes a sloped distal surface to reduce the most distal surface area of ​​the nozzle tip 408, which can reduce the potential for trauma to tissue as the device is advanced distally. The edges of the distal face are curved and rounded or smooth compared to sharp corners for the same reason of reducing the possibility of trauma. This beveled distal face or rounded and smooth edges can be implemented in any of the nozzle tip 408 configurations disclosed above. The nozzle tip 408 is shown to include four irrigation ports arranged in two pairs, a pair of upper irrigation ports 412 and a pair of lower irrigation ports 410, although only one of each pair is visible in the perspective views of FIGS. 60 and 61. The pairs of irrigation ports 410 and 412 have a groove shape and can direct irrigation fluid forward and laterally from the distal end of the nozzle tip 150. An image sensor 414 is located on the nozzle tip 408, and light sources 416 can be on either side of the image sensor 414. As with the previous embodiment, the image sensor 414 can be a semiconductor chip designed for image capture, and the light sources 416 can be light emitting diodes or similar light sources. The area around the image sensor 414 and light source 416 may be filled with a potting material of the type commonly used with electronic devices, provided that the material is biocompatible or otherwise suitable for use with medical devices.

[0072]

[0122] 62A and 62B show perspective and side views, respectively, of one embodiment of the nozzle tip 408 of the distal assembly 400. The nozzle tip 408 includes a pair of upper irrigation ports 412 and a pair of lower irrigation ports 410 disposed about the aspiration lumen 404. The nozzle tip 408 includes an upper recess 478 that provides a location for mounting an image sensor and a light source. FIG. 62B shows the angled distal surface of the nozzle tip 408. The nozzle tip 408 includes two conduits 480, one on each side of the nozzle tip 408, that provide a fluid path between the irrigation ports 410 and 412 and the irrigation lumen in the shaft section of the catheter. The nozzle tip 408 can include multiple conduits 480. In the example shown in FIGS. 62A and 62B, each conduit 480 includes a partition 482 that helps direct fluid to each of the irrigation ports 410 and 412. Depending on the number of irrigation ports at the nozzle tip, there can be multiple partitions in the conduit to distribute the fluid to the irrigation ports. The dimensions of the partitions affect the flow characteristics of the irrigation fluid at each irrigation port and can be varied to achieve the desired flow characteristics at each port.

[0073]

[0123] 62C shows an end view of nozzle tip 408 and shows that upper irrigation port 412 and lower irrigation port 410 include front openings. As disclosed herein, the interior of irrigation ports 410 and 412 can be angled, as described herein, such that irrigation fluid exits the nozzle tip at an exit angle relative to the central axis of the nozzle tip. Irrigation ports 410 and 412 can be characterized by shape, radial distribution, exit angle, and front area, among other parameters.

[0074]

[0124] In some examples of nozzles (e.g., any of the nozzle tips 408 described above), the radial distribution of the irrigation ports is such that the irrigation ports are substantially uniformly distributed around the circumference of the nozzle. In some examples (e.g., any of the nozzles 408 described above), in a cross-sectional view of the nozzle tip, the maximum angle between any two adjacent irrigation ports measured from center to center of each irrigation port is less than about 110 degrees, depending on the number of irrigation ports on the nozzle. In the case of more than three irrigation ports, there may be a pair of adjacent irrigation ports where the angle measured from center to center of each irrigation port is substantially about 110 degrees, and some other irrigation ports have an angle measured from center to center of each irrigation port that is substantially less than about 110 degrees.

[0075]

[0125] In some examples of nozzles (e.g., any of the nozzle tips 408 described above), the irrigation ports have a major axis that is at an angle to the central longitudinal axis of the nozzle. This angle, or nozzle exit angle, may be in the range of about 30 degrees to about 60 degrees and may be referred to as the irrigation port exit angle. A nozzle may be configured with an irrigation port that has an exit angle that is different from other irrigation ports on the same nozzle, or the same as that irrigation port. A set of irrigation ports may have the same exit angle, which may be different from another set of irrigation ports on the same nozzle. In some preferred examples, the irrigation port exit angle is about 45 degrees. In other preferred examples, the irrigation port angles are 30 degrees, 31 degrees, 32 degrees, 33 degrees, 34 degrees, 35 degrees, 36 degrees, 37 degrees, 38 degrees, 39 degrees, 40 degrees, 41 degrees, 42 degrees, 43 degrees, 44 degrees, 45 degrees, 46 degrees, 47 degrees, 48 ​​degrees, 49 degrees, 50 degrees, 51 degrees, 52 degrees, 53 degrees, 54 degrees, 55 degrees, 56 degrees, 57 degrees, 58 degrees, 59 degrees, or 60 degrees. In one preferred example, on a nozzle there is one set of irrigation ports with an exit angle of 34 degrees and another set of irrigation ports with an exit angle of 50 degrees. Table 1 shows the exit angles of pairs of irrigation ports for several different nozzle designs.

[0076]

[0126] [Table 1]

[0077]

[0127] The hydraulic diameter can be a useful parameter for characterizing various perfusion port configurations. Generally, the hydraulic diameter is used when characterizing flow in non-circular channels in fluid calculations that are general to circular channels. If the cross section is uniform along the channel length, the hydraulic diameter D H is defined as follows:

number

[0078]

[0128] Several nozzle tips were fabricated to characterize preferred examples of nozzle tip designs. The nozzle tips contained two pairs of irrigation ports, where the top and bottom (i.e., upper and lower) were symmetric pairs with the same groove shape and exit angle. Table 2 shows the relevant dimensions of several different nozzle designs. The area and perimeter of each individual port of the pair are shown in the table.

[0079]

[0129] [Table 2]

[0080]

[0130] Test samples were constructed with representative aspiration lumens and camera wires to approximate the pressure drop and flow characteristics of a fully constructed device.

[0081]

[0131] The flow rate can be determined by measuring the mass of water exiting the nozzle as a function of time. The experimental setup included a conventional saline irrigation bag under a specific pressure (e.g., 2 psi or 4 psi) connected to the catheter and nozzle compartments of the device. Table 3 shows the results of flow rate testing in grams per second for several nozzle configurations.

[0082]

[0132] [Table 3]

[0083]

[0133] From an empirical analysis of various nozzle designs including multiple irrigation ports, the preferred minimum irrigation mass flow rate from a saline bag at 2 psi is about 0.55 g / s, and the preferred minimum irrigation mass flow rate from a saline bag at 4 psi is about 0.75 g / s. In a nozzle, each irrigation port contributes 1 / N of the total mass flow rate, where N is the number of irrigation ports, and this fraction can be converted to a percentage. From an empirical analysis of various nozzle designs with four irrigation ports, the various irrigation ports were measured to contribute 15%-30% of the total irrigation mass flow rate, compared to the calculated amount of 25%. In some examples of nozzles, the irrigation mass flow rate is substantially similar from each of the irrigation ports. In other examples of nozzles, the irrigation mass flow rate can be 2-4 times greater from some irrigation ports than from other irrigation ports. This asymmetry can be advantageously used to provide high irrigation mass flow in some directions from the nozzle.

[0084]

[0134] The area affected by the nozzle design can be determined empirically. FIG. 63A shows a test apparatus 484 for determining the affected area, including a flat test surface 486 having a checkerboard pattern on which a bed of kidney stone fragments 488 or simulated kidney stone fragments having a size range of about 1.8 mm to 2.0 mm is spread. A preferred test apparatus includes a bed of kidney stone fragments having a substantially uniform size. The test apparatus includes a mount 490 for aligning the distal end of the device, including the nozzle 408, at a fixed distance above and parallel to the bed of kidney stones on the checkerboard pattern. Using a pressurized saline bag, irrigation fluid is delivered through the nozzle for a set time, and the area affected by the fluid spurting from the nozzle is calculated using the checkerboard pattern. The pressure on the saline bag can be in the range of about 0.5 psi to about 6.0 psi. In some preferred examples, the pressure on the saline bag is 2 psi or 4 psi. The nozzle is then rotated a fixed amount about its longitudinal axis, the test is repeated, and the area affected by the fluid is calculated. Figure 63B shows a top view of the test bed after the test has been performed. Areas free of kidney stone fragments can be seen on the surface, and this area can be measured using a grid pattern on the surface.

[0085]

[0135] In a preferred example of testing, the nozzle is rotated 90 degrees so that four test runs can approximate the three-dimensional volume affected by the irrigation port placement on the nozzle. Additionally, the distance of the nozzle above the grid surface can be varied to approximate a larger or smaller three-dimensional volume. In some preferred examples, the distance from the nozzle to the grid surface is about 6 mm. Table 4 shows the results of the affected area testing in square millimeters for several nozzle placements.

[0086]

[0136] [Table 4]

[0087]

[0137] The grid surface test bed approximates a large volume that is open and virtually infinite compared to an anatomical scale cavity. Alternative test methods can be used to approximate closed systems such as the renal pelvis or calyx.

[0088]

[0138] In one example of a closed system test apparatus, kidney stone fragments or simulated kidney stone fragments having a size range of approximately 1.8 mm to 2.0 mm are placed in a test tube. The length and diameter of the test tube define the volume of the test cavity. For example, a test tube having a diameter of 14 mm and a length of 100 mm can approximate a closed environment at an anatomically relevant scale. The test apparatus includes a fixture or mount for coaxially aligning the distal end of the device, including the nozzle, with the cross section of the test tube. The distal end of the nozzle can be advanced and retracted relative to the end of the test tube while irrigation fluid is applied at a given pressure. The extent of movement of the kidney stone fragments is measured as a function of distance. Table 5 shows the results of the closed environment test, with the distances reflecting the maximum distance the nozzle design can cause stone fragment movement within the test apparatus when delivering irrigation fluid at 2 psi.

[0089]

[0139] [Table 5]

[0090]

[0140] Empirical testing of various nozzle configurations disclosed herein has demonstrated several preferred performance characteristics for embodiments of the method in which it is desired to mobilize kidney stone fragments. In some preferred embodiments, the fluid velocity is in the range of about 0.50 m / s to about 1.50 m / s, and preferably at least about 1.00 m / s, when the applied pressure is 2 psi. In other preferred embodiments, the fluid velocity is in the range of about 0.9 m / s to about 2.00 m / s, and preferably at least about 1.45 m / s, when the applied pressure is 4 psi.

[0091]

[0141] FIG. 64 shows a cross-sectional view of a portion of the catheter 14. The outer member of the catheter 14 includes an outer jacket 492 and an outer hypotube 494. Within the outer member are pull wires 496 disposed within pull wire hypotubes 498 such that the pull wires 496 are free to slide longitudinally relative to the pull wire hypotubes 498. In some examples, the pull wire hypotubes 498 may be fixed relative to the outer member and on both sides of the outer member. In other examples, the pull wire hypotubes 498 are fixed only at the distal end of the catheter 14. An electrical cable 500 is also within the outer member and connects an image sensor in the distal assembly with the handle. The electrical cable 500 is free to move within the outer member but is fixed within the outer member at or near the distal and proximal ends. An aspiration shaft 502 containing an aspiration lumen 504 is also within the outer member and connects the aspiration lumen 504 defined by the nozzle tip with the handle 12. The aspiration shaft 502 is also free to move within the outer member, but is fixed within the outer member at or near its distal and proximal ends. The remaining space within the outer member that is not occupied by the pullwire hypotube 498, the electrical cable 500, or the aspiration shaft 502 is the perfusion space 506 where irrigation fluid can flow from the handle to conduits within the distal assembly. Because the electrical cable 500 and the aspiration shaft 502 are free to move within the outer member, the perfusion space 506 is not a fixed shape. One advantage of this arrangement is that there is no dedicated perfusion shaft, which reduces the number of structures within the catheter shaft assembly 14. Fewer structures facilitate easier manufacturing and increased flexibility in the catheter shaft assembly. For example, when the catheter shaft is generally straight, the perfusion space may take the general shape of an annulus between the outer member and the aspiration shaft, but when the catheter shaft is curved, the perfusion space may take the general crescent shape as the aspiration shaft is pressed against the inner wall of the outer member.

[0092]

[0142] Instrument Guidance Device The above catheter advances have provided the ability to combine camera, laser, aspiration, and irrigation components into one system to streamline kidney stone removal procedures and reduce the potential for adverse effects associated with kidney stone treatment procedures, most specifically the need for repeated insertion and removal of ureteroscopes and extraction catheters to remove all stones. However, a challenge associated with catheter systems has been the inability to maintain an adequate catheter diameter. The integration of components, particularly lasers, requires additional channels, resulting in larger catheter dimensions than desired. Larger diameter catheters may cause more tissue inflammation and damage as they pass through the ureter, renal pelvis, and calyx. In some cases, larger diameter catheters may not be able to access the kidney at all due to narrow and / or tortuous ureters. Thus, to maintain a low catheter dimension, existing lumens, such as the aspiration lumen (described above), may be used for the laser and other instruments. The use of the aspiration lumen is reasonable, since the aspiration lumen is wide enough to accommodate the laser. The laser fiber is smaller in diameter than the aspiration lumen (the diameter of the aspiration lumen is much larger than the diameter of the working channel of a conventional ureteroscope that receives the laser device). However, this large difference in diameter results in movement of the laser fiber within the aspiration lumen. Unwanted movement of the laser fiber can prevent the clinician from accurately targeting the stone. Lateral movement of the laser fiber within the aspiration lumen can not only make stone fragmentation difficult, but also increase the risk of the laser causing damage to nearby tissue. The embodiments of the instrument guidance device provide an instrument to allow the laser to be effectively used with an extraction catheter system to fragment kidney stones, while allowing the stone to pass through the laser and flow through the aspiration lumen, among other things.

[0093]

[0143] The aspiration lumen of the catheter and nozzle (e.g., for lumens 404 and 504 described above) may be used to insert and remove a stone fragmentation-inducing device, such as a lithotripsy device, or most preferably a laser lithotripsy device. The inner diameter of the inner tube or the diameter of the aspiration lumen (e.g., 404 and 504) must be large enough to accommodate the passage of many stone fragments without clogging. In an embodiment of the present invention, the diameter of the aspiration lumen (e.g., 404 and 504) may be, for example, 2.0 mm to 3.0 mm, or about 2.5 mm in some configurations. However, the laser fiber and the lithotripsy device are significantly smaller in diameter than the aspiration lumen diameter. This large difference in diameter causes the fragmentation-inducing device to move around or shift within the aspiration lumen during operation. Unintended movement of the laser makes it difficult for the surgeon to accurately target the stone.

[0094]

[0144] Thus, an embodiment of the present invention provides an intermediate device for securing a shatter-inducing device (preferably a laser device or fiber) to the aspiration lumen (e.g., 404 and 504). The intermediate device is configured to completely prevent or significantly minimize movement of the laser fiber at the distal end of the aspiration lumen while not interfering with the function of the aspiration lumen and allowing fluids and solids to flow past the laser fiber. FIG. 65 illustrates an intermediate device, referred to herein as a guide 508. The guide 508 includes an elongated body or tube 510 that is configured to be inserted through the working channel (e.g., ports 42 and 138) of the handle 12 and through the proximal end of the catheter 14 and pushed through the aspiration lumen until the distal end of the guide 508 is positioned exactly at or approximately adjacent to the distal end of the aspiration lumen (e.g., aspiration lumen 404 and 504) (e.g., at the end of the distal assembly 400 and nozzle tip 408). In one embodiment, the length of the guide 508 is equivalent to the length of the aspiration lumen in which the guide will be positioned. Preferably, the guide 508 is configured such that when the guide 508 is disposed completely within the aspiration lumen 404 or in an operating position, the distal tip of the guide 508 does not extend beyond the distal end opening of the aspiration lumen 404 (or nozzle tip 408), i.e., to hold the laser tip at the distal end of the aspiration lumen 404 (or nozzle tip 408). The guide 508 includes at least two wings, ridges, flanges, or extensions 512, which terms are used interchangeably herein. The wings 512 protrude or extend from a distal segment of the elongated body 510. In one embodiment, the wings 512 extend from a distal segment of the elongated body 510 such that when the elongated body 510 is disposed in an operating position within the aspiration lumen 404, the wings 510 reside at the distal-most segment of the aspiration lumen 404 of the nozzle tip 408. The wings 510 can be an integral extension of the elongated body 510, meaning that the body 510 and the wings 512 are made or molded from one piece, or the wings 512 can be provided on a distal segment of the elongated body 510 and be an extension of a smaller tube attached to the distal segment.A lumen 514 extends through the center of the elongated body 510 to receive a milling inducing device, preferably a laser fiber. The lumen 514 has a diameter to accommodate the laser fiber to be used. In other words, the diameter of the lumen 514 is large enough to allow the laser fiber to be freely inserted and removed from the lumen, but small enough to prevent or significantly minimize non-rotational or lateral movement of the laser fiber. The very distal end of the guide 508 forward of the wings 512 can include a knob segment 516 having a tapered end with a smaller diameter than the elongated body 510. The knob segment 516 facilitates insertion of the guide 508 into the access ports and aspiration lumens (e.g., 404 and 504) of the handle 12. The aspiration lumens (e.g., 404 and 504) of the nozzle tip 408 can include a tapered segment (not shown). The knob segment 516 may contact this small tapered end of the nozzle tip 408 and act as a stop to prevent the guide 508 from extending out of the aspiration lumen 404 .

[0095]

[0145] FIG. 66 shows a front view of one embodiment of guide 508. The guide includes (or consists of) two wings 512a and 512b extending from an elongated body 510. Wings 512a and 512b are sized to allow guide 508 to slide freely in and out of the aspiration lumen (e.g., lumens 404 and 504, as well as nozzle lumen, e.g., lumen 438), while preventing lateral or non-rotational movement of the winged section of guide 508 within the aspiration lumen (and nozzle lumen). In other words, the maximum diameter D of guide 508, including the width (i.e., height) of wings 512, should be slightly smaller than the inner diameter of the aspiration lumen to allow wings 512 to traverse through the aspiration lumen, but prevent significant lateral movement of wings 512 within the aspiration lumen. In one embodiment, diameter D can match or be approximately equal to the inner diameter of the aspiration lumen (e.g., aspiration lumen 404 in FIGS. 48A and 48B), where wings 512 can be made from a softer or more pliable plastic material that allows wings 512 to compress slightly when fitted through the aspiration lumen.

[0096]

[0146] 66, the guide 508 can include (or consist of) three wings 512 or four wings 512. Although embodiments of the invention can include any number of wings, a two- to four-wing design is preferred because more wings can inhibit the function of the aspiration lumen by causing stones to clog the aspiration lumen or become lodged between the aspiration lumen and the elongate body 510.

[0097]

[0147] FIG. 67 is a general schematic front view of a guide 508 with (or consisting of) four wings 512a-512d disposed at the most distal end of the suction tube 518 (or, for example, the suction shaft 406 of FIGS. 48A and 48B) for securing the tip of a laser device or fiber at the distal tip of the suction tube 518. A laser device or fiber 520 is shown disposed in a lumen 514 of the guide 508. The limited diameter of the lumen 514 prevents or greatly minimizes movement of the laser fiber 520 within the suction tube 518 unintentionally by the physician while allowing insertion and removal of the laser fiber 520 through the guide 508. The stability of the laser 520 allows the physician to apply laser pulses to the kidney stone with great precision, thereby effectively fragmenting the stone while reducing the risk of damage caused by misaligned laser pulses. The wings 512a-512d should be wide or tall enough (i.e., the distance between the elongated body 510 and the suction tube 518) to create a gap 522 between the guide 508 and the suction tube 518. The gap 522 allows the suction lumen to provide suction to remove fluid, debris, and kidney stone fragments throughout the laser procedure. The number of wings 512 determines the number of gaps 522. For example, two wings 512 would result in two large gaps 522, three wings 512 would result in three medium sized gaps 522, and the illustrated four wing 512 configuration would result in four smaller gaps 522. Larger gaps 522 are preferred to minimize the chance of stones getting stuck or lodged at the entry point or along the distal section of the guide 508.

[0098]

[0148] FIG. 67 shows four wings 512a-512d, where the circumferential distance is the same between any two adjacent wings. That is, the distance between each of 512a-512b, 512b-512c, 512c-512d, and 512d-512a is equal. In one embodiment, the circumferential distance between two adjacent wings may be different from the distance between another pair of adjacent wings (even if there is one shared wing). For example, the distance between adjacent wings 512a-512b and the distance between 512c-512d may be the same, and the distance between 512a-512d and the distance between 512b-512c may be the same, but the distance between 512a-512b or the distance between 512d-512c is smaller than the distance between 512a-512d or the distance between 512b-512c. This configuration provides two small gaps 522 to allow the passage of smaller stones and two large gaps 522 to allow the passage of larger stones, which may not be removed if the gaps 522 were the same size. In a three-wing configuration, the distance between each wing can vary, thus providing three gaps 522, each having a different size. Alternatively, in a three-wing configuration, the distance between two pairs of adjacent wings can be the same, but the third pair is spaced apart a different distance. In some embodiments, instead of or in addition to changing the distance between the wings 512 to vary the size of the gaps 522, the width of the wings (the distance between the elongated tube 510 and the aspiration lumen 518) can be varied, thus providing gaps 522 of different sizes. By providing wings 512 with different widths, the position of the laser head is offset from the center of the aspiration lumen. Thus, in some embodiments, at least two different sized gaps 522 can be provided.

[0099]

[0149] FIG. 68 is one embodiment of the wing 512 design. The wing 512 includes an intermediate section 512-1 that extends to a distal segment 512-2 and a proximal segment 512-3. The length of the intermediate section 512-1 (in the x direction, i.e., along the longitudinal axis) is greater than the length of the distal segment 512-2 and the proximal segment 512-3. The intermediate section 512-1 can have a constant width (in the y direction, i.e., along the radial axis). The intermediate section 512-1 can have a rectangular shape, which allows the intermediate section to have sufficient surface contact with the inside of the aspiration lumen to create stability and prevent unintentional slippage of the distal end of the guide 508 on which the wing 512 is located. The distal segment 512-2 and the proximal segment 512-3 of the wing 34 are angled or tapered from the intermediate section 512-1 to the elongated tube 32. The thickness (in the z-direction) of the wing 512 can be the same along the entire span of the wing 512. In alternative embodiments, the thickness (in the z-direction) of the wing 512 can vary such that the wing 512 tapers along the x-direction or longitudinal direction. For example, as best shown in FIG. 69A, the wing 512 can have its thickest dimension at the distal end of the tip of the wing and its thinnest dimension at the proximal end of the wing. In one embodiment, the sidewalls of the wing 512 can converge at an angle as shown in FIG. 69A to provide the wing 512 with an isosceles triangular shape when viewed from above. According to another embodiment, the longitudinal axis of the wing 512 is not aligned with the longitudinal x-axis of the guide 508 as shown in FIG. 69B. The longitudinal axis of the wing 512 is rotated with respect to the x-axis of the guide 508. According to another embodiment not shown, the wing 512 can have a long radius of curvature in the longitudinal direction. The wings 512 can be symmetrically disposed about the elongate body or tube 510 or the wings 512 are asymmetrically disposed about the elongate body or tube 510.

[0100]

[0150] 70 illustrates another embodiment of guide 508. Guide 508 includes a distal end section 524 configured to extend from an aspiration lumen (e.g., lumens 404 and 438 or nozzle tip 408) when guide 30 is in place. Distal end section 524 can be, for example, a soft tip. Wings 512 are located proximally of distal end section 524 but are designed to sit at the distal end segment of the aspiration tube.

[0101]

[0151] The guide 508 allows the aspiration lumen to aspiration stones, debris, and fluids during the laser procedure while simultaneously fragmenting the kidney stones, and provides fixed support for the head of the laser fiber at the distal tip of the aspiration lumen or nozzle tip. However, the presence of the guide 508 reduces the working inner diameter of the aspiration lumen. Thus, the guide 508 increases the likelihood that larger sized stones will accumulate and / or get stuck at the entry point of the aspiration lumen, as well as in the gap 522 or between the wings 512. Such clogging can reduce drainage efficiency and require manual removal of debris or increased internal pressure. The flow indicator 322 of the handle 12 (described above) can provide feedback of clogging and reduced drainage to the user. Thus, a device can be used to induce back and forth movement, vibration, or rocking of the guide 508 to dislodge or push out the stuck or stuck stone. A slight back and forth movement of the guide 508 can be effective in removing debris and clearing the aspiration lumen. According to one embodiment, an actuator 526 is provided that may be permanently attached to the guide 508 or removably coupled thereto, as shown in FIG. 71A and FIG. 71B. The actuator 526 may include a biasing band 528. The biasing band 528 is a self-returning body such that an inward compression (i.e., squeezing) and release of the band 528 may cause back and forth movement of the guide 508 and wings 512 within the aspiration lumen (e.g., in the case of lumens 404 and 438). One end of a shaft 530 passes through a hole 532 in the band 528. The shaft 530 may be fixedly secured to the band 528 by two pairs of opposed tabs 534 extending from the shaft 530. A cylindrical housing 536 receives the opposed ends of the shaft 530. The shaft 530 may telescopically move back and forth within the cylindrical housing 536 as the band 528 is compressed and released. A cylindrical housing 536 is coupled to the opposite side of band 528 to which shaft 530 is coupled.The shaft 530 can include a shaft head 537 that can be permanently attached to the proximal tail of the guide 508, or the shaft head 537 can be configured to be removably coupleable to the proximal tail of the guide 508. For example, the shaft head 537 and the proximal tail of the guide 508 can have a female / male coupling member. A tubular member 538 can extend from the proximal end of the cylindrical housing 536. The member 538 can be configured to connect to and disconnect from a handle of a catheter (e.g., the handle 12 described above). An access channel 540 can extend from the member 538, the cylindrical housing 536, and the shaft 530 and communicate with the lumen 514 of the guide 508. A laser fiber can be inserted into an entrance opening of the access channel 540, threaded through the actuator 526, and inserted into the lumen 514 of the guide 508. The laser fiber can be pushed through the lumen 514 of the guide 508 until the head of the laser reaches the distal tip of the aspiration lumen (or nozzle tip), with the wings 512 of the guide 508 preventing unintentional movement of the head of the laser.

[0102]

[0152] FIG. 72 illustrates another embodiment of the actuator 542. The actuator 542 may be permanently attached to the guide 508 or may be removably coupled thereto. The actuator 542 may include a first (or, as oriented in the figure, an upper or distal) lever 544 coupled to a second (or lower or proximal) lever 546 via a fulcrum bar 548. The actuator 542 is self-returning, such that inward compression (i.e., squeezing) and release of the levers 544 and / or 546 may cause back and forth movement of the guide 508 and wings 512 within the aspiration lumen (e.g., lumens 404 and 428). A shaft 550 is coupled to the upper lever 544 and extends from an opening in the upper lever 544. A cylindrical housing 552 receives the opposing ends of the shaft 550. The shaft 550 can telescopically move back and forth within the cylindrical housing 552 when the levers 554 and / or 546 are compressed and released. The cylindrical housing 552 is coupled to the lower lever 546. The shaft 550 includes a shaft head 554 that can be permanently attached to the proximal tail of the guide 508, or alternatively, the shaft head 554 can be configured to be removably coupleable to the proximal tail of the guide 508. For example, the shaft head 554 and the proximal tail of the guide 508 can have a female / male coupling member. A tubular member 556 can extend from the proximal end of the cylindrical housing 552. The tubular member 556 can be configured to connect to and disconnect from a handle of a catheter (e.g., the handle 12 described above). A channel 558 may be accessible from member 556 and extend from member 558, cylindrical housing 552, and shaft 550 and communicate with lumen 514 of guide 508. A laser fiber may be inserted into the entrance opening of access channel 558, threaded through actuator 542, and inserted into lumen 514 of guide 508. The laser fiber may be pushed through lumen 514 of guide 508 until the head of the laser reaches the distal tip of the aspiration lumen or nozzle tip, with wings 512 of guide 508 preventing unintentional movement of the head of the laser fiber.In operation, when the actuator 542 is squeezed inwardly at position P1 (e.g., the upper lever 554 and the lower lever 546 are clamped against each other), the shaft 550 is actuated outwardly (upwardly in the figures) and away from the lower lever 546. The upper lever 544 and / or the lower lever 546 now pivot about the fulcrum arm 548 to create a wider gap between the levers 544 / 546 at the shaft end of the actuator 542 and a smaller gap between the levers 544 / 546 at the end labeled position P1. When the actuator 542 is squeezed inwardly at position P2 (e.g., the upper lever 554 and the lower lever 546 are clamped against each other or the upper lever 554 is pushed downwardly toward the lower lever 546), the shaft 550 is actuated inwardly (downwardly in the figures) and toward the lower lever 546. Here, the upper lever 544 and / or the lower lever 546 pivot about a fulcrum arm 548 to create a smaller gap between the levers 544 / 546 at the shaft end of the actuator 542, and a wider gap between the levers 544 / 546 at the end labeled position P1. Thus, movement of the shaft head 554 can be away from or towards the lower lever 546 based on the force applied at either P1 or P2.

[0103]

[0153] For the treatment of kidney stones, a guidewire can be used to guide the catheter into the kidney. The guide 508 can be inserted into the aspiration lumen before inserting the catheter into the patient. The lumen 514 of the guide 508 can be used to accept a guidewire to guide the catheter over the guidewire. Alternatively, the guide 508 can be inserted into the catheter at any point during the procedure, including when the catheter reaches its intended location. When the guidewire is in the lumen 514, it is removed, followed by the insertion of the laser fiber. The laser fiber is guided through the lumen 514 of the guide 508 until the head of the laser reaches the end of the knob 516. The physician can apply laser pulses to the kidney stone while simultaneously aspirating debris, stone, and fluid through the catheter and nozzle aspiration lumen. If a stone is lodged in the opening of the guide 508, the actuator 526 or 542 can be used to move the guide 508 in the aspiration lumen to remove the stone. After the laser procedure, the guide 508 may be removed and the suction lumen may be used for extraction of remaining unfragmented or fragmented stones for treatment of kidney stones.

[0104]

[0154] Various examples, aspects, and embodiments of the kidney stone removal system disclosed herein provide various advantages when used to treat kidney stones. One of the advantages is the ability to prevent or mitigate the possibility of excessive pressure on the kidney during kidney stone treatment. In conventional laser lithotripsy of kidney stones, irrigation fluid may be introduced during ureteroscopy and / or laser lithotripsy. In most cases, irrigation fluid can only exit the kidney through a narrow space between the ureteroscope and the access sheath. This narrow space may be further narrowed by debris, such as kidney stone fragments, blood clots, or other material. If the egress of fluid from the kidney is restricted by such a narrow space, continued infusion of irrigation fluid creates a risk of high pressure within the kidney, which may lead to sepsis and / or other complications. The kidney stone removal system disclosed herein provides a much larger exit channel via a large diameter suction lumen. Furthermore, it is possible to apply suction through the large diameter suction lumen while introducing irrigation fluid. The large diameter of the suction lumen, combined with the ability to apply suction while delivering irrigation fluid, greatly reduces the chance of overpressurizing the kidney, resulting in a safer kidney stone removal procedure.

[0105]

[0155] Another advantage of the kidney stone removal system disclosed herein is the ability to prevent or mitigate thermal damage to the kidney during laser lithotripsy. During laser lithotripsy of kidney stones, especially with higher power lasers, heat is generated within the kidney. This heat can damage the kidney and is a concern for physicians performing laser lithotripsy. Perfusion fluid can help dissipate heat via conductive heat transfer, but as described herein, perfusion fluid can also accumulate within the kidney if the pathway for drainage is relatively narrow. The kidney stone removal system disclosed herein provides a much larger exit channel via a large diameter suction lumen, combined with the ability to apply suction while delivering the perfusion fluid. The kidney stone removal system disclosed herein can rapidly remove heated perfusion fluid from the kidney and maintain a safe temperature within the kidney by continuously introducing a relatively cooler perfusion fluid during laser lithotripsy. In examples, aspects, and embodiments of the kidney stone removal system including laser guidance, heated irrigation fluid can easily and quickly flow through the aspiration lumen while the laser fiber is being used to break up the kidney stone, and relatively cool irrigation fluid can easily and quickly enter the kidney through the irrigation port on the nozzle. This rapid heat transfer through the irrigation fluid that is quickly introduced and removed from the kidney greatly reduces the chance of thermal damage to the kidney, resulting in a safer kidney stone removal procedure.

[0106]

[0156] Another advantage of the kidney stone removal system disclosed herein is the ability to improve visibility within the kidney during laser lithotripsy. In conventional laser lithotripsy, debris from crushing the kidney stone often obscures the view from the imaging portion of the ureteroscope, making it difficult for the physician to view the area of ​​interest within the kidney and / or the kidney stone during fragmentation. Physicians often experience a "snow globe" phenomenon during laser lithotripsy, in which debris is randomly and chaotically released from the kidney stone, quickly obscuring the physician's view. The kidney stone removal system disclosed herein can improve visibility by rapidly removing debris mobilized in the irrigation fluid from the kidney through a large diameter suction lumen and continuously introducing a clear irrigation fluid during laser lithotripsy. In examples, aspects, and embodiments of the kidney stone removal system including a laser guide, debris suspended or mobilized in the irrigation fluid can easily and quickly flow through the suction lumen even while the laser fiber is being used to break up the kidney stone. Moreover, rather than a random and chaotic field of view, the kidney stone removal system disclosed herein provides a predictable pattern as debris moves in a regular motion across the field of view and into the aspiration lumen. Such a regular pattern makes it easier for the physician to remain oriented with anatomical landmarks in the field of view. Furthermore, due to the relatively large exit channel (compared to the narrow channel between the ureteroscope and the access sheath), more debris is removed and removed faster using the kidney stone removal system disclosed herein. In some cases, the large diameter of the aspiration lumen provides sufficient passive outflow to substantially improve visibility, even when little or no suction is applied. The large diameter of the aspiration lumen, combined with the ability to apply suction while delivering irrigation fluid, combined with a regular debris flow pattern, significantly improves visibility during laser lithotripsy, providing a safer, more efficient, and more effective kidney stone removal procedure.

[0107]

[0157] Another advantage of the kidney stone removal system disclosed herein is the ability to rapidly apply and remove therapeutic or diagnostic agents within the kidney during laser lithotripsy. The perfusion fluid can have chemical or biological agents applied to it from a source bag or using ports adjacent to the system handle. These agents can be therapeutic agents such as, but not limited to, hemostatic agents, antibiotic agents, and / or bacteriolytic agents. These agents can also be diagnostic agents such as, but not limited to, contrast agents.

[0108]

[0158] Another advantage of the kidney stone removal system disclosed herein is the orientation of the irrigation ports relative to the distal end of the aspiration lumen. The irrigation ports deliver irrigation fluid at an exit angle relative to the central axis of the cross section of the aspiration lumen. This angle, combined with the suction applied through the aspiration lumen, creates a flow pattern that affects a volume much larger than the diameter of the distal end of the device. This flow pattern can also be regular rather than turbulent, reducing, mitigating, and / or eliminating vortices that may form when a conventional ureteroscope delivers fluid to the kidney. Furthermore, experience has shown that irrigation ports that deliver fluid in a straight line distally from the end of the ureteroscope tip push debris away from the distal tip, making it difficult to aspirate the debris. In contrast, the kidney stone removal system disclosed herein can bring debris closer to the aspiration lumen by creating a regular flow pattern that first diverges away from the nozzle and then returns to the central axis of the nozzle away from the distal end of the nozzle. The kidney stone removal system disclosed herein does not need to be aimed directly at the kidney stone fragments to act on the kidney stone fragments and bring them closer to the aspiration lumen. Thus, the effective area of ​​the kidney stone removal system disclosed herein is significantly larger than the area directly in front of the nozzle, which can be used to remove the fragments from the cupule without the nozzle being aimed directly at the fragments.

[0109]

[0159] Another advantage of the kidney stone removal system disclosed herein is that the irrigation port can provide a flow rate that is independent of the instrument being used in the aspiration lumen. Conventional ureteroscopes typically provide irrigation through a working channel, and this same working channel is used to provide access for a laser fiber or basket. The presence of an instrument in the working channel changes the fluid dynamics, altering the flow rate and other flow characteristics. In contrast, the kidney stone removal system disclosed herein maintains flow characteristics independent of the instrument, if any, being used in the aspiration lumen, delivering irrigation fluid through a dedicated irrigation port.

[0110]

[0160] As used herein, connected, attached, coupled, or in communication are terms that may be used interchangeably, and when a feature or element is referred to herein as being connected, attached, coupled, or in communication with another feature or element, the feature or element may be directly connected to the other feature or element, or there may be intervening features or elements. In contrast, when a feature or element is referred to as being directly connected to another feature or element, there are no intervening features or elements present.

[0111]

[0161] When a feature or element is referred to herein as being "on" another feature or element, that feature or element may be directly on the other feature or element, or intervening features and / or elements may also be present. In contrast, when a feature or element is referred to as being directly on another feature or element, there are no intervening features or elements present.

[0112]

[0162] Although the above description refers to "embodiments," any one of the features or embodiments described above may be used, implemented, or combined with any other of the features or embodiments described herein.

[0113]

[0163] As used herein, the singular forms "a," "an," and "the" are intended to include the plural forms as well, unless the context clearly indicates otherwise.

[0114]

[0164] It will be further understood that the terms "comprises" and / or "comprising", as used herein, specify the presence of stated features, steps, operations, elements, and / or components, but do not exclude the presence or addition of one or more other features, steps, operations, elements, components, and / or groups thereof.

[0115]

[0165] As used herein, the term "and / or" includes any and all combinations of one or more of the associated listed items and may be abbreviated as " / ".

[0116]

[0166] Spatially relative terms such as "below", "lower", "bottom", "above", "top" and the like may be used herein for ease of description to describe the relationship of one element or feature to another element or feature as depicted in the figures. It will be understood that the spatially relative terms are intended to encompass different orientations of the device in use or operation in addition to the orientation depicted in the figures. For example, if the device in the figures is inverted, an element described as being "below" or "directly below" the other element or feature would be oriented "above" the other element or feature. Thus, the exemplary term "below" can encompass both an orientation of above and below. The device may be oriented differently (rotated 90 degrees or at other orientations) and the spatially relative descriptors used herein will be interpreted accordingly. Similarly, terms such as "upward", "downward", "vertical", "horizontal", and the like are used herein for descriptive purposes only, unless otherwise noted.

[0117]

[0167] When a feature is said to be located "adjacent" another feature, the feature may be positioned next to the other feature with no overlapping or underlying portions, or it may have portions that overlap or underlying the adjacent feature.

[0118]

[0168] Spatially relative terms such as "proximal," "distal," and the like may be used herein for ease of description to describe the relationship of one element or feature to another. It will be understood that proximal describes a spatial location closer to the user or the intended location of the user, and distal describes a location farther from the user or the intended location of the user. Furthermore, when used in reference to a minimally invasive device such as a catheter, proximal and distal locations refer to portions of the device that are intended to be closer or farther from the user, respectively, and do not change when the device is in use.

[0119]

[0169] The terms "first" and "second" may be used herein to describe various features / elements (including steps), but these features / elements should not be limited by these terms unless the context indicates otherwise. These terms may be used to distinguish one feature / element from another. Thus, a first feature / element may be referred to as a second feature / element, and similarly, a second feature / element may be referred to as a first feature / element, without departing from the teachings of the present invention.

[0120]

[0170] As used herein, including when used in the examples, unless expressly specified otherwise, all numbers may be read as if they begin with the word "about" or "approximately", even if the term does not explicitly appear. The phrase "about" or "approximately" may be used when describing a magnitude and / or location to indicate that the described value and / or location is within a reasonable expected range of values ​​and / or locations. For example, a numerical value may have a value of + / -0.1% of the stated value (or range of values), + / -1% of the stated value (or range of values), + / -2% of the stated value (or range of values), + / -5% of the stated value (or range of values), + / -10% of the stated value (or range of values), etc. Any numerical value given herein should also be understood to include about or approximately that value, unless the context indicates otherwise. For example, if the value "10" is disclosed, then "about 10" is also disclosed. Any numerical range recited herein is intended to include all subranges subsumed therein. As would be well understood by one of ordinary skill in the art, when a value is disclosed, it is also understood that "less than or equal to that value," "greater than or equal to that value," and possible ranges between the values ​​are also disclosed. For example, if a value "X" is disclosed, "less than or equal to X" as well as "greater than or equal to X" are also disclosed (e.g., where X is a numerical value). It is also understood that throughout this application, data is provided in several different formats, and this data represents end and starting points, as well as ranges for any combination of the data points. For example, if a specific data point "10" and a specific data point "15" are disclosed, it is understood that greater than, greater than, less than, less than, and equal to 10 and 15 are considered to be disclosed, as well as between 10 and 15. It is also understood that each unit between two specific units is also disclosed. For example, if 10 and 15 are disclosed, then 11, 12, 13, and 14 are also disclosed.

[0121]

[0171] Disclosed herein are systems, devices, and methods for guided removal of objects in vivo. In particular, the systems, devices, and methods may be adapted to traverse compact areas, such as the urinary tract, and remove debris, such as kidney stones or kidney stone fragments, by suction through a suction tube. The term "kidney stone" as used herein may refer to kidney stone fragments, including fragments resulting from therapeutic fragmentation of a kidney stone, such as with a device described herein or by another device. The term "kidney stone" may refer to stones or stone fragments that are within the ureter and kidney, and the systems, devices, and methods disclosed herein may be capable of removing kidney stones from the kidney or ureter.

[0122]

[0172] Although various exemplary embodiments have been described above, any of a number of modifications may be made to the various embodiments without departing from the scope of the invention as described by the claims. For example, the order in which the various described method steps are performed may often be changed in alternative embodiments, and in other alternative embodiments, one or more method steps may be skipped entirely. Optional features of the various device and system embodiments may be included in some embodiments and not included in other embodiments. Thus, the above description has been provided primarily for illustrative purposes and should not be construed as limiting the scope of the invention as described in the claims.

[0123]

[0173] The examples and illustrations contained herein show, by way of illustration and not limitation, specific embodiments in which the subject matter may be practiced. As noted above, other embodiments may be utilized and derived from those specific embodiments, such that structural and logical substitutions and changes may be made without departing from the scope of the present disclosure. Such embodiments of the subject matter of the present invention may be referred to herein, individually or collectively, by the term "invention" when more than one is actually disclosed, merely for convenience and without any intention of spontaneously limiting the scope of the present application to any single invention or inventive concept. Thus, although specific embodiments have been shown and described herein, any arrangement contemplated to achieve the same purpose may be substituted for the specific embodiment shown. The present disclosure is intended to cover any adaptations or variations of the various embodiments. Combinations of the above embodiments, as well as other embodiments not specifically described herein, will be apparent to those skilled in the art upon reviewing the above description.

[0124]

[0174] It will be understood that the present disclosure is in many respects merely illustrative of numerous alternative device embodiments of the invention. Changes may be made in details, particularly with respect to the shape, size, materials and arrangement of the various device components, without exceeding the scope of the various embodiments of the invention. Those skilled in the art will appreciate that the exemplary embodiments and their description are merely illustrative of the invention as a whole. While several principles of the invention have been demonstrated in the exemplary embodiments described above, those skilled in the art will appreciate that modifications in structure, arrangement, proportions, elements, materials and methods of use may be utilized in the practice of the invention or otherwise specifically adapted to particular environments and operating requirements without departing from the scope of the invention. Furthermore, although certain features and elements have been described in connection with certain embodiments, those skilled in the art will appreciate that those features and elements may be combined with other embodiments disclosed herein.

Claims

1. 1. A kidney stone removal mechanism comprising: A perfusion tube; A suction tube; a trigger mechanism including a user-operable trigger, the trigger located at a proximal end of the kidney stone removal mechanism, the trigger mechanism operable to selectively contract, close, and open the irrigation tube to irrigate a treatment area in response to user manipulation of the trigger, and to selectively create suction in the aspiration tube to remove some or all of a kidney stone in response to user manipulation of the trigger; 1. A kidney stone removal mechanism comprising:

2. 10. The kidney stone removal mechanism of claim 1, wherein the trigger comprises a first protrusion, and wherein user manipulation of the trigger causes the first protrusion to selectively contract, close, and open the irrigation tube.

3. 3. The kidney stone removal mechanism of claim 2, wherein user manipulation of the trigger causes the first protrusion to progressively open the irrigation tube.

4. 4. The kidney stone removal mechanism of claim 1, wherein the trigger comprises a second protrusion, and wherein user actuation of the trigger causes the second protrusion to selectively induce suction in the suction lumen.

5. 5. The kidney stone removal mechanism of claim 4, wherein user operation of the trigger causes the second protrusion to progressively create suction within the suction lumen.

6. a catheter connected at its proximal end to a distal end of the kidney stone removal mechanism, the catheter having a distal tip at the distal end of the catheter; a steering mechanism located at the proximal end of the kidney stone removal mechanism, the steering mechanism operable to steer the distal tip to facilitate partial or complete removal of a kidney stone; 6. The kidney stone removal mechanism of any one of claims 1 to 5, further comprising:

7. 7. The kidney stone removal mechanism of claim 6, wherein the steering mechanism comprises at least one wire connected between the steering mechanism and the catheter for moving the distal tip to a desired location to facilitate removal of part or all of a kidney stone.

8. The kidney stone removal mechanism of any one of claims 2 to 7, wherein the first protrusion comprises a roller.

9. The kidney stone removal mechanism of any one of claims 4 to 8, wherein the second protrusion comprises a roller.

10. 10. The kidney stone removal mechanism of any one of claims 1-9, wherein the trigger comprises a third protrusion, and the trigger mechanism comprises a first detent selectively engageable with the third protrusion to alert the user of a predetermined amount of depression of the trigger.

11. The kidney stone removal mechanism of claim 10 , wherein the first detent comprises an edge of a protrusion on the interior of the trigger mechanism.

12. The kidney stone removal mechanism of claim 10 , wherein the first detent includes a recessed edge within the trigger mechanism.

13. The kidney stone removal mechanism of claim 10 , wherein the third protrusion comprises a roller.

14. The kidney stone removal mechanism of any one of claims 10 to 13, further comprising a second detent to alert the user to a full amount of depression of the trigger.

15. The kidney stone removal mechanism of claim 14 , wherein the second detent includes the protrusion on an interior side of the trigger mechanism.

16. 15. The kidney stone removal mechanism of claim 14, wherein the second detent includes an opposing edge of a recess within the trigger mechanism, and the third protrusion engages the opposing edge of the recess to alert the user to a full amount of depression of the trigger mechanism.

17. The kidney stone removal mechanism of any one of claims 1 to 16, further comprising a resilient device that interacts with the trigger mechanism to return the trigger mechanism to a home position in response to user release of the trigger.

18. 20. The kidney stone removal mechanism of claim 17, wherein the resilient device comprises a spring.

19. The kidney stone removal mechanism of any one of claims 1 to 18, further comprising a suction actuation tube connected to said suction tube.

20. 20. The kidney stone removal mechanism of claim 19, wherein the second protrusion pinches the suction actuation tube closed, thereby creating suction within the suction tube.

21. 20. The kidney stone removal mechanism of claim 19, wherein the second protrusion covers a port of the suction actuation tube, thereby creating suction in the suction tube.

22. A method for removing kidney stones comprising the step of operating a kidney stone removal mechanism according to any one of claims 1 to 21.

23. an irrigation tube configured to carry a fluid and having a portion passing through the trigger mechanism; a bypass structure connected to the perfusion tube at two locations and configured to allow fluid to flow from a first portion of the perfusion tube to a second portion of the perfusion tube without passing through the portion of the perfusion tube within the trigger mechanism; 1. A kidney stone removal mechanism comprising: a trigger mechanism including a user-operable trigger, the trigger mechanism operable to selectively contract, close, and open the first irrigation tube to irrigate a treatment area in response to user operation of the trigger. Kidney stone removal mechanism.

24. 24. The kidney stone removal mechanism of claim 23, wherein the bypass structure comprises a flow restriction.

25. 25. The kidney stone removal mechanism of claim 23 or 24, wherein user depression of the trigger causes progressive opening of the irrigation tube.

26. The kidney stone removal mechanism of any one of claims 23 to 25, further comprising a suction tube configured to be actuated by said trigger mechanism.

27. a catheter connected at its proximal end to a distal end of the kidney stone removal mechanism, the catheter having a distal tip at the distal end of the catheter; a steering mechanism located at a proximal end of the kidney stone removal mechanism, the steering mechanism operable to steer the distal tip to facilitate partial or complete removal of a kidney stone; 27. The kidney stone removal mechanism of any one of claims 23 to 26, further comprising:

28. 28. A method for removing kidney stones comprising the step of operating a kidney stone removal mechanism according to any one of claims 23 to 27.

29. A perfusion tube; A suction tube; a stone capture assembly in communication with the suction tube; a flow indicator mechanism including a flow indicator connected to the stone capture assembly; 1. A kidney stone removal mechanism comprising:

30. 30. The kidney stone removal mechanism of claim 29, wherein the flow director comprises one or more vanes that move in response to a fluid or air flow.

31. a catheter connected at its proximal end to a distal end of the kidney stone removal mechanism, the catheter having a distal tip at the distal end of the catheter; a steering mechanism located at a proximal end of the kidney stone removal mechanism, the steering mechanism operable to steer the distal tip to facilitate partial or complete removal of a kidney stone; 31. The kidney stone removal mechanism of claim 29 or 30, further comprising:

32. 32. A method for removing kidney stones comprising the step of operating a kidney stone removal mechanism according to any one of claims 29 to 31.

33. The nozzle further comprises: an aspiration lumen in communication with the aspiration tube and sized to remove a kidney stone or a kidney stone fragment; one or more irrigation ports in communication with the irrigation tube, the irrigation ports being disposed at a distal end of the nozzle and having an irrigation port exit angle of 30-60 degrees for directing irrigation fluid forward and laterally from the distal end of the nozzle; 33. The kidney stone removal mechanism of any one of claims 1 to 32, comprising:

34. 34. The kidney stone removal mechanism of claim 33, wherein at least one of said irrigation ports has an arc shape.

35. A kidney stone removal catheter; a nozzle included in a distal end of the catheter; 1. A kidney stone removal mechanism comprising:

1. A kidney stone removal mechanism, wherein the nozzle comprises an aspiration lumen sized to remove kidney stones or kidney stone fragments, and one or more irrigation ports at a distal end of the nozzle, at least one of the irrigation ports having an irrigation port exit angle of 30-60 degrees for directing irrigation fluid forward and laterally from the distal end of the nozzle.

36. 36. The kidney stone removal mechanism of claim 35, comprising a first irrigation port configured to direct irrigation fluid in a forward direction but not in a radially expanding direction, and a second irrigation port configured to direct irrigation fluid in a radially expanding direction.

37. 37. The kidney stone removal mechanism of claim 35 or 36, wherein at least two of the irrigation ports have different opening sizes, different shapes, and / or different irrigation port exit angles.

38. 38. The kidney stone removal mechanism of claim 37, wherein a first one of the irrigation ports is one of a circular, elliptical, or arcuate shape, and a second one of the irrigation ports has a different shape than the first irrigation port and is one of a circular, elliptical, or arcuate shape.

39. 36. The kidney stone removal mechanism of claim 35, comprising a first irrigation port disposed directly between a second irrigation port and a third irrigation port, wherein an arcuate distance between said first irrigation port and said second irrigation port is different from an arcuate distance between said first irrigation port and said third irrigation port.

40. The kidney stone removal mechanism of any one of claims 35 to 39, further comprising an image sensor and a light source.

41. 41. The kidney stone removal mechanism of claim 40, wherein said nozzle includes an upper recess for receiving said image sensor and said light source.

42. 42. The kidney stone removal mechanism of any one of claims 35 to 41, further comprising a distal manifold configured for insertion into a proximal end of the nozzle, the distal manifold having conduits for directing irrigation fluid to the irrigation ports of the nozzle.

43. 43. The kidney stone removal mechanism of claim 42, further comprising a shaft manifold configured to connect to the distal manifold, the shaft manifold having an irrigation lumen for directing irrigation fluid to the conduits of the distal manifold.

44. The kidney stone removal mechanism of any one of claims 35 to 43, wherein the nozzle includes a distal face having rounded or curved edges.

45. The kidney stone removal mechanism of any one of claims 35 to 44, wherein the suction lumen is offset from the center of the nozzle.

46. 46. ​​The kidney stone removal mechanism of any one of claims 35 to 45, wherein the nozzle comprises at least one conduit for providing a fluid path between the catheter and the irrigation port, the at least one conduit comprising a partition for directing fluid to the irrigation port.

47. (a) a suction tube; (b) a laser guide configured to be removably inserted into the suction tube; and 1. A kidney stone removal system comprising: (i) a tubular body having an inner lumen configured to receive a laser device; (ii) wings extending from the distal end segment of the tubular body for guiding the distal end segment of the tubular body within the suction tube and creating a flow gap between the tubular body and the suction tube; A kidney stone removal system comprising:

48. 48. The kidney stone removal system of claim 47, wherein the tubular body is configured so as not to extend from a distal end of the suction tube when the tubular body is fully inserted into the suction tube and placed in an operative position.

49. 48. The kidney stone removal system of claim 47, wherein the guide comprises two to four wings.

50. 48. The kidney stone removal system of claim 47, wherein said guide consists of three or four wings, and the circumferential distance is the same between each pair of adjacent wings.

51. 48. The kidney stone removal system of claim 47, wherein the guide comprises three or four wings, and a circumferential distance between a first pair of adjacent wings is different from a circumferential distance between a second pair of adjacent wings.

52. 52. The kidney stone removal system of claim 51, wherein said first pair and said second pair of adjacent wings share a common wing.

53. 48. The kidney stone removal system of claim 47, wherein at least two of said gaps have different sizes.

54. 54. The kidney stone removal system according to any one of claims 47 to 53, wherein each wing comprises an intermediate segment having a rectangular shape that transitions into a tapered end segment that tapers down into the tubular body.

55. 55. The kidney stone removal system according to any one of claims 47 to 54, wherein each wing has a variable thickness that increases along the longitudinal axis from a proximal end of the wing to a distal end of the wing.

56. 56. The kidney stone removal system according to any one of claims 47 to 55, wherein each wing has a longitudinal axis that is at an angle relative to the longitudinal axis of the tubular body.

57. 57. The kidney stone removal system of any one of claims 47 to 56, further comprising an actuator for moving said tubular body within said suction tube.

58. The actuator, (a) a biasing element; (b) a shaft coupled to the tubular body for moving the tubular body back and forth within the suction tube upon actuation of the biasing element; 58. The kidney stone removal system of claim 57, comprising:

59. 60. The kidney stone removal system of claim 58, wherein the shaft is configured to be removably coupled to a proximal end of the tubular body.

60. 60. The kidney stone removal system of claim 58, wherein said shaft is permanently attached to the proximal end of said tubular body.

61. 59. The kidney stone removal system of claim 58, wherein the biasing element comprises a band coupled to a distal section of the shaft, and the actuator further comprises a cylindrical housing coupled to the band and configured to receive the shaft, such that inward compression and release of the band telescopically moves a portion of the shaft in and out of the cylindrical housing.

62. 62. The kidney stone removal system according to any one of claims 57 to 61, wherein the actuator comprises a channel for receiving the laser device, the channel configured to communicate with the lumen of the tubular body.

63. (a) a suction tube; (b) a guide device configured to be removably positioned within the suction tube to receive a debris-disintegration device; A catheter assembly comprising: A catheter assembly, wherein the guide device is configured to allow fluid and debris to flow through the crushing device and through the suction tube while preventing unintended movement of the crushing device when the crushing device is positioned at the distal end of the suction tube.

64. 64. The catheter assembly of claim 63, further comprising an actuation device for moving the guide device within the suction tube to remove debris.

65. 65. A catheter assembly as described in claim 63 or 64, wherein the disruption device comprises a laser fiber.

66. 67. A method for removing kidney stones comprising the step of operating a kidney stone removal mechanism according to any one of claims 47 to 62 or a catheter assembly according to any one of claims 63 to 65.

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