Abstract:
Methods and systems for modifying tissue use a pressurized fluid stream carrying coherent light energy. The methods and systems may be used for resecting and debulking soft and hard biological tissues. The coherent light is focused within a stream of fluid to deliver energy to the tissue to be treated.

Description:
CROSS-REFERENCES TO RELATED APPLICATIONS 
     This application claims the benefit of provisional application No. 61/097,497, filed on Sep. 16, 2008, and of provisional application No. 61/034,412, filed on Mar. 6, 2008, the full disclosures of which are incorporated herein by reference. The subject matter of this application is related to that of commonly-owned application Ser. No. 11/968,445 which claimed the benefit of provisional application No. 60/883,097, filed on Jan. 2, 2007, the full disclosures of which are incorporated herein by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates generally to medical methods and devices. In particular, the present invention relates to methods and devices for applying energy to ablate, cut, drill, or otherwise modify soft or hard tissues. 
     Both water jet technology and laser technology have been proposed for various tissue cutting and modification protocols. While each of these approaches has achieved commercial success, neither is ideally suited for all tissue modification protocols. For example, water jet or stream cutting alone does not cauterize tissue and therefore cannot prevent excessive bleeding. Furthermore, it can require very high pressure water delivery systems which can be difficult to control. Similarly, the use of lasers for modifying tissue can require very high energies, which can only be generated with large high power and expensive laser equipment. While laser technology can be effectively applied to cauterize tissue and stop bleeding, an extensive tissue zone of thermal damage is unavoidable. The consequences are the formation of edema and swelling of the treated tissue. With prostate tissue for example, tissue edema and swelling may result with the patient going into urinary retention requiring catheterization. Thus, improved energy-based methods and devices for ablating, cutting, drilling, and otherwise modifying tissues, would be desirable. 
     A number of medical conditions affect the male urethra causing a variety of symptoms including painful or difficult urination, a swollen prostate, blood in the urine, lower back pain, and the like. Some of these conditions, such as prostatitis, are bacterial infections which can be treated with antibiotics and other drugs. Other conditions, however, such as benign prostatic hyperplasia (BPH) and prostatic carcinoma, result in enlargement of the prostate and obstruction of the urethra, sometimes leading to complete loss of bladder function. 
     Both BPH and prostatic cancer require treatments which remove, resect, or shrink tissue in the prostate surrounding the urethra. Common treatments include transurethral resection of the prostate (TURP) where a resectoscope is placed in the urethra and used to remove excess prostatic tissue. Another procedure, referred to as transurethral incision of the prostate (TUIP), relies on cutting muscle adjacent to the prostate to relax the bladder opening to relieve difficulty in urination. More recently, a procedure referred to as transurethral needle ablation (TUNA) has been introduced where a needle is advanced through the urethra into the prostate and used to deliver energy, such as microwave, radiofrequency, or ultrasound energy, to shrink the size of the prostate, again relieving pressure on the urethra. Laser resection or ablation using transurethral optical fibers also finds use. 
     One minimally invasive laser resection protocol is photoselective vaporization of the prostate (PVP) where a laser beam with output powers ranging from 60 to 120 W is directed from the urethra against prostatic tissue to achieve irradiance (power density) levels over a certain volumetric power density, referred to as a vaporization threshold, below which tissue coagulation rather than vaporization occurs. As the irradiance level increases above the vaporization threshold, tissue vaporization increases and coagulation decreases. Lasers, even those having the highest possible beam quality, produce divergent beams. Therefore, the laser spot size enlarges with increasing probe distance from the tissue, and the power density decreases, reducing the rate of vaporization. Hence, in order to maximize the rate of tissue vaporization and thereby limit the extent of the zone of thermal damage characterized by tissue coagulation left after the procedure, the physician must steadily hold the fiber a fixed distance (e.g., 1-2 mm) away from the tissue and slowly scan the beam over the target tissue without varying the distance. Clearly, the effectiveness and duration of this procedure is highly dependent on the skill of the treating physician and the use of a high-power laser. 
     While generally successful, none of these methods are adequate to treat all patients and all conditions. In particular, patients having severe tissue intrusion into the urethral lumen resulting from BPH or prostatic cancer are difficult to treat with minimally invasive protocols which rely on tissue shrinkage rather than resection. Additionally, those treatments which resect tissue often cause substantial bleeding which can be difficult to staunch. Thus, many of these patients will eventually require conventional surgical resection or follow-up procedures to stop bleeding. 
     For these reasons, it would be desirable to provide alternative and improved tissue-modifying systems which rely on the application of energy from one or more sources to the tissue. In particular, it would be desirable to provide minimally invasive methods and devices which provide for enlarging the luminal area and/or volumetric resection of tissue surrounding the urethra. It would be particularly desirable if such methods and devices were transurethrally introduced and provided for rapid removal or destruction of such tissues surrounding the urethra where the removal or destruction products can be removed from the lumen to relieve pressure on the urethra, even where large volumes of tissue are being removed. It would be particularly desirable if the methods and devices allowed for controllable tissue resection and/or ablation depth from very shallow depths to several millimeters or deeper. It would also be advantageous if the ablation could simultaneously cauterize treated tissue to limit bleeding. It would also be desirable if the depth of residual coagulated tissue that remains after tissue ablation were minimized or completely eliminated. It would be a further advantage if the use of a high-power laser were not required. It would be particularly beneficial if the methods and devices allowed for rapid and controlling tissue ablation or resection which is less dependent on skill of the treating physician. Methods and devices for performing such protocols should present minimal risk to the patient, should be relatively easy to perform by the treating physician, and should allow for alleviation of symptoms with minimal complications and side effects even in patients with severe disease. At least some of these objectives will be met by the inventions described below. 
     2. Description of the Background Art 
     The use of water or other fluid jets as waveguides for carrying a laser beam for cutting and other manufacturing operations is described in U.S. Patent Application No. 2007/0278195, published Canadian application 2,330436 A1, PCT publication WO 99/56907, and U.S. Pat. Nos. 7,163,875; 5,902,499; and 5,773,791. U.S. Patent Application No. 2007/0025874 describes the use of laser fluid jets for disinfecting hands. The use of lasers for cutting biological tissue is described in U.S. Patent Application No. 2002/0128637 and for ablating prostate tissue is described in U.S. Pat. Nos. 5,257,991; 5,514,669; and 6,986,764. Use of a transurethral endoscope for bipolar radiofrequency prostate vaporization is described in Boffo et al. (2001)  J. Endourol.  15:313-316. Pressurized water streams for effecting surgical incisions are described in U.S. Pat. Nos. 7,122,017 and 5,620,414, and for drilling teeth are described in U.S. Pat. Nos. 7,326,054. 5,785,521 and 6,607,524 describe the use of laser energy to cause thermo-elastic failure and fracture of hard biological materials combined with water/air technology to cool and remove (or further fracture) the already fractured material and debris from the treatment site. Radiofrequency discharge in saline solutions to produce tissue-ablative plasmas is discussed in Woloszko et al. (2002)  IEEE Trans. Plasma Sci.  30:1376-1383 and Stalder et al. (2001)  Appl. Phys. Lett.  79:4503-4505. Air/water jets for resecting tissue are described in Jian and Jiajun (2001)  Trans. ASME  246-248. US2005/0288639 described a needle injector on a catheter based system which can be anchored in a urethra by a balloon in the bladder. U.S. Pat. Nos. 6,890,332; 6,821,275; and 6,413,256 each describe catheters for producing an RF plasma for tissue ablation. Other patents and published applications of interest include: U.S. Pat. Nos. 7,015,253; 6,953,461; 6,890,332; 6,821,275; 6,451,017; 6,413,256; 6,378,525; 6,296,639; 6,231,591; 6,217,860; 6,200,573; 6,179,831; 6,142,991; 6,022,860; 5,994,362; 5,872,150; 5,861,002; 5,817,649; 5,770,603; 5,753,641; 5,672,171; 5,630,794; 5,562,703; 5,322,503; 5,116,615; 4,760,071; 4,636,505; 4,461,283; 4,386,080; 4,377,584; 4,239,776; 4,220,735; 4,097,578; 3,875,229; 3,847,988; US2002/0040220; US2001/0048942; WO 93/15664; and WO 92/10142. 
     BRIEF SUMMARY OF THE INVENTION 
     Methods, devices, and systems according to the present invention provide for delivery of coherent light and fluid energy to ablate, resect, drill, cut, or otherwise modify tissue. The tissues to be treated can be soft tissue, such as muscle, organ tissue, nerve tissue, cerebral tissue, skin tissue, glandular tissue or the like, or can be hard tissue, such as tooth, bone, cartilage, or the like. Particular treatments include ablation, such volumetric tissue ablation where volumes or regions of the tissue are vaporized, shrunk, necrosed or the like. The tissue modification can also be cutting where the tissue is severed into pieces or regions along a resection plane, or can be drilling where a hole is formed into the tissue, such as drilling into a tooth, or the like. 
     The present invention is particularly intended for treating/modifying soft and hard biological tissue. Depending on the power levels, treatment times, and treatment patterns selected, the present invention can provide for tissue resection, e.g. cutting along a line of tissue; tissue volume reduction; tissue surface modification; and the like. A particular advantage of the present invention arises from the simultaneous delivery of both fluid energy (constant or pulsating) in the form of a pressurized liquid medium and coherent light energy which will be propagated with constant power density through the fluid medium by total internal reflection thereby eliminating the need of laser focus-distance control. Where the pressurized fluid medium is principally relied on for cutting or tissue ablation, the coherent light can be delivered at an energy level selected to provide cauterization, i.e. the staunching of bleeding which would otherwise occur as a result of the tissue resection or ablation. Alternatively, by using higher coherent light energy levels, the coherent light can work together with the pressurized fluid stream to achieve faster, deeper, or otherwise enhanced cutting, tissue volume reduction, or other tissue modifications with significantly diminished laser power requirements as compared to current treatments such as photoselective vaporization of the prostate (PVP). 
     Specific prostate treatments according to the present invention comprise positioning a coherent light and fluid energy source within the urethra and directing a fluid stream carrying the energy radially outwardly from the energy source toward the urethral wall within the prostate. The fluid stream will usually be moved relative to the urethra to remove a pre-defined volume of prostate tissue surrounding the urethral lumen in order to partially or fully relieve the compression and/or obstruction. In other embodiments, the treatments of the present invention may be combined with chemotherapy and other forms of drug delivery, as well as treatment with external X-ray and other radiation sources and administration of radiopharmaceuticals comprising therapeutic radioisotopes. For example, one or more drugs may be combined with the saline or other fluid which is being delivered. The combination liquid/coherent light delivery can be used to both resect tissue and wash the tissue away while leaving intra-prostatic blood vessels, capsule, and sphincter muscle undamaged. 
     Benefits of the high pressure liquid/light energy source include reduced or no bleeding with reduced or no need for cauterization and decreased risk of perforating or otherwise damaging the capsule of sphincter muscles. Alternatively, the device which is used to position the fluid/light energy source can be utilized to separately deliver a desired chemotherapeutic or other drug (as just set forth), either before, during, or after energy treatment according to the present invention. While the present invention is specifically directed at transurethral treatment of the prostate, certain aspects of the invention may also find use in the treatment of other body lumens, organs, passages, tissues, and the like, such as the ureter, colon, esophagus, lung passages, bone marrow, and blood vessels. 
     Thus, in a first aspect of the present invention, methods for modifying tissue comprise generating a stream of a light transmissive fluid medium, such as saline, water, alcohol, liquefied CO 2  and other liquefied gases (gases which are liquids at the pressure and temperature of use), fluid containing drug compounds such as vasocontricting agents (to reduce bleeding) and/or anesthetic agents (to reduce pain) and/or anti-inflammatory agents, antibiotics (to reduce infection), or the like. A source of coherent light, such as a laser, is coupled to the light transmissive medium through a waveguide or other optical coupler so that light is transmitted through said stream by total internal reflection. The fluid stream which carries the coherent light is then directed at target tissue, such as within the prostate. 
     While a particular advantage of the present invention is the simultaneous delivery of a pressurized fluid stream and laser or other optical energy, in some instances either the fluid stream or the optical energy may be delivered alone. For example, it may be desirable to deliver the fluid stream without optical energy to perform conventional water jet resection or volume reduction of tissue. After such water jet treatment, the optical energy can be added to cauterize and/or perform a procedure at a higher total energy. Optionally, the pressure, volume, flow velocity, temperature, or other characteristics of the fluid stream may be varied depending on whether optical energy is present, e.g., cauterization may be performed at lower pressures than tissue resection. In all cases the removed tissue and/or remaining tissue can be used for histological evaluation or other diagnostic procedures. It is a particular advantage that the removed tissue has not been vaporized or otherwise damaged to the extent it is with PVP and the subsequent analysis is impaired. 
     The liquid stream may be generated in a variety of ways, typically being delivered under pressure through a nozzle, where the nozzle typically has an area in the range from 0.0005 mm 2  to 5 mm 2 , usually from 0.02 mm 2  to 0.2 mm 2 , and the pressure is in the range from 10 psi to 1000 psi, typically from 50 Psi to 500 Psi. The light which is coupled into the light transmissive fluid will typically have a power level in the range from 10 mW to 40 W, typically from 100 mW to 10 W. Suitable laser sources include solid state lasers. For treating prostate tissue, the stream will be directed radially outward from a location in the urethra within the prostate. 
     Typically, prostate treatment will comprise positioning a probe within the urethra, directing the pressurized stream of light transmissive liquid medium radially outward from the probe to the prostate tissue surrounding the urethra. The coherent light is focused within the stream of liquid medium as the stream is directed at the prostate tissue. In this way, tissue volume reduction of the prostate may be efficiently carried out, while the coherent light can provide cauterization with minimal laser power to reduce the bleeding associated with the treatment. 
     In a second aspect of the present invention, a system for delivering laser or other coherent light energy to tissue comprises a tissue probe, a fluid nozzle on the probe, and a waveguide disposed within the probe. The tissue probe is suitable for introducing into solid tissue, tissue lumens, body cavities, or the like. In the exemplary embodiment, the tissue probe is suitable for transurethral introduction into the prostate so that a distal end of the probe is positioned within the prostate. A nozzle is provided for emitting a stream of light transmissive fluid, and a waveguide transmits coherent light into the fluid so that the fluid acts as a guide for further directing the coherent light to the tissue for treatment. Usually, the tissue probe will be adapted to be advanced through the urethra, but a wide variety of other specific designs would also be available for delivery into solid tissue, body lumens, or body cavities. Probes of the present invention typically have at least one central axial passage for delivering the light transmissive fluid to the nozzle, and the nozzle is typically disposed on the probe to deliver the fluid radially outwardly (laterally) under pressure. 
     In an exemplary embodiment, the probe comprises an outer tube having an axial lumen and an inner fluid delivery tube reciprocally mounted in the axial lumen. A central axial passage is disposed in the inner fluid delivery tube, and the waveguide is disposed in the central axial passage. In this way, the light transmissive fluid can be delivered through the central axial passage and diverted outwardly through the nozzle. The waveguide would be disposed to deliver coherent light through the central axial passage and to reflect or otherwise divert the light radially so that it is focused within the light transmissive fluid being delivered through the nozzle. By focusing the energy as it is emanating from the tissue probe, the light will be delivered through the fluid stream to assist in propagation. 
     In the specific embodiments, the distal end of the inner fluid delivery tube is disposed adjacent to a window in the outer tube. The inner tube may then be reciprocated and/or rotated relative to the outer tube so that the fluid stream and coherent light emanating from the inner fluid delivery tube may be delivered into tissue adjacent to or surrounding the outer tube through the window. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a schematic illustration of a device suitable for performing intraurethral prostatic tissue debulking in accordance with the principles of the present invention. 
         FIG. 2  is a detailed illustration of the pressurized fluid/coherent light delivery mechanism used in the device of  FIG. 1 . 
         FIGS. 2A and 2B  illustrate two alternative arrangements for focusing coherent light from a waveguide into a pressurized liquid stream in the mechanism of  FIG. 2 . 
         FIGS. 3A-3C  illustrate use of the device of  FIG. 1  in performing prostatic tissue debulking. 
         FIGS. 4A-4E  illustrate an alternative design for the tissue debulking device of the present invention, illustrating specific components and features for delivering fluids, inflating balloons, rotating and reciprocating the fluid and light delivery mechanism, and the like. 
         FIG. 5  is a detailed, cross-sectional view of a portion of the rotating and reciprocating fluid and light delivery mechanism of  FIGS. 4A-4E . 
         FIG. 6  illustrates use of the device of  FIGS. 4A-4E  in debulking tissue. 
         FIG. 7  is a schematic illustration of a device constructed in accordance with the present invention suitable for performing tissue cutting or other procedures where an axial pressurized liquid stream is delivered from a distal tip of the device and carries focused coherent light from a waveguide. 
         FIG. 8  illustrates another handheld device constructed in accordance with the principles of the present invention, where the pressurized liquid stream carrying the coherent light is directed laterally from the shaft of the device. 
         FIG. 9  illustrates a robotically deployed pressurized fluid/coherent light delivery mechanism. 
         FIG. 10  illustrates use of the device of  FIG. 7  as a scalpel for cutting tissue. 
         FIG. 11  illustrates the use of the device of  FIG. 8  for drilling a tooth. 
         FIG. 12  illustrates a system for deploying a tissue debulking device similar to that illustrated in  FIGS. 4A-4E  and including a tissue stabilization sheath and schematically illustrating the various drive mechanisms in accordance with the principles of the present invention. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     Referring to  FIG. 1 , an exemplary prostatic tissue debulking device  10  constructed in accordance with the principles of the present invention comprises a catheter assembly generally including a shaft  12  having a distal end  14  and a proximal end  16 . The shaft  12  will typically be a polymeric extrusion including one, two, three, four, or more axial lumens extending from a hub  18  at the proximal end  16  to locations near the distal end  14 . The shaft  12  will generally have a length in the range from 15 cm to 25 cm and a diameter in the range from 1 mm to 10 mm, usually from 4 mm to 8 mm. The shaft will have sufficient column strength so that it may be introduced upwardly through the male urethra, as described in more detail below. 
     The shaft will include a fluid/coherent light energy source  20  positioned near the distal end  14  of the shaft  12 . The source  20 , in turn, is connected to an external light source  22  and light transmissive fluid source  28 . Distal to the energy source  20 , an inflatable anchoring balloon  24  will be positioned at or very close to the distal end  14  of the shaft. The balloon will be connected through one of the axial lumens to a balloon inflation source  26  connected through the hub  18 . In addition to the light source  22 , fluid pump  28 , and balloon inflation source  26 , the hub will optionally further include connections for an aspiration (a vacuum) source  30 , and/or an insufflation (pressurized CO 2  or other gas) source  32 . In the exemplary embodiment, the fluid pump  28  can be connected through an axial lumen (not shown) to one or more port(s)  34  on an inner fluid delivery tube  35 . The aspiration source  30  can be connected to a window or opening  38 , usually positioned proximally of the energy source  20 , while the insufflation source  32  can be connected to a port  36  formed in the wall of shaft  12 . The energy will be directed through the window  38  as described in more detail below. 
     Referring now to  FIG. 2 , the fluid/coherent light energy source  20  is defined by window  38  in the wall of shaft  12 . The inner fluid delivery tube  35  is reciprocatably and rotatably mounted within a central lumen of the shaft  12  so that the port  34  may be rotated and/or axially advanced and retracted within the window relative to the shaft. The inner fluid delivery tube  35  has a central passage  40  which is attachable to the transmissive fluid pump  28  through the hub  18  to carry the transmissive fluid under pressure and emit a fluid or jet stream through the port  34  in a lateral direction. An optical waveguide  42  is also positioned within the central passage  40  of the inner fluid delivery tube  35 . 
     As shown in  FIGS. 2A and 2B , the light transmissive fiber  42  includes an element  44  ( FIG. 2A ) or  46  ( FIG. 2B ) for transversely or laterally reflecting light transmitted through the fiber so that it may be emitted through the port  34  and into the flowing fluid stream passing therethrough. It will be desirable that the light emitted from the optical waveguide  42  be focused at a point F within the flowing fluid stream so that the light may then be transmitted and propagated through the stream by total internal reflection. Reflective element  44  may have a parabolic or other shaped surface to effect the desired focusing. In contrast, the reflective element  46  may have a flat, non-focusing surface that passes the light through a focusing lens  48 , as shown in  FIG. 2B . 
     Referring now to  FIGS. 3A-3C , the prostatic tissue debulking device  10  is introduced through the male urethra U to a region within the prostate P which is located immediately distal to the bladder B. The anatomy is shown in  FIG. 3A . Once the catheter  10  has been positioned so that the anchoring balloon  24  is located just distal of the bladder neck BN ( FIG. 3B ) the balloon can be inflated, preferably to occupy substantially the entire interior of the bladder, as shown in  FIG. 3C . Once the anchoring balloon  24  is inflated, the position of the prostatic tissue debulking device  10  will be fixed and stabilized within the urethra U so that the energy source  20  is positioned within the prostate P. It will be appreciated that proper positioning of the energy source  20  depends only on the inflation of the anchoring balloon  24  within the bladder. As the prostate is located immediately proximal to the bladder neck BN, by spacing the distal end of the energy delivery region very close to the proximal end of the balloon, the delivery region can be properly located, typically being spaced by a distance in the range from 0 mm to 5 mm, preferably from 1 mm to 3 mm from the bladder neck. After the anchoring balloon  24  has been inflated, light and high fluid energy can be delivered into the prostate for debulking as shown by the arrows in  FIG. 2 , while simultaneously removing the debulked/destroyed tissue and residual fluid by aspiration, typically at both ends of the window, as shown by the arrows  49  in  FIG. 3C . Alternatively, the prostate (urethra) can be insufflated or flushed at a pressure greater than that of the aspiration (exhaust) system to enhance tissue and debris collection. Once the energy has been delivered for a time and over a desired surface region, the energy region can be stopped. 
     As shown in  FIG. 3C , the inner fluid delivery tube  35  may be axially translated and/or rotated in order to sweep the fluid/coherent light stream  47  over the interior of the urethra within the prostate P. The energy carried by the fluid/light stream both ablates the prostatic tissue and cauterizes the tissue to limit bleeding after debulking. Once a sufficient volume of tissue has been removed, the fluid stream and light source may be turned off, the balloon  24  deflated, the catheter  10  removed from the urethra. 
     Referring now to  FIGS. 4A-4E , a device  60  constructed in accordance with the principles of the present invention comprises a central shaft  62  having a window  64  near a distal end thereof. A hypotube  66  is carried in a proximal bushing  68  ( FIG. 4A ) and a threaded region  70  of the hypotube  66  is received within internal threads of the bushing  68 . Thus, rotation of the hypotube can axially advance and retract the hypotube relative to the bushing and central shaft  62 . Typically, rotation and axial movement of the hypotube  66  relative to the bushing  68  and central shaft  62  is achieved by separately controlling the axial and rotational movement of the hypotube, thereby obviating the need for internal threads and allowing for more versatility of movement within the window  64 . 
     The hypotube  66  carries a laser fiber  72  and includes a lumen  74  which can receive and deliver a water or other fluid jet as will be described in more detail below. The central shaft  62  further includes a balloon inflation lumen  76  and lumen  78  for the suction removal of ablated tissue. 
     When introduced through the urethra, the device  60  will typically be covered by a sheath  80  as illustrated in  FIG. 4D  (only a portion of the sheath  80  is shown in  FIG. 4A ). When fully covered with sheath  80 , the window  66  is protected so that it reduces scraping and injury to the urethra as the device is advanced. 
     Once in place, the sheath  80  will be retracted, exposing the window, as illustrated in  FIG. 4E . The hypotube  66  may then be rotated and advanced and/or retracted so that the fluid stream FS which carries the optical energy may be delivered through the delivery port  82 . Additionally, a balloon  84  may be inflated in order to anchor the device  60  within the bladder as previously described. 
     The fiberoptic wave guide  72  is positioned within a lumen  86  of the hypotube  66 , as best seen in  FIG. 5 . Fluid may be delivered through the lumen, surrounding the laser fiber  72  and ejected through the delivery port  82  in a lateral direction. Optical energy delivered through fiber  72  is also reflected laterally and focused by optional lens  88  so that the light is carried by the fluid with internal reflection, as described previously. In use, the hypotube  66  is axially translated within the window  64 , as shown in  FIG. 6 . A fluid stream FS which carries the optical energy is thus directed radially outwardly and against a wall of the body lumen, for example of the urethra U. The energized fluid stream FS is able to ablate a desired depth of tissue T, where the depth can be controlled by the amount of energy delivered and the dwell time or scan time of the fluid stream FS against the tissue. 
     As shown in  FIG. 7 , a handheld device  100  may comprise a shaft  102  having a distal end with a nozzle  104  oriented to deliver a pressurized fluid in an axial stream or water jet FS. A laser fiber  106  is disposed axially within the shaft  102  and terminates in a lens  108  which focuses light into the axial water jet FS. Water or other fluid is delivered under pressure in an annular region  110  of the shaft  102  which surrounds the laser fiber  106  and is enclosed by an outer perimeter of the shaft. The handheld device  100  is capable of delivering an axial water jet or other pressurized fluid stream and is useful for the manual cutting of tissue or bone, as shown in  FIG. 10 . The handheld device  100  is connected to a pressurized fluid source  120 , a light source  122 , and control circuitry  124 , typically by a connecting cord  126 . The user can thus control the fluid pressure, the amount of light energy being introduced into the fluid stream, movement of the nozzle (velocity, direction, limits, etc.) and other aspects of the treatment protocol in addition to the axial and rotational movement parameters using the control circuitry. Optionally, although not illustrated, the nozzle  104  will be adjustable in order to adjust the width and focus of the fluid stream FS in order to allow further flexibility for the treatment. When used for cutting tissue, it can be manipulated much as a scalpel. 
       FIG. 8  illustrates another handheld device  140  where a principle difference with the device of  FIG. 7  is that the water jet or other pressurized fluid stream FS is directed in a lateral direction from shaft  142 , illustrated as a right angle relative to an axis of the shaft  142 . Light is delivered through a laser fiber  144  and reflected, typically by an air mirror  146 , or side firing optical fiber, laterally near a distal end  148  of the shaft  142  so that light enters the lateral water jet or other pressurized fluid stream FS, as described previously. The pressurized fluid stream FS is created through a fixed or adjustable nozzle  150  on the side of the shaft  142 , where the fluid is delivered under pressure through a lumen or other conduit  152  formed within the shaft  142 . As with previous embodiments, a focusing lens  154  is optionally provided to deliver the coherent light from the laser fiber  144  into the water jet or other pressurized fluid stream FS. The device of  FIG. 8  may be used for a variety of procedures, such as tooth drilling as illustrated in  FIG. 11 . The lateral flow handheld device  140  can be held and manipulated by the dentist in a manner similar to conventional dental drills. The distal end  148  of the shaft will be held in the mouth so that the stream FS is directed against the dental surface to be treated. The shaft  142 , laser fiber  144 , and flow lumen  152  will be connected to a water or other fluid source  160 , a suitable laser light source  162 , and control circuitry  164  by connecting cable  166 . 
     As illustrated in  FIG. 9 , a scalpel-type device  180  may be attached to a programmable machine arm  182  so that the systems can be used in robotic or other automatic, programmable systems. The programmable machine arm  182  may be suspended over tissue T to be treated, and the water jet or other pressurized fluid stream FS carrying the coherent light is used to cut or incise the tissue, as illustrated. The programmable machine arm may be moved in any of the X, Y, and/or Z directions, where the control is provided by computer or by a manual control system, for example, guided by a joystick or other manipulator. 
     A system  200  for the automatic deployment of the light fluid delivery device  60  of  FIGS. 4A-4E  is illustrated in  FIG. 12 . The central shaft  62 , hypotube  66 , and sheath  80  of the device are connected to a control shaft  202  which in turn is connected to a base unit  204  which includes motors and control circuitry (not shown) for controlling the relative movements of the shaft, hypotube, and sheath. The base unit  204  in turn will be connected to a pressurized fluid source  210 , a laser or other optical energy source  212 , and an external console or controller  214  which provides an interface for programming and/or manipulating the device  60 . In addition to the device  60 , the system  200  may include an external anchor frame  230  which can be automatically (or manually) advanced and retracted coaxially over the device  60 . The anchor frame  230  typically includes an atraumatic ring  232  for engaging and anchoring the system against tissue after the device has been introduced and the balloon expanded to allow the device to be tensioned. 
     The apparatus and systems of the present invention may include a number of other optional features. For example, blades or other cutting elements could be included within the waste lumen(s)  78  of the device  60  in order to macerate tissue and other debris as it is being aspirated/evacuated and removed. The device  60  or any of the other configurations of the present invention may optionally be provided with imaging and illumination fibers, cameras, or the like, in order to provide for visual monitoring during the procedure. Optical fibers or cameras may be placed anywhere on the device, optionally within the treatment windows as described before. Means may be provided for keeping the cameras, fibers, lenses, or the like, clean so that good images may be obtained. In all of the above embodiments, instead of employing mirrors, the light may be directed into the fluid stream by bending the light fiber. Additionally, depending on the size of the light fiber and proximity of the fluid nozzle, a focusing lens may or may not be necessary. 
     While the above is a complete description of the preferred embodiments of the invention, various alternatives, modifications, and equivalents may be used. Therefore, the above description should not be taken as limiting the scope of the invention which is defined by the appended claims.