Ureteroscopy with thulium fiber laser lithotripsy results in shorter operating times and large cost savings

Thulium Fiber Laser Versus Holmium:Yttrium Aluminum Garnet for Lithotripsy: A Systematic Review and Meta-analysis

CONTEXT

Thulium fiber laser (TFL) emerged as a competitor of holmium:yttrium aluminum garnet (Ho:YAG) laser for the treatment of urinary stones.

OBJECTIVE

To compare the efficacy between Ho:YAG and TFL for laser lithotripsy of renal and ureteral stones.

EVIDENCE ACQUISITION

A literature search was conducted using PubMed/Medline, Embase, and Web of Science databases to identify reports published until May 2023. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The primary outcome was to compare the stone-free rate (SFR) between Ho:YAG and TFL for laser lithotripsy.

EVIDENCE SYNTHESIS

Eleven studies met our inclusion criteria, and data from 1286 and 880 patients who underwent, respectively, Ho:YAG and TFL laser lithotripsy were reviewed. Most studies included ureteroscopy (URS) and retrograde intrarenal surgeries as procedures, two included percutaneous nephrolithotomy, and one included URS exclusively. Only two studies reported results in pediatric patients. TFL was associated with a higher SFR (odds ratio [OR] 1.84, 95% confidence interval [CI]: 1.06-3.20; p = 0.031) when no residual fragment is considered, but not when SFR refers to the presence of fragments <3 mm (OR 2.48, 95% CI: 0.98-6.29; p = 0.055) or when only Ho:YAG with MOSES is considered (p = 0.068). According to the stones' location, TFL was associated with higher SFRs than Ho:YAG for renal (OR 3.14, 95% CI: 1.69-5.86; p < 0.001) but not for ureteral (p = 0.8) stones. TFL was associated with a lower intraoperative complication rate (OR 0.34, 95% CI: 0.19-0.63; p < 0.001). No difference was found in major (p = 0.4) or overall (p = 0.4) complication rate, operative time (p = 0.051), and laser time (p = 0.9).

CONCLUSIONS

TFL is a promising laser for the treatment of urinary stones with some advantages over Ho:YAG. Further high-quality studies are needed to confirm these findings and optimize the surgical settings.

PATIENT SUMMARY

The use of thulium fiber laser rather than holmium:yttrium aluminum garnet permits to reach a higher stone-free rate in stones located in the kidney rather than in the ureter.

Comparison of Thulium Fiber Laser versus Holmium laser in ureteroscopic lithotripsy: a Meta-analysis and systematic review

OBJECTIVES

To compare the efficacy and safety of thulium fiber laser (TFL) to holmium: YAG (Ho: YAG) laser in ureteroscopic lithotripsy for urolithiasis.

METHODS

PubMed, Web of Science, Embase, CENTRAL, SinoMed, CNKI database, VIP and Wanfang Database were systematically searched for all relevant clinical trials until September 2023. References were explored to identify the relevant articles. Meta-analysis was carried out for the retrieved studies using RevMan5.4.1 software, and the risk ratio, mean difference and 95% confidence interval were expressed. Statistical significance was set at p < 0.05. The main outcomes of this meta-analysis were stone-free rate (SFR), perioperative outcomes and intraoperative or postoperative complications.

RESULTS

Thirteen studies, including 1394 patients, were included. According to the results of pooled analysis, TFL was associated with significantly higher stone-free rate (SFR) [0.52, 95% CI (0.32, 0.85), P = 0.009], shorter operation time [-5.47, 95% CI (-8.86, -2.08), P = 0.002], and less stone migration [0.17, 95% CI (0.06, 0.50), P = 0.001]. However, there was no significant difference in terms of the laser time, duration of hospital stay, drop of hemoglobin level, total energy, postoperative ureteral stenting, the incidence of intraoperative complications or postoperative complications between TFL and Ho: YAGs.

CONCLUSION

The findings of this study demonstrated several advantages of TFL in terms of higher SFR, shorter operative time and less stone migration.

TRIAL REGISTRATION

The protocol of this systematic review was listed in PROSPERO ( www.crd.york.ac.uk/PROSPERO ) (Protocol number: CRD42022362550).

Experts' recommendations in laser use for the treatment of urolithiasis: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group

PURPOSE

To identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications.

METHODS

After literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified.

RESULTS

Twenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely.

CONCLUSIONS

Laser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse's and generator settings' physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications.

Advances in lasers for the minimally invasive treatment of upper and lower urinary tract conditions: a systematic review

PURPOSE

Technological advancements in laser lithotripsy are expanding into numerous fields of urology, like ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and benign and malignant soft-tissue treatments. Since the amount of research regarding lasers in urology has grown exponentially, we present a systematic review of the most recent and relevant advances encompassing all lasers used in urological endoscopic treatment.

METHODS

We performed a literature search using PubMed (May 2023) to obtain information about lasers for urological purposes. We included only recent data from published articles between 2021 and 2023 or articles ahead of print.

RESULTS

Lasers are widely used in lithotripsy for ureteric, renal, and bladder stones, benign prostate surgery, and bladder and upper tract tumor ablation. While the holmium (Ho:YAG) laser is still predominant, there seems to be more emphasis on pulse modulation and newer lasers such as thulium fiber laser (TFL) and pulsed Tm:YAG laser.

CONCLUSION

The use of lasers and related technological innovations have shown increasing versatility, and over time have proven to be invaluable in the management of stone lithotripsy, treatment of benign and malignant prostate diseases, and urothelial tumors. Laser endoscopic treatment is heavily based on technological nuances, and it is essential to know at least the basics of these technologies. Ultimately the choice of laser used depends on its availability, cost, surgeon experience and expertise.

Navigating urolithiasis treatment: assessing the practicality and performance of thulium fiber laser, holmium YAG, and thulium YAG in real-world scenarios

BACKGROUND

The management of urolithiasis has undergone significant advancements with the introduction of pulsed lasers, particularly the holmium:yttrium-aluminum-garnet (Ho:YAG) laser, which is currently considered the gold standard in endourology. However, the Ho:YAG laser has certain limitations, such as the inability to support small laser fibers (150 μm) and the requirement of a heavy water cooling system, making it challenging to transfer between operating rooms. These limitations have led to the emergence of new laser technologies, including the thulium fiber laser (TFL) and the thulium:yttrium-aluminum-garnet laser (Tm:YAG), as potential alternatives to the Ho:YAG laser.

METHODS

In this review, we aimed to evaluate the effectiveness and safety of TFL, Ho:YAG, and Tm:YAG lasers in real-life scenarios by comparing clinical trial data with laboratory findings. A literature review was conducted, and relevant in vitro studies and clinical trials until March 2023 were analyzed.

RESULTS

The findings indicate that TFL has demonstrated high ablation efficiency for stones of any composition, size, and location, superior the capabilities of Ho:YAG lasers. TFL has shown superior dusting and fragmentation abilities, lower retropulsion, and increased patient safety. The laser parameters, such as ablation efficiency, speed, operative time, dust quality, retropulsion, visibility, temperature safety, and stone-free rate, were compared between laboratory studies and clinical outcomes.

CONCLUSION

Although the number of studies on TFL is limited, the available evidence suggests that TFL represents a significant advancement in laser technology for lithotripsy. However, further research is needed to fully explore the implications and limitations of TFL and Tm:YAG lasers.

Thulium Fiber Laser vs Pulse-Modulated Holmium MOSES Laser in Flexible Ureteroscopy for the Management of Kidney Stones: A Single-Center Retrospective Analysis

Introduction and Objective: The study's primary objective was to compare the laser efficiency and clinical outcomes of two widely used systems, the holmium MOSES laser and the thulium fiber laser (TFL), in managing kidney stones. The secondary outcomes were to evaluate the impact of stone composition on laser efficacy. Methods: We conducted a retrospective review of patients who underwent flexible ureteroscopy (f-URS) for solitary renal calculi between December 2020 and August 2022 at our institution and had a 3-month postoperative CT scan. Patient demographics and stone parameters were recorded, including stone site, size, volume, and density. Intraoperative data were collected and analyzed, including total operative time, ureteroscopy time, lasing time, technique, total energy delivered, and stone composition. All patients underwent a CT scan at 3 months follow-up. We recorded the presence of residual stones and the percentage of stone volume reduction. Ablation efficiency was calculated by dividing the energy utilized (J) by the stone volume (mm3). The ablation speed was calculated by dividing the stone volume (mm3) by the lasing time (seconds). Patients with a stone size <4 mm were deemed stone-free. Results: The MOSES and TFL groups comprised 62 and 49 patients, respectively. There were no significant differences between groups for baseline patient demographics or stone characteristics. The two modalities had comparable total energy, laser time, efficacy, and ablation speeds. No differences were detected in stone-free rates or complications between both groups. When dealing with calcium phosphate stones, we observed that the lasing time was significantly shorter with MOSES than TFL (7.95 vs 10.85 minutes, respectively [p = 0.01]). Conclusions: MOSES and TFL laser systems had comparable efficacy for lithotripsy of renal calculi during f-URS; however, calcium phosphate stones had a longer lasing time with TFL. REB Number: 100210.

Controversies in ureteroscopy: lasers, scopes, ureteral access sheaths, practice patterns and beyond

Ureteroscopy has become an increasingly popular surgical intervention for conditions such as urinary stone disease. As new technologies and techniques become available, debate regarding their proper use has risen. This includes the role of single use ureteroscopes, optimal laser for stone lithotripsy, basketing versus dusting, the impact of ureteral access sheath, the need for safety guidewire, fluoroscopy free URS, imaging and follow up practices are all areas which have generated a lot of debate. This review serves to evaluate each of these issues and provide a balanced conclusion to guide the clinician in their practice.

Endoscopic Conservative Treatment of Upper Urinary Tract Urothelial Carcinoma with a Thulium Laser: A Systematic Review

INTRODUCTION

Thulium lasers (TLs), namely the Thulium fiber laser (TFL) and the Thulium:YAG (Tm:YAG), are being increasingly adopted for the conservative treatment of upper urinary tract urothelial carcinoma (UTUC). However, to date, the real clinical impact of TLs on UTUC management remains not well-characterized. We performed a review of the literature to summarize the current evidence on TLs for UTUC treatment.

MATERIALS AND METHODS

We performed a systematic review in January 2023 using the Embase and Medline online databases, according to the PRISMA recommendations and using the PICO criteria. Outcomes of interest were: (i) to assess the safety and feasibility of TLs in the treatment of UTUC, and (ii) to evaluate the oncological outcomes in terms of tumor recurrence and conservative treatment failure. Moreover, we described TL characteristics and its interaction with soft tissue.

RESULTS

a total of 458 articles were screened, and six full texts including 273 patients were identified. All the included studies were retrospective series. Mean patient age ranged from 66 to 73 years. The indication of a conservative treatment was elective and imperative in 21.7-85% and 15-76% of cases, respectively. Laser power settings varied from 5 to 50 W. No intraoperative complications were reported, and all the procedures were successfully performed. The tumor recurrence rate was 17.7-44%, and the indication to radical nephroureterectomy was 3.7-44% during a follow-up of 6-50 months. Most of the postoperative complications were mild and transient, and ureteral strictures were reported in two studies. Major limitations were the retrospective nature of the studies, the small sample sizes, and the short follow-up.

CONCLUSIONS

TL is an effective and safe technology for endoscopic UTUC treatment. However, current available literature lacks prospective and multicentric studies with large population sizes and long-term follow-up.

Lasers for stone lithotripsy: advantages/disadvantages of each laser source

PURPOSE

The purpose of this article was to make a narrative review of the literature in search of all articles regarding thulium:yttrium-aluminium-garnet (YAG), thulium laser fiber (TFL) and holmium:YAG (Ho:YAG) for lithotripsy from 2020 to 2023. A selection of articles of special interest and best evidence was made in order to give a better perspective on their advantages and disadvantages.

RECENT FINDINGS

New Ho:YAG technologies of as high power, high frequency and pulsed modulations have shown promising results for lithotripsy by reducing retropulsion with good ablation efficiency. High peak power makes it particularly good for percutaneous nephrolithotomy. High intrarenal temperatures and correct setting are still concerning points.TFL has arrived to be one of the main players in flexible ureteroscopy. Being highly efficient and quick, and by producing micro-dusting the laser is quickly heading to become a gold standard. The new pulsed Thulium YAG is the newest laser. For now, only in-vitro studies show promising results with efficient lithotripsy. As the peak power lies between Ho:YAG and TFL it may be able to adequately perform when needing and low power lithotripsy.

SUMMARY

Several new technologies have been developed in the last years for stone lithotripsy. All being efficient and safe if well used. Different advantages and disadvantages of each laser must be taken into consideration to give each laser the proper indication.

Comparing dusting and fragmenting efficiency using the new SuperPulsed thulium fiber laser versus a 120 W Holmium:YAG laser

PURPOSE

Holmium:YAG laser lithotripsy requires high amperage power and has an upper limit of frequency and a minimal fiber size. The technology utilizing thulium-doped fiber offers low pulse energy settings and high pulse frequencies up to 2,400 Hz. We compared the novel SuperPulsed thulium fiber laser (SOLTIVE™; Olympus) to a commercially available 120 W Ho:YAG laser.

MATERIALS AND METHODS

Bench-top testing was conducted with 125 mm³ standardized BegoStones (Bego USA). Time to ablate the stone into particles <1 mm was recorded for efficiency calculations. Finite energy was delivered, and resulting particle sizes were measured to determine fragmentation (0.5 kJ) and dusting (2 kJ) efficiencies. Remaining mass or number of fragments were measured to compare efficacy.

RESULTS

SOLTIVE™ was faster at ablating stones to particles <1 mm (2.23±0.22 mg/s, 0.6 J 30 Hz short pulse) compared to Ho:YAG laser (1.78±0.44 mg/s, 0.8 J 10 Hz short pulse) (p<0.001). Following 0.5 kJ of energy in fragmentation testing, fewer particles >2 mm remained using SOLTIVE™ than Ho:YAG laser (2.10 vs. 7.20 fragments). After delivering 2 kJ, dusting (1.05±0.08 mg/s) was faster using SOLTIVE™ (0.1 J 200 Hz short pulse) than 120 W 0.46±0.09 mg/s (0.3 J 70 Hz Moses) (p=0.005). SOLTIVE™ (0.1 J 200 Hz) produced more dust particles <0.5 mm (40%) compared to 24% produced by the P120 W laser at 0.3 J 70 Hz Moses and 14% at 0.3 J 70 Hz long pulse (p=0.015).

CONCLUSIONS

The efficacy of SOLTIVE™ is superior to the 120 W Ho:YAG laser by producing smaller dust particles and fewer fragments. Further studies are warranted.

Prospective Comparison of Thulium and Holmium Laser Lithotripsy for the Treatment of Upper Urinary Tract Lithiasis

Background

Lithotripsy with holmium:yttrium-aluminum-garnet (Ho:YAG) laser is the current gold standard for treating stones of the upper urinary tract (UUT). The recently introduced thulium fiber laser (TFL) has the potential to be more efficient and as safe as Ho:YAG.

Objective

To compare the performance and complications between Ho:YAG and TFL for UUT lithotripsy.

Design setting and participants

This was a prospective single-center study of 182 patients treated between February 2021 and February 2022. In a consecutive approach, laser lithotripsy was performed via ureteroscopy with Ho:YAG for 5 mo, and then with TFL for 5 mo.

Outcome measurements and statistical analysis

Our primary outcome was stone-free (SF) status at 3 mo after ureteroscopy with Ho:YAG versus TFL lithotripsy. Secondary outcomes were complication rates and results regarding the cumulative stone size. Patients were followed at 3 mo with abdominal imaging (ultrasound or computed tomography).

Results and limitations

The study cohort comprised 76 patients treated with Ho:YAG laser and 100 patients treated with TFL. Cumulative stone size was significantly higher in the TFL than in the Ho:YAG group (20.4 vs 14.8 mm; p = 0.01). SF status was similar in both groups (68.4% vs 72%; p = 0.06). Complication rates were comparable. In subgroup analysis, the SF rate was significantly higher (81.6% vs 62.5%; p = 0.04) and the operative time was shorter for stones measuring 1-2 cm, whereas the results were similar for stones <1 cm and >2 cm. The lack of randomization and single-center design are the main limitations of the study.

Conclusions

TFL and Ho:YAG lithotripsy are comparable in terms of the SF rate and safety for the treatment of UUT lithiasis. According to our study, for a cumulative stone size of 1-2 cm, TFL is more effective than Ho:YAG.

Patient summary

We compared the efficiency and safety of two laser types for the treatment of stones in the upper urinary tract. We found that stone-free status at 3 months did not significantly differ between the holmium and thulium lasers.

Thulium fibre laser vs holmium: yttrium-aluminium-garnet laser lithotripsy for urolithiasis: meta-analysis of clinical studies

OBJECTIVE

To compare and assess the clinical outcomes between thulium fibre laser (TFL) and holmium: yttrium-aluminium-garnet (Ho:YAG) laser endoscopic lithotripsy of urolithiasis through a meta-analysis of comparative clinical studies.

METHODS

A systematic literature search was performed in May 2022, grey literature search in July 2022. Comparative clinical studies were evaluated according to Cochrane recommendations. Assessed outcomes include the stone-free rate (SFR), complication rate, operative time (OT), laser utilisation time (LUT), ablation rate (stone volume/laser time), ablation efficiency (energy use/stone volume), total energy usage, degree of retropulsion, and hospital stay. Risk ratios (RRs) and standardised mean differences (SMDs) were extrapolated. Subgroup analyses, heterogeneity, publication bias, and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessment were performed. International Prospective Register of Systematic Reviews (PROSPERO) registration: CRD42022300788.

RESULTS

A total of 15 studies with 1698 cases were included in this review. The outcome of SFR showed no significant between-group difference (RR 1.09, 95% confidence interval [CI] 0.99-1.20). However, subgroup analysis of TFL vs Ho:YAG with no pulse modulation showed a SFR favouring TFL (RR 1.11, 95% CI 1.01-1.23). The composite postoperative complication rate was comparable between the two intervention groups (RR 0.97, 95% CI 0.66-1.43). OT, LUT and ablation rate were significantly better for TFL than Ho:YAG (SMD -1.19, 95% CI -1.85 to -0.52; SMD -1.67, 95% CI -2.62 to -0.72; SMD 0.59, 95% CI 0.15-1.03; respectively). The degree of retropulsion was significantly lower for TFL than Ho:YAG without pulse modulation (SMD -1.23, 95% CI -1.74 to -0.71). Ablation efficiency, total energy usage, and hospital stay were all comparable. Based on GRADE criteria, the evidence certainty was determined to be very low.

CONCLUSION

Overall, there was no between-group difference for the SFR. However, compared to Ho:YAG with no pulse modulation, TFL rendered a better SFR. Shorter OT and LUT, a lesser degree of retropulsion, and a better ablation rate were noted in favour of the TFL. There was no overall between-group difference for composite postoperative complication rate, ablation efficiency, total energy usage, and hospital stay. Currently, the available clinical evidence was assessed to be of very low certainty.

Unfavorable factors in accessing the pelvicalyceal system during retrograde flexible ureteroscopy (fURS)

Flexible ureteroscopy (fURS) is a well-established procedure for treating multiple upper-urinary tract pathologies, particularly renoureteral lithiasis. Endoscopes have undergone significant advancements, including miniaturization, improved optics, and increased maneuverability. In addition, advancements in accessory instruments, such as the performance of laser fibers, guidewires, and extraction probes, have played a significant role in improving the overall performance of flexible ureteroscopy procedures. However, despite these advancements, unique circumstances can make achieving optimum results during flexible ureteroscopy challenging. These include congenital renal anomalies (horseshoe kidneys, ectopic kidneys, rotation anomalies), as well as the unique intrarenal anatomy (infundibulopelvic angle, infundibular length) or the specifications of the endoscope in terms of maneuverability (active and passive deflection). This review explored challenging scenarios during flexible ureteroscopy procedures in the pyelocaliceal system.

Thulium fiber laser lithotripsy: Is it living up to the Hype?

Objective

The holmium:yttrium-aluminium-garnet laser (Ho:YAG) has been the gold standard for laser lithotripsy over the last three decades. After demonstrating good in vitro efficacy, the thulium fiber laser (TFL) has been recently released in the market and the initial clinical results are encouraging. This article aims to review the main technology differences between the Ho:YAG laser and the TFL, discuss the initial clinical results with the TFL as well as the optimal settings for TFL lithotripsy.

Methods

We reviewed the literature focusing on the technological aspects of the Ho:YAG laser and TFL as well as the results of in vitro and in vivo studies comparing both technologies.

Results

In vitro studies show a technical superiority of TFL compared to the Ho:YAG laser and encouraging results have been demonstrated in clinical practice. However, as TFL is a new technology, limited studies are currently available, and the optimal settings for lithotripsy are not yet established.

Conclusion

TFL has the potential to be an alternative to the Ho:YAG laser, but more reports are still needed to determine the optimal laser for lithotripsy of urinary tract stones when considering all parameters including effectiveness, safety, and costs.