A Systematic Review of Thulium Fiber Laser: Applications and Advantages of Laser Technology in the Field of Urology

Patrick Rice,1 Bhaskar K Somani1,2 1Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK; 2Manipal Academy of Higher Education, Manipal, IndiaCorrespondence: Bhaskar K SomaniUniversity Hospital Southampton NHS Trust, Southampton, UKTel +44 2381206873Email bhaskarsomani@yahoo.comAbstract: Laser technology is widely used in urological surgery, from lithotripsy, prostate surgery to en-bloc resection of tumours. While Holmium:YAG has been widely employed over the last two decades, in recent years, there has been a surge of interest in Thulium Fiber Laser (TFL), which offers theoretical advantages of better water absorption and lower stone ablation thresholds. A systematic review was conducted to assess the evidence from clinical research on TFL’s application for lithotripsy and prostate surgery. It identified 357 articles and 8 (1506 patients) were selected, of which 4 clinical studies each investigated TFL enucleation of prostate (ThuFLEP) and TFL lithotripsy. For flexible ureteroscopic lithotripsy (FURSL), stone ablation settings ranged from 0.1– 4 J, and 7– 300 Hz, mean operative time ranged from 23.4– 39.8 minutes and lasing time ranged from 1.2– 10 minutes. For stone dusting in percutaneous nephrolithotomy (PCNL), settings of 0.2 J and 125– 200 Hz were found to be optimal. For ThuFLEP, all studies showed a significant improvement in IPSS (International Prostate Symptom Score), urinary flow rate (Qmax), quality of life measures, and post-void residual volume, with mean operative time ranging from 67– 104.5 minutes. Our review shows that there is limited evidence on the use and clinical outcomes of TFL. ThuFLEP might suggest equivalence to the widely used HoLEP in the available evidence so far. TFL lithotripsy shows promising results but further prospective, randomized trials are required to properly assess its usability, clinical effectiveness and standardisation of the settings for successful adoption of the technology.Keywords: ureteroscopy, percutaneous nephrolithotomy, kidney calculi, BPH, TFL, thulium fiber lase