[Urethral reconstruction]. / Harnröhrenrekonstruktion.

A urethral stricture is an abnormal narrowing of the urethra due to spongiofibrosis of the urethral mucosa and the underlying corpus spongiosum. The diagnostics include uroflowmetry, sonography and radiology. For penile strictures the success rate of endoscopic treatment is low. Therefore, urethroplasty should always be performed, preferably using oral mucosa. Depending on the complexity, reconstruction must be carried out in one or multiple stages. For short bulbous strictures endoscopic treatment can primarily be carried out. In the case of recurrence urethroplasty should be carried out. The indications for urethral reconstruction are primarily given for long bulbous strictures. Depending on the length and extent of the stricture, a scar resection and end-to-end anastomosis, non-transsecting end-to-end anastomosis or augmentation urethroplasty can be performed. Perineal urethrostomy (the so-called boutonnière procedure) is a treatment option for patients with complex strictures or for patients who want a straightforward solution.

[Prostate Surgery for Benign Prostatic Syndrome >200 ml: Endoscopic, Robotic, or Open Approach]. / Prostatachirurgie beim benignen Prostatasyndrom >200 ml: Endoskopisch, robotisch oder doch offen?

Surgical approaches for benign prostatic hyperplasia have evolved and diversified over the past decades. While numerous studies document the efficacy of surgical procedures for moderate prostate sizes, there remains insufficient data for large prostate volumes >200 ml, leaving important questions unanswered regarding their effectiveness and safety. Consequently, selecting and adapting suitable therapeutic options for this specific patient group often poses a significant challenge. In this context, this review comprehensively summarizes and discusses current insights into surgical treatment options for large prostate volumes (>200 ml) following an extensive literature review.In summary, the surgical treatment of prostate volumes >200 ml is a challenge regardless of the chosen surgical method. Minimally invasive approaches should be considered standard practice today. Anatomical endoscopic enucleation of the prostate is a size-independent method and has the lowest morbidity. As it may be performed in spinal anaesthesia, endoscopic enucleation is feasible in patients with an increased anaesthetic risk. In extremely large prostate glands, the procedure poses challenges even for highly experienced surgeons. Especially in obese patients, the surgeon should be familiar with different exit strategies. Robot-assisted simple prostatectomy provides a minimally invasive alternative that may also treat pathologies such as diverticula or large bladder stones in the same surgical session. Due to its transabdominal approach, the morbidity and anaesthetic risk is comparatively higher. Each centre and surgeon should individually decide in which method they have the greatest expertise and which option is best suited for the specific case. In cases of limited expertise, it is advisable to refer patients to a centre with appropriate specialization.

[Development of endoscopic enucleation of the prostate]. / Entwicklung der endoskopischen Enukleation der Prostata.

This article deals with lasers from their initial description to the most advanced applications in the treatment of benign prostate enlargement.

[How good are we really? Incidence of postoperative bleeding requiring intervention and intraoperative electrocoagulation during Thulium laser enucleation of the prostate]. / Wie gut sind wir wirklich? Interventionsbedürftige Nachblutungen und intraoperative Elektrokoagulationen bei der Thulium-Laser-Enukleation der Prostata.

The need for intervention due to postoperative bleeding represents a significant complication in Thulium Laser Enucleation of the Prostate (ThuLEP). This study aimed to retrospectively analyse this complication in the treatment of benign prostatic enlargement. This study focuses on investigating potential causative factors for postoperative bleeding requiring intervention as well as the use of intraoperative electrocoagulation. A total of 503 ThuLEP procedures performed between 08/2021 and 07/2022 were examined. Postoperatively, 4.2% (n=21) of patients experienced bleeding requiring intervention. Study data revealed a significant association between these instances of bleeding and a high prostate volume (p=0.004), high enucleation weight (p=0.004), and intraoperative electrocoagulation (p=0.048). In total, intraoperative electrocoagulation was applied in 41.2% (n=207) of cases. In these cases, statistically significant factors leading to the application of electrocoagulation included intraoperative capsule perforation (p=0.005) and high enucleation weight (p=0.002).

[Should we all switch to en-bloc resection of bladder tumours?] / Sollten wir alle zur En Bloc Resektion von Blasentumoren wechseln?

In En-Bloc Resection of Bladder Tumours (ERBT), tumours are not removed in fragments, but are dissected in one layer and, if possible, extracted in one piece. This method represents a significant shift in the surgical management of non-muscle-invasive bladder tumours, providing multiple benefits over the traditional transurethral resection of the bladder (TUR-B). The histological analysis of ERBT specimens is more accurate, enhancing diagnostic precision. Additionally, the presence of detrusor muscle in ERBT specimens is more frequent, indicating a more complete removal of the tumours. Recent years have seen the consolidation of a robust evidence base emphasizing the advantages of ERBT. Notably, a multicentric, prospective randomized trial has recently revealed a significant reduction in recurrence rates at 12 months follow-up compared with TUR-B. Experienced endourologists should explore this technique, as it may soon become the standard of care. The technique's elegance and effectiveness make it too important to be ignored.

[Minimally-Invasive Surgical Techniques (MIST): Shedding Light on the Mist]. / Minimal Invasive Surgical Techniques (MIST): wie relevant ist der ganze Mist?

As life expectancy increases and there is growing demand for BPH treatments, innovative technologies have been developed, allowing for swift recovery, symptom relief, low complication rates, and the possibility of performing procedures on an outpatient basis, often under local anaesthesia. This review aims to describe the outcomes of newly developed minimally-invasive surgical therapies (MIST) for BPH treatment in terms of functional voiding parameters and sexual function. These therapies are categorized into primarily ablative (Aquablation [Aquabeam]), non-ablative (Prostatic Urethral Lift (PUL, Urolift), temporary implantable devices [iTind]), and secondarily ablative procedures (convective water vapor ablation, Rezum, Prostate Artery Embolization [PAE]). All MIST technologies have advanced the medical care of patients with BPH while preserving ejaculation. However, there is a shortage of long-term data specifically addressing re-intervention rates and the preservation of functional voiding parameters. Although there is promising data from regulatory trials and randomized studies, all MIST therapies are potentially associated with severe complications. Patients considering such methods must be thoroughly informed about their inferiority compared with established transurethral procedures like TUR-P and enucleation.

[Imaging in nephroureterolithasis]. / Bildgebung bei Nephroureterolithiasis.

In the acute diagnostics of a suspected nephroureterolithiasis, ultrasonography should be the examination modality of choice. In cases of suspected urolithiasis, unclear flank pain with fever or in cases of a solitary kidney, a noncontrast computed tomography (CT) scan should always subsequently be performed. If the sonography findings are inconclusive in pregnant women a magnetic resonance imaging (MRI) examination can be considered. If there are indications for urinary diversion, a retrograde imaging study should be performed as part of the urinary diversion. This or CT imaging is also suitable for preinterventional imaging before shock wave lithotripsy, percutaneous nephrolithotomy or ureteroscopy. Postinterventional imaging is not always necessary and sonography is often sufficient. In a conservative treatment approach an abdominal plain X­ray can be used for follow-up assessment.

[Lichen sclerosus in clinically relevant phimosis: incidence, risk factors, and association with squamous cell carcinoma of the penis]. / Lichen sclerosus bei klinisch relevanter Phimose: Häufigkeit, Risikofaktoren und Assoziation mit Plattenepithelkarzinomen des Penis.

BACKGROUND: Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory skin disease. It is frequently diagnosed following circumcision. Diabetes mellitus (DM) is a known risk factor in men. Malignant pathology is more common in patients with LSA. Data on LSA in men are very limited. OBJECTIVE: This study investigated the incidence of LSA in men who had undergone circumcision. Risk factors and likelihood of malignancy were captured. MATERIALS AND METHODS: Data of 215 patients were retrospectively analyzed. As potential risk factors, age, body mass index (BMI), DM, coronary heart disease (CHD) and arterial hypertension were identified. Data were analyzed and displayed graphically as spike histograms. Logistic regression was applied. Age and BMI were transformed using cubic spline function. RESULTS: Mean age of patients was 37 years (±â€¯22 years). Mean BMI was 26.4. In all, 24% of the patients had a BMI > 30. Of the patients, 11% had DM, 5.1% had CHD, and 19% had arterial hypertension. Pathology revealed LSA in 47% of patients. Malignant disease was apparent in 3.3% of patients (2.7% without concomitant LSA, 4% with concomitant LSA). Age (55 vs 20 years, odds ratio [OR]: 3.210 [1.421, 7.251]) was a significant risk factor for LSA. BMI (30 vs 22 kg/m2, OR 1.059 [0.614, 1.828]) and DM (OR: 0.42 [0.148, 1.192]) elevated the risk for LSA. CONCLUSION: We saw high rates of LSA in patients had undergone circumcision. Higher age represents a significant risk factor. In 3.3%, final pathology revealed squamous cell carcinoma of the penis. Therefore, pathologic work-up of circumcision specimen is mandatory.

[Randomised comparison of different exit strategies in hydrocele resection]. / Randomisierter Vergleich unterschiedlicher Exit-Strategien bei der Hydrozelenresektion.

INTRODUCTION: Adult hydrocele is a benign enlargement of the scrotum seen in approximately 60/100,000 men >18 years of age. Surgical resection of the hydrocele has been established as the gold standard for the treatment of symptomatic hydroceles. Postoperative complications are common with this surgery. Due to the lack of guidelines for the therapy of hydrocele, treatment is based primarily on clinical experience. The aim of the study was to conduct a randomised study on the influence of drains on complications in hydrocele resection according to von Bergmann. MATERIAL AND METHODS: A total of 60 patients were prospectively randomised into three groups. The groups each received an Easy-Flow drainage, a Cuti-Med Sorbact drainage, or no drainage. Haematoma and swelling, postoperative bleeding, infection, epididymal injury and revision surgery were clinically diagnosed as complications. RESULTS: A complication was observed in 31.6% (n=19/60) of all patients. The complication rate was 50% (n=10) for the easy-flow drainage, 30% (n=6) for the Cuti-Med-Sorbact and 15% (n=3) for the group without drainage. Overall, a haematoma with swelling was observed most frequently, in 20% (n=12) of the cases. Revision surgery was required in 5% (n=3) of cases. Epididymal injuries were found histologically in 10% (n=6). Comparing the collective with the Easy-Flow drainage with the collective without drainage, the occurrence of complications was observed significantly more frequently in the drainage group (p<0.018). A statistically significant correlation regarding complications between the group of Cuti-Med-Sorbact and no drainage could not be shown (p<0.25). CONCLUSIONS: Hydrocele resection is a complicated procedure. Based on the data presented here, the insertion of a drain is associated with an increased risk of postoperative complications. If the decision to insert a wound drainage is made intraoperatively, the Cuti-Med-Sorbact drainage appears to be associated with fewer complications.

Influence of Prostate Cancer on Thulium Vapoenucleation of the Prostate-A Multicentre Analysis.

Purpose: Prostate cancer (PCa) and benign prostatic hyperplasia (BPH) are common in elderly men. Data on the laser-based surgery known as thulium vapoenucleation of the prostate (ThuVEP) in PCa patients are rare. Our objective was to analyse the feasibility, safety and functional outcome of ThuVEP in patients with lower urinary tract symptoms (LUTS) and PCa. Methods: Multicentre study, including 1256 men who underwent ThuVEP for LUTS. Maximum urinary flow rate (Qmax) and post-void residual volume (PVR) were measured perioperatively. The International Prostate Symptome Score (IPSS) was measured perioperatively and at follow-up (FU). Perioperative complications were captured. Reoperation rate was captured at FU. Results: Of 994 men with complete data, 286 (28.8%) patients had PCa. The most common Gleason score was 3 + 3 in 142 patients (49.7%). Most common was low-risk PCa (141 pts; 49.3%). PCa patients were older, had smaller prostates and had higher prostate-specific antigen (PSA) values (all p < 0.001). Comparing non-PCa and PCa patients, no differences occurred perioperatively. IPSS, quality of life and PVR decreased (all p < 0.001) and Qmax improved (p < 0.001) in both groups. Reoperation rates did not differ. The results of low- vs. intermediate-/high-risk PCa patients were comparable. Conclusion: ThuVEP is a safe and long-lasting treatment option for patients with LUTS with or without PCa. No differences occurred when comparing low- to intermediate-/high-risk PCa patients.

Hospital rating websites play a minor role for uro-oncologic patients when choosing a hospital for major surgery: results of the German multicenter NAVIGATOR-study.

PURPOSE: Hospital rating websites (HRW) offer decision support in hospital choice for patients. To investigate the impact of HRWs of uro-oncological patients undergoing elective surgery in Germany. METHODS: From 01/2020 to 04/2021, patients admitted for radical prostatectomy, radical cystectomy, or renal tumor surgery received a questionnaire on decision-making in hospital choice and the use of HRWs at 10 German urologic clinics. RESULTS: Our study includes n = 812 completed questionnaires (response rate 81.2%). The mean age was 65.2 ± 10.2 years; 16.5% were women. Patients were scheduled for prostatectomy in 49.1%, renal tumor surgery in 20.3%, and cystectomy in 13.5% (other 17.1%). Following sources of information influenced the decision process of hospital choice: urologists' recommendation (52.6%), previous experience in the hospital (20.3%), recommendations from social environment (17.6%), the hospital's website (10.8%) and 8.2% used other sources. Only 4.3% (n = 35) used a HRW for decision making. However, 29% changed their hospital choice due to the information provided HRW. The most frequently used platforms were Weisse-Liste.de (32%), the AOK-Krankenhausnavigator (13%) and Qualitaetskliniken.de (8%). On average, patients rated positively concerning satisfaction with the respective HRW on the Acceptability E-Scale (mean values of the individual items: 1.8-2.1). CONCLUSION: In Germany, HRWs play a minor role for uro-oncologic patients undergoing elective surgery. Instead, personal consultation of the treating urologist seems to be far more important. Although patients predominantly rated the provided information of the HRW as positive, only a quarter of users changed the initial choice of hospital.

Long-term evaluation of outcomes and costs of urolithiasis re-interventions after ureteroscopy, extracorporeal shockwave lithotripsy and percutaneous nephrolithotomy based on German health insurance claims data.

PURPOSE: Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term follow-up are rare. We aimed to analyze re-intervention rates, costs and sick leave days of URS, SWL and PCNL patients within 7 years. METHODS: This retrospective cohort study was based on German health insurance claims data. We included 54,609 urolithiasis patients incidentally treated in 2008-2010. We investigated time to re-intervention, number of sick leave days and healthcare costs. We applied negative binomial, extended Cox regression and gamma models. RESULTS: 54% were incidentally treated with URS, 40% with SWL and 6% with PCNL. 15% of URS, 26% of SWL and 23% of PCNL patients were re-treated within 7 years. Time to re-intervention was significantly lower for PCNL (955 days) and SWL (937 days) than URS (1078 days) patients. Costs for incident treatment were significantly higher for PCNL (2760€) and lower for SWL (1342€) than URS (1334€) patients. Yet, total costs including re-interventions were significantly higher for PCNL (5783€) and SWL (3240€) than URS (2979€) patients. Total number of sick leave days was increased for PCNL (13.0 days) and SWL (10.1 days) compared to URS (6.8 days) patients. CONCLUSION: This study describes outcomes after use of different intervention options for urolithiasis. URS patients showed longest time free of re-interventions and lowest number of sick leave days. Although SWL patients initially had lower costs, URS patients had lower costs in the long run. PCNL patients showed high costs and sick leave days.

[Image-guided biopsy of the prostate gland]. / Bildgesteuerte Biopsie der Prostata.

The recommendations on carrying out a multiparametric magnetic resonance imaging (mpMRI) for the primary diagnostics and during active surveillance of prostate cancer, include as a consequence an image-guided sampling from conspicuous areas. In doing so, the information on the localization provided by mpMRI is used for a targeted biopsy of the area suspected of being a tumor. The targeted sampling is mainly performed under sonographic control and after fusion of MRI and ultrasound but can also be (mostly in special cases) carried out directly in the MRI scanner. In an ultrasound-guided biopsy, it is vital to coregister the MR images with the ultrasound images (segmentation of the contour of the prostate and registration of suspect findings). This coregistration can either be carried out cognitively (transfer by the person performing the biopsy alone) or software based. Each method shows specific advantages and disadvantages in the prioritization between diagnostic accuracy and resource expenditure.

Outcomes and costs of ureteroscopy, extracorporeal shockwave lithotripsy, and percutaneous nephrolithotomy for the treatment of urolithiasis: an analysis based on health insurance claims data in Germany.

PURPOSE: Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term health and economic outcomes based on claims data are rare. Our aim was to analyze URS, SWL, and PCNL regarding complications within 30 days, re-intervention, healthcare costs, and sick leave days within 12 months, and to investigate inpatient and outpatient SWL treatment as the latter was introduced in Germany in 2011. METHODS: This retrospective cohort study based on German health insurance claims data included 164,203 urolithiasis cases in 2008-2016. We investigated the number of complications within 30 days, as well as time to re-intervention, number of sick leave days and hospital and ambulatory health care costs within a 12-month follow-up period. We applied negative binomial, Cox proportional hazard, gamma and two-part models and adjusted for patient variables. RESULTS: Compared to URS cases, SWL and PCNL had fewer 30-day complications, time to re-intervention within 12 months was decreased for SWL and PCNL, SWL and PCNL were correlated with a higher number of sick leave days, and SWL and particularly PCNL were associated with higher costs. SWL outpatients had fewer complications, re-interventions and lower costs than inpatients. This study was limited by the available information in claims data. CONCLUSION: URS cases showed benefits in terms of fewer re-interventions, fewer sick leave days, and lower healthcare costs. Only regarding complications, SWL was superior. This emphasizes URS as the most frequent treatment choice. Furthermore, SWL outpatients showed less costs, fewer complications, and re-interventions than inpatients.

Perioperative and Pathological Outcome of Nerve-Sparing Radical Cystectomy With Ileal Neobladder.

Purpose: So far, it has not been described whether the perioperative course and the pathologic outcome of patients who undergo radical cystectomy (RC) with orthotopic bladder substitution differs if nerve sparing (NS) is performed or not. Material and Methods: In all, there were 472 patients who underwent RC between 2012 and 2019 at our department. We performed a retrospective analysis of 116 patients who underwent RC with ileal neobladder. We analyzed perioperative complications according to the Clavien-Dindo classification system, as well as the pathological outcome. Results: Of 116 patients, 68 (58.6%) underwent RC, and 48 (41.4%) underwent NS RC. Clavien-Dindo complications ≥3b occurred in 15 (12.9%) of all patients. Only infectious complications differed among the groups [NS RC: 25 patients (52.1%) vs. RC: 20 patients (29.4%); p = 0.02]. There was no significant difference concerning tumor stage. Concomitant Cis was present in 24 patients (35.3%) of the RC group and in 27 patients (56.3%) of the NS RC group (p = 0.036). Nodal status and positive surgical margin status of the bladder tumor did not differ among the groups. In all, 42 of all male patients (45.7%) had an incidental prostatic carcinoma. Positive surgical margins concerning the prostate carcinoma occurred in six patients, with all cases in the RC group (p = 0.029). Conclusions: Our data suggest that performing NS during RC in carefully selected patients is a safe procedure and does not impair perioperative outcome. Pathological outcome of NS RC is comparable as well.

Novel Biocompatible Adhesive to Remove Stone Dust: Usability Trial in a Kidney Model.

Introduction and Objective: "Clinically insignificant residual fragments" are an independent predictive factor for recurrence of nephrolithiasis. To improve the stone-free rates (SFR), we tested the viability of a novel bioadhesive system for intrarenal embedding and retrieval of residual fragments <1 mm in a kidney model. Materials and Methods: All procedures were performed in a standardized setting, including a kidney model (Kidney module right, Samed GmbH, Dresden) in a plastic basin filled with water. We used a Viper URF flexible ureterorenoscope (fURS) (6.6/8F, Richard Wolf, Knittlingen). A mean amount of 138 mg (standard deviation [SD] ±32.2 mg) of sand grains (range, 0.2-0.8 mm) was inserted in renal calices of the kidney model. We assessed the extraction efficacy of fURS using the bioadhesive system. In total, eight different surgeons performed each one trial, respectively. The endoscopic and macroscopic SFR, the level of the surgeons' experience, and the overall time of stone retrieval were evaluated. Additionally, a survey of the participants was conducted, to assess the contentment with this novel system. Results: The extraction of the sand grains was only possible using the bioadhesive system, otherwise they were too small sized to grab with a retrieval basket. The total SFR was 84% (SD ±11.7%). The operation time (p = 0.052) and the percentage of extracted sand grains (p = 0.194) were not significantly different between experienced and less experienced surgeons. All participants stated that it was a promising technique, which they could imagine using on a daily basis. Conclusions: The bioadhesive system improves the SFR with fragments from 0.2 to 0.8 mm (0% vs 84%). Also, the performance of this operation is not dependent on the surgeon's experience level. This method might improve the SFR in difficult anatomic conditions, that is, lower calices or anomalous kidneys.

Radiation exposure during retrograde intrarenal surgery (RIRS): a prospective multicenter evaluation.

PURPOSE: Retrograde intrarenal surgery (RIRS) may require extensive X-ray usage. We evaluated the impact of preoperative surgeon briefing regarding the inclusion and evaluation of fluoroscopy time (FT) and dose area product (DAP) in a multicenter study on the applied X-ray usage. METHODS: A prospective multicenter study of 6 tertiary centers was performed. Each center recruited up to 25 prospective patients with renal stones of any size for RIRS. Prior to study´s onset, all surgeons were briefed about hazards of radiation and on strategies to avoid high doses in RIRS. Prospective procedures were compared to past procedures, as baseline data. FT was defined as the primary outcome. Secondary parameters were stone-free rate (SFR), complications according to the Clavien, SATAVA and postureteroscopic lesion scale. Results were analyzed using T test, chi-squared test, univariate analysis and confirmed in a multivariate regression model. RESULTS: 303 patients were included (145 retro- and 158 prospective). Mean FT and DAP were reduced from 130.8 s/565.8 to 77.4 s/357.8 (p < 0.05). SFR was improved from 85.5% to 93% (p < 0.05). Complications did not vary significantly. Neither stone position (p = 0.569), prestenting (p = 0.419), nor surgeons' experience (> 100 RIRS) had a significant impact on FT. Significant univariate parameters were confirmed in a multivariate model, revealing X-ray training to be radiation protective (OR - 44, p = 0.001). CONCLUSIONS: Increased surgeon awareness of X-ray exposure risks has a significant impact on FT and DAP. This "awareness effect" is a simple method to reduce radiation exposure for the patient and OR staff without the procedures´ outcome and safety being affected.

The impact of the laser fiber-tissue distance on histological parameters in a porcine kidney model.

PURPOSE: To evaluate the impact of the fiber-tissue distance on histological parameters in a porcine kidney model. METHODS: Four lasers were tested at 60 W using a 600-µm bare-ended fiber: a continuous wave (cw) thulium fiber laser (TFL), a super pulsed (SP) TFL, a Ho:YAG laser, and a blue diode laser (BDL). All tissue samples were mounted on a motorized XY-translation stage. The fiber-tissue distance was changed within a range from 0to 6 mm. Ten incisions were made with each laser at each distance. Afterwards, the tissue samples were sliced with a microtome for lactate dehydrogenase staining to determine zones of thermal damage. RESULTS: In contact mode, the largest incision depth was found for the cw TFL (1.7 ± 0.1 mm) compared to the SP TFL (1.0 ± 0.1 mm), BDL (0.9 ± 0.1 mm) and HoYAG laser (1.1 ± 0.1 mm), respectively. With regard to the coagulative properties, the SP TFL and the Ho:YAG laser showed comparable coagulation depths with 0.7 ± 0.1 and 0.6 ± 0.1 mm, respectively. At 2 mm fiber-tissue distance, the Ho:YAG laser was the only laser that vaporized tissue (incision depth: 0.2 ± 0.1 mm). The BDL was the only laser that caused coagulation at a distance of 3-5 mm. CONCLUSION: Our results support the clinical observation that cw TFL must be defocused for best coagulation, while the coagulation depth of the SP TFL remains nearly constant within the range of 0-3 mm. Increasing the distance of the laser fiber to the tissue up to 5 mm did not cause significant differences with regard to coagulation depth using the BDL.

Current use of thulium lasers in endourology and future perspectives. / Uso actual del láser de tulio en endourología y perspectivas de futuro.

Thulium lasers operate at wavelengths between1940-2013 nm either in a continuous wave or in a pulsed mode, which enables smooth incisions with fast vaporization or effective laser lithotripsy for urolithiasis. Thulium laser enucleation is a minimally invasive and size-independent treatment for benign prostatic hyperplasia (BPH) with excellent long-term results. Since its introduction, several modifications in the technology and surgical techniques have been proposed such as vaporesection, vaporization and enucleation with regard to BPH treatment. Recent developments in the thulium laser technology include the introduction of a super pulsed thulium fiberlaser.  This technique delivers the laser energy through anactive fiber with an absorption maximum in water at awavelength of 1940 µm. Preclinical studies showed asignificantly higher stone fragmentation rate in differentex vivo models compared to the Ho:YAG laser. Another innovative thulium laser that works, as a hybrid laser has yet not been tested clinically, however, will soon be introduced. With the introduction of both new thulium lasers as novel devices, the armamentarium in the field of endourology for lithotripsy and enucleation increases. We here present different thulium lasers and surgical techniques that are possible to perform with each device including the reasons and advantages of each modification.

El láser de tulio opera entre 1940 y2013 nm en onda continua o pulsada. Esto permite incisiones sencillas y una vaporización rápida o una litotricia láser para el tratamiento de las litiasis urinarias. La enucleación con láser tulio es mínimamente invasiva e independiente del tamaño de la hiperplasia benigna de próstata con excelentes resultados a largo plazo. Desde su introducción, varias modificaciones en la tecnología y en la técnica quirúrgica se han propuesto como la vaporesección, la vaporización y la enucleación. El desarrollo reciente de la tecnología del láser tulio incluye la introducción de una fibra de láser de superpulsación. Esta técnica administra la energía del láser a través de una fibra activa con una absorción máxima a 1940 nm. Estudios preclínicos han demostrado una mejor fragmentación de las litiasis en diferentes modelos ex vivo en comparación con láser Ho:YAG. Otra innovación del laser tulio es que funciona como un láser híbrido, pero aun no se ha testado clínicamente. Con la introducción de nuevas tecnologías en láser, el conjunto de técnicas en endourología y enucleación incrementa. En este resumen presentamos los diferentes lásers tulio y las técnicas quirúrgicas que son posiblesde realizar con cada aparato, incluyendo el racional y las ventajas para cada modificación.