A novel technique for thulium laser enucleation of the prostate: anterior releasing with ThuLEP (ARTh technique).

Thulium laser enucleation of the prostate (ThuLEP) is a highly effective approach to the treatment of benign prostatic hyperplasia. We present here a description of the "ARTh Technique" and the benefits it offers in terms of improved visualization, short operation times, and easy recognition of the dissection plane, describing specifically the anterior release (AR) technique using ThuLEP(Th). Included in this retrospective study were 32 consecutive patients operated on between January 2022-November 2022. Parameters were measured before and after the procedure: the International Prostate Symptom Score(IPSS), maximum flow rate(Qmax), post-void residual urine(PVR) prostate-specific antigen(PSA), prostate volume, operation-time, morcellation-time, catheterization-time and presence of transient urinary incontinence, and compared. The median age of patients undergoing enucleation of the prostate using the ARTh technique was 64 years (range: 44-83). The median prostate volume of the patients was 83.5 ml(50-128 ml), preoperative-IPSS was 24.8(15-33), postoperative-IPSS was 7(5-11), preoperative-Qmax was 8.1 ml/Sects. (5-11.5 ml/sec), postoperative-Qmax was 26.9 ml/Sect. (20.8-34 ml/sec), preoperative-PVR was 145 ml(75-258 ml), postoperative-PVR was 36.2 ml(0-66 ml), total operation time was 51.4 min(28-82 min), enucleation time was 36.9 min(19-51 min) and morcellation time was 15.3 min(8-27 min). The ARTh technique is a safe procedure that allows the surgeon to easily recognize and adhere to the defined dissection plane, thus decreasing operation times, significantly reducing the rate of postoperative transient urinary incontinence (TUI).

Thirty versus 60-Watt thulium laser enucleation of prostate: Toward the development of low-power anatomical enucleation of the prostate.

Introduction: We aimed to study whether using 30 W versus 60 W thulium enucleation of the prostate (ThuLEP) would affect postoperative outcomes in patients with benign prostatic hyperplasia (BPH). Materials and Methods: We prospectively identified male patients with moderate or severe lower urinary tract symptoms due to BPH. We randomized patients into 30 W (Group 1) or 60 W (Group 2) thulium yag laser with a 550 µm laser fiber and a 26 Fr continuous flow resectoscope. We collected data related to prostate size, enucleation time, morcellation time, laser time, perioperative complications, and 1-year functional outcomes. Results: A total of 120 patients were included, with a mean age of 67 years and a mean prostate size of 105 g. The preoperative characteristics were similar across both groups. The mean operative time was shorter in the 60 W group, 74 ± 27 vs. 91 ± 33 min in the 30 W group (P = 0.001), and the mean laser time was 55 ± 20 in 60 W versus 71 ± 25 in 30 W (P = 0.0001). The mean hospital stay was 1 day in both groups and at 1-year follow-up; there was a similar improvement in mean Qmax and International Prostate Symptom Score symptom scores. Discussion/Conclusion: Both 30 and 60 W ThuLEP provided a safe and comparable outcome with a relatively shorter operative time for the 60 W groups. Perhaps using a 30-W setting would be beneficial in the early learning curve or cases with more bleeding capsular perforators; besides, the financial benefit of manufacturing low-cost low-power devices that may help in the widespread of AEEP.

Optimal parameter settings of thulium fiber laser for ureteral stone lithotripsy: a comparative study in two different testing environments.

This study aims to identify optimal parameters for using Thulium fiber lasers (TFL) in ureteral stone lithotripsy to ensure laser safety and maximize efficacy. Our goal is to improve the outcomes of single-use semi-rigid ureteroscopy for treating stones located in the proximal ureter. A clinically relevant thermal testing device was designed to investigate heating effects during TFL stone fragmentation. The device was utilized to identify safe power thresholds for TFL at various irrigation rates. Three other devices were used to assess varying pulse energy effects on stone fragmentation efficiency, dusting, retropulsion, and depth of tissue vaporization. Comparative experiments in fresh porcine renal units were performed to validate the efficacy and safety of optimal TFL parameters for semi-rigid ureteroscopy in proximal ureteral stone procedures. Our study found that the improved device generated a higher thermal effect. Furthermore, the safe power threshold for laser lithotripsy increased as the irrigation rate was raised. At an irrigation rate of 40 ml/min, it is safe to use an average power of less than 30 watts. Although increasing pulse energy has a progressively lower effect on fragmentation and dust removal efficiency, it did lead to a linear increase in stone displacement and tissue vaporization depth. Thermal testing showed 20 W (53.87 ± 2.67 °C) indicating potential urothelial damage. In our study of laser lithotripsy for proximal ureteral stones, the group treated with 0.3 J pulses had several advantages compared to the 0.8 J group: Fewer large fragments (> 4 mm): 0 vs. 1.67 fragments (1-2.25), p = 0.002, a lower number of collateral tissue injuries: 0.50 (0-1.25) vs. 2.67 (2-4), p = 0.011, and lower stone retropulsion grading: 0.83 (0.75-1) vs. 1.67 (1-2), p = 0.046. There was no significant difference in operating time between the groups (443.33 ± 78.30 s vs. 463.17 ± 75.15 s, p = 0.664). These findings suggest that TFL irradiation generates a greater thermal effect compared to non-irradiated stones. Furthermore, the thermal effect during laser lithotripsy is influenced by both power and irrigation flow rate. Our study suggests that using a power below 15 W with an irrigation flow rate of 20 ml/min is safe. Moreover, a pulse energy of 0.3 J appears to be optimal for achieving the best overall stone fragmentation effect.

Holmium:yttrium-aluminium-garnet laser with MOSES technology is more efficient than thulium fibre laser in supine mini-percutaneous nephrolithotomy.

OBJECTIVES: To address the paucity of literature comparing outcomes achieved with utilisation of the high-power holmium:yttrium-aluminium-garnet (Ho:YAG) laser with MOSES technology vs those achieved with the thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (PCNL). METHODS: A retrospective review was performed of patients undergoing supine mini-PCNL between August 2021 and May 2023. Exclusion criteria were urinary diversion, simultaneous utilisation of >1 laser platform, use of any other form of fragmentation, and ureteric stones. The Ho:YAG platform (Lumenis Pulse P120H™ with MOSES technology, 120W; Boston Scientific®) and the TFL (Soltive SuperPulsed Thulium Fibre [SPTF], 60W; Olympus®) were compared. Data on stone-free rate (SFR) were determined by computed tomography performed on the first postoperative day and presented as absence of stone fragments, no fragments larger than 2 mm, or no fragments larger than 4 mm. RESULTS: A total of 100 patients met the inclusion criteria, 51 mini-PCNLs with the Ho:YAG laser and 49 with the SPTF laser. No significant differences in demographics or stone characteristics were detected between the two groups. The Ho:YAG laser utilised less energy and time, resulting in higher ablation efficiency (P < 0.05) and less total operating time (P < 0.05). Overall, there was no difference in SFR in any category between the Ho:YAG group and the SPTF group (no fragments: relative risk [RR] 0.81, 95% confidence interval [CI] 0.59-1.12, P = 0.21; fragments <2 mm: RR 0.86, 95% CI 0.67-1.10, P = 0.23; fragments <4 mm: RR 0.96, 95% CI 0.80-1.15, P = 0.67). CONCLUSIONS: Although we observed an equivalent postoperative SFR, this study supports a shorter operating time and greater intra-operative laser efficiency with the Ho:YAG laser over the SPTF laser in mini-PCNL.

Coherent beam combining of two all-PM thulium-doped fiber chirped pulse amplifiers.

In this paper, we report a coherent beam combining (CBC) system that involves two thulium-doped all-polarization maintaining (PM) fiber chirped pulse amplifiers. Through phase-locking the two channels via a fiber stretcher by using the stochastic parallel gradient descent (SPGD) algorithm, a maximum average power of 265 W is obtained, with a CBC efficiency of 81% and a residual phase error of λ/17. After de-chirping by a pair of diffraction gratings, the duration of the combined laser pulse is compressed to 690 fs. Taking into account the compression efficiency of 90% and the main peak energy proportion of 91%, the corresponding peak power is calculated to be 4 MW. The laser noise characteristics before and after CBC are examined, and the results indicate that the CBC would degrade the low frequency relative intensity noise (RIN), of which the integration is 1.74% in [100 Hz, 2 MHz] at the maximum combined output power. In addition, the effects of the nonlinear spectrum broadening during chirped pulse amplification on the CBC efficiency are also investigated, showing that a higher extent of pulse stretching is effective in alleviating the spectrum broadening and realizing a higher output power with decent combining efficiency.

Surgical outcomes of endoscopic enucleation of the prostate in community aging males with or without preoperative urinary retention.

OBJECTIVES: This study aims to investigate the surgical outcomes of endoscopic enucleation of the prostate in older males with or without preoperative urinary retention (UR). MATERIAL AND METHODS: We conducted a study on selected patients with symptomatic benign prostatic hyperplasia (BPH) who underwent either thulium:YAG laser (vela XL) prostate enucleation (ThuLEP) or bipolar plasma enucleation of the prostate (B-TUEP) at the geriatric urology department of our institution. The studied patients were categorized into two groups, namely the UR group and the non-UR group, on the basis of whether they experienced UR in the 1 month preceding their surgery. Their clinical outcomes following prostate endoscopic surgery were evaluated and analyzed. RESULTS: Our results revealed comparable outcomes for operation time, length of hospital stay, percentage of tissue removed, re-catheterization rate, and urinary tract infection rate within the 1 month between the B-TUEP and ThuLEP surgery groups, regardless of UR history. However, the non-UR B-TUEP group experienced more blood loss relative to the non-UR ThuLEP group (P = .004). Notably, patients with UR exhibited significantly greater changes in IPSS total, IPSS voiding, and prostate-specific antigen values relative to those without UR. CONCLUSIONS: Both ThuLEP and B-TUEP were effective in treating BPH-related bladder outlet obstruction. Our study identified more pronounced changes in IPSS total, IPSS voiding, and prostate-specific antigens within the UR group. Moreover, the rate of postoperative UR in this group was not higher than that observed in the non-UR group. Our study also revealed that the presumed benefits of laser surgery in reducing blood loss were less pronounced for patients with UR.

Is "Kidney Stone Calculator" efficient in predicting ureteroscopic lithotripsy duration? A holmium:YAG and thulium fiber lasers comparative analysis.

PURPOSE: This study aimed to evaluate the ability of Kidney Stone Calculator (KSC), a flexible ureteroscopy surgical planning software, to predict the lithotripsy duration with both holmium:YAG (Ho:YAG) and thulium fiber laser (TFL). METHODS: A multicenter prospective study was conducted from January 2020 to April 2023. Patients with kidney or ureteral stones confirmed at non-contrast computed tomography and treated by flexible ureteroscopy with laser lithotripsy were enrolled. "Kidney Stone Calculator" provided stone volume and subsequent lithotripsy duration estimation using three-dimensional segmentation of the stone on computed tomography and the graphical user interface for laser settings. The primary endpoint was the quantitative and qualitative comparison between estimated and effective lithotripsy durations. Secondary endpoints included subgroup analysis (Ho:YAG-TFL) of differences between estimated and effective lithotripsy durations and intraoperative outcomes. Multivariate analysis assessed the association between pre- and intraoperative variables and these differences according to laser source. RESULTS: 89 patients were included in this study, 43 and 46 in Ho:YAG and TFL groups, respectively. No significant difference was found between estimated and effective lithotripsy durations (27.37 vs 28.36 min, p = 0.43) with a significant correlation (r = + 0.89, p < 0.001). Among groups, this difference did not differ (p = 0.68 and 0.07, respectively), with a higher correlation between estimated and effective lithotripsy durations for TFL compared to Ho:YAG (r = + 0.95, p < 0.001 vs r = + 0.81, p < 0.001, respectively). At multivariate analysis, the difference was correlated with preoperative (volume > 2000 mm3 (Ho:YAG), 500-750 mm3 SV and calyceal diverticulum (TFL)), operative (fragmentation setting (p > 0.001), and basket utilization (p = 0.05) (Ho:YAG)) variables. CONCLUSION: KSC is a reliable tool for predicting the lithotripsy duration estimation during flexible ureteroscopy for both Ho:YAG and TFL. However, some variables not including laser source may lead to underestimating this estimation.

Influence of Prostate Volume on the Incidence of Complications and Urinary Incontinence Following Thulium Fiber Laser Enucleation of the Prostate: Results from Multicenter, Real-world Experience of 2732 patients.

Background: The use of the new thulium fiber laser in enucleation of the prostate (ThuFLEP) has been introduced recently. Objective: To evaluate complications and urinary incontinence (UI) after ThuFLEP in small and large prostate volume (PV). Design setting and participants: We retrospectively reviewed patients who underwent ThuFLEP in six centers (from January 2020 to January 2023). The exclusion criteria were concomitant lower urinary tract surgery, previous prostate/urethral surgery, prostate cancer, and pelvic radiotherapy. Outcome measurements and statistical analysis: Patients were divided into two groups: group 1: PV ≤80 ml; group 2: PV >80 ml. Univariable and multivariable logistic regression analyses were performed to evaluate the independent predictors of overall UI. Results and limitations: There were 1458 patients in group 1 and 1274 in group 2. There was no significant difference in age. The median PV was 60 (61-72) ml in group 1 and 100 (90-122) ml in group 2. En bloc enucleation was employed more in group 1, while the early apical release technique was used more in group 2. The rate of prolonged irrigation for hematuria, urinary tract infection, and acute urinary retention did not differ significantly. Blood transfusion rate was significantly higher in group 2 (0.5% vs 2.0%, p = 0.001). There was no significant difference in the overall UI rate (12.3% in group 1 vs 14.7% in group 2, p = 0.08). A multivariable regression analysis showed that preoperative postvoiding urine residual (odds ratio 1.004, 95% confidence interval 1.002-1.007, p < 0.01) was the only factor significantly associated with higher odds of UI. A limitation of this study was its retrospective nature. Conclusions: Complications and UI rates following ThuFLEP were similar in patients with a PV up to or larger than 80 ml except for the blood transfusion rate that was higher in the latter. Patient summary: In this study, we looked at outcomes after thulium fiber laser in enucleation of the prostate stratified by PV. We found that blood transfusion was higher in men with PV >80 ml, but urinary incontinence was similar.

A prospective analysis of thulium laser enucleation in benign prostatic hyperplasia comparing low- and high-power approaches for prostates exceeding 80 g.

INTRODUCTION AND OBJECTIVES: To compare the perioperative and functional outcomes of low-power and high-power thulium:YAG VapoEnucleation (ThuVEP) of the prostate for the treatment of large-volume benign prostatic hyperplasia (BPH) (> 80 ml). PATIENTS AND METHODS: A prospective analysis of 80 patients with symptomatic BPO and prostatic enlargement (more than 80 ml) was conducted. They were divided randomly into two groups (40 patients in each group). One group was treated with low-power ThuVEP, and the other group was treated with high-power ThuVEP. All patients were assessed preoperatively and early postoperatively, and 12-month follow-up data were analyzed. The complications were noted and classified according to the modified Clavien classification system. RESULTS: The mean age at surgery was 68 (± 6.1) years, and the mean prostate volume was 112 (± 20.1) cc, and there were no differences between the groups (p = 0.457). The mean operative time was 88.4 ± 11.79 min for group A and 93.4 ± 16.34 min for group B, while the mean enucleation time was 59.68 ± 7.24 min for group A and 63.13 ± 10.75 min for group B. There were no significant differences between the groups regarding catheterization time and postoperative stay. The quality of life (QoL), International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), postvoiding residual urine (PVR), and prostate volume improved significantly after treatment and were not significantly different between those treated with the different energies. The incidence of complications was low and did not differ between both the groups. CONCLUSION: Low-power ThuVEP is feasible, safe, and effective with comparable results with high-power ThuVEP in the treatment of BPO.

Flexible ureteroscopic treatment of kidney stones: How do the new laser systems change our concepts?

Objective: Flexible ureteroscopy (fURS) has become a widely accepted and effective technique for treating kidney stones. With the development of new laser systems, the fURS approach has evolved significantly. This literature review aims to examine the current state of knowledge on fURS treatment of kidney stones, with a particular focus on the impact of the latest laser technologies on clinical outcomes and patient safety. Methods: We conducted a search of the PubMed/PMC, Web of Science Core Collection, Scopus, Embase (Ovid), and Cochrane Databases for all randomized controlled trial articles on laser lithotripsy in September 2023 without time restriction. Results: We found a total of 22 relevant pieces of literature. Holmium laser has been used for intracavitary laser lithotripsy for nearly 30 years and has become the golden standard for the treatment of urinary stones. However, the existing holmium laser cannot completely powder the stone, and the retropulsion of the stone after the laser emission and the thermal damage to the tissue have caused many problems for clinicians. The introduction of thulium fiber laser and Moses technology brings highly efficient dusting lithotripsy effect through laser innovation, limiting pulse energy and broadening pulse frequency. Conclusion: While the holmium:yttrium-aluminum-garnet laser remains the primary choice for endoscopic laser lithotripsy, recent technological advancements hint at a potential new gold standard. Parameter range, retropulsion effect, laser fiber adaptability, and overall system performance demand comprehensive attention. The ablation efficacy of high-pulse-frequency devices relies on precise targeting, which may pose practical challenges.

MnO2 nanosheet quenched thulium doped photon-up conversion luminescent immunoprobe for the 'turn-on' detection of cardiac troponin T.

A "turn-on" photon up conversion nano couple based on NaYF4: Yb, Tm UCNPs quenched with MnO2 nanosheet was developed for the rapid and selective detection of cTnT. Herein, MnO2 nanosheet hold on the surface of Antibody cTnT (Ab-cTnT) conjugated blue emitting up conversion nanoprobe (λem at 475 nm), which leads to quenching of fluorescence due to energy transfer from photon up conversion nanoparticles to MnO2 nanosheets. On introducing cTnT antigen to the system, the energy transfer process is hindered due to strong antigen -antibody interface on the surface. This in turn, influences the nano-couples positions and effectively separates up conversion nanoprobe from MnO2 nanosheets surface resulting in restriction to energy transfer process enabling fluorescence recovery. The developed probe shows a linear response towards cTnT in the range of 0.16-2.77 ng/mL with a Limit of Detection (LoD) of 0.025 ng/mL. The practical feasibility of the nanoprobe is performed with possible coexisting biomolecules. Biological study in human blood serum samples exhibited sufficient recovery percentage in the range of 92-103 % is obtained.

Getting hot in here! Comparison of Holmium vs. thulium laser in an anatomic hydrogel kidney model.

As laser technology has advanced, high-power lasers have become increasingly common. The Holmium: yttrium-aluminum-garnet (Ho:YAG) laser has long been accepted as the standard for laser lithotripsy. The thulium fiber laser (TFL) has recently been established as a viable option. The aim of this study is to evaluate thermal dose and temperature for the Ho:YAG laser to the TFL at four different laser settings while varying energy, frequency, operator duty cycle (ODC). Utilizing high-fidelity, 3D-printed hydrogel models of a pelvicalyceal collecting system (PCS) with a synthetic BegoStone implanted in the renal pelvis, laser lithotripsy was performed with the Ho:YAG laser or TFL. At a standard power (40W) and irrigation (17.9 ml/min), we evaluated four different laser settings with ODC variations with different time-on intervals. Temperature was measured at two separate locations. In general, the TFL yielded greater cumulative thermal doses than the Ho:YAG laser. Thermal dose and temperature were typically greater at the stone when compared away from the stone. Regarding the TFL, there was no general trend if fragmentation or dusting settings yielded greater thermal doses or temperatures. The TFL generated greater temperatures and thermal doses in general than the Ho:YAG laser with Moses technology. Temperatures and thermal doses were greater closer to the laser fiber tip. It is inconclusive as to whether fragmentation or dusting settings elicit greater thermal loads for the TFL. Energy, frequency, ODC, and laser-on time significantly impact thermal loads during ureteroscopic laser lithotripsy, independent of power.

Propensity score-matched analysis comparing perioperative, functional, and safety outcomes between thulium fiber laser and bipolar enucleation of the prostate performed by a single surgeon with two years of follow-up.

PURPOSE: To compare perioperative, functional, and safety outcomes between thulium fiber laser enucleation of the prostate (ThuFLEP) and bipolar enucleation of the prostate performed by a single surgeon with use of propensity score (PS)-matched analysis. MATERIALS AND METHODS: Data were from 675 patients, 422 of whom underwent ThuFLEP and bipolar enucleation by a single highly experienced surgeon. ThuFLEP was performed with Fiberlase U1 (IRE Polus Ltd.). Perioperative parameters, safety, and functional outcomes, such as International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual volume (PVR), and maximum urinary flow rate (Qmax) were assessed. To control for selection bias, a 1:1 PS-matched analysis was carried out using the following variables as covariates: total prostate volume, preoperative IPSS and early sphincter release. RESULTS: Of 422 patients, 370 (87.7%) underwent ThuFLEP and 52 (12.3%) underwent bipolar enucleation. Operation, enucleation, and morcellation time were comparable between groups before and after PS-matched analysis (p=0.954, p=0.474, p=0.362, respectively). Functional parameters (IPSS, QoL, PVR, Qmax) were also comparable between groups at every time point before and after PS matching. Significant improvements in IPSS, QoL score, Qmax, and PVR were observed during the 24-month follow-up period for both ThuFLEP and bipolar enucleation without any significant differences between groups. Early and late postoperative complications before and after PS-matched analysis were similar. CONCLUSIONS: ThuFLEP was comparable to bipolar enucleation in perioperative characteristics, improvement in voiding parameters, and complication rates. Both procedures were shown to be effective and safe in the management of benign prostatic hyperplasia.

Long-term functional outcomes and surgical retreatment after thulium laser enucleation of the prostate: A 10-year follow-up study.

BACKGROUND: To evaluate the 10-year functional outcomes (primary) and frequency and predictors of BPH surgical retreatment (secondary) after ThuLEP. MATERIALS AND METHODS: A single-center retrospective analysis of consecutive patients undergoing ThuLEP between 2010 and 2013 was performed. Inclusion criteria were: age ≥ 40 years, prostate volume (PV) ≥ 80 mL, International Prostate Symptom Score (IPSS)-Total score ≥ 8 points. IPSS-Total score was the primary outcome, and BPH surgical retreatment rate was the secondary outcome. Paired t-test, McNemar test, and Wilcoxon signed-rank test were used to compare variables. Logistic regression analysis was performed to evaluate predictors of surgical retreatment. RESULTS: A total of 410 patients with a mean ±SD age of 63.9 ± 9.7 years and a PV of 115.6 ± 28.6 mL were included. Mean ±SD follow-up was 108.2 ± 29.6 months. IPSS-Total score was significantly improved at 1 year compared to baseline (23.3 ± 4.7 vs. 10.3 ± 3.8; p<0.001). It was similar after 5 years (10.5 ± 3.6 vs. 10.7 ± 5.0; p=0.161), with a significant worsening at 10 years (10.3 ±4.8 vs. 13.8 ±4.5; p=0.042) but remaining statistically and clinically better than baseline (13.8 ±4.5 vs. 22.1 ±4.3; p<0.001). After 10 years, 21 (5.9%) patients had undergone BPH reoperation. Baseline PV (adjusted OR 1.27, 95% CI 1.09-1.41; p<0.001) and time from BPH surgery (adjusted OR 1.32, 95% CI 1.15-1.43; p<0.001) were predictors of BPH surgical retreatment. CONCLUSIONS: ThuLEP is associated with optimal functional outcomes and a low frequency of BPH surgical retreatment in the long-term. Baseline PV and time from surgery were predictors of BPH reoperation.

Laser Technology Advancements in the Treatment of Benign Prostatic Hypertrophy.

PURPOSE OF REVIEW: Lasers have had a significant impact on the treatment of benign prostatic hypertrophy. This article attempts to distill the advancements in laser technology for the treatment of benign prostatic hypertrophy (BPH) into key and understandable points to help make this topic more accessible to urologists. RECENT FINDINGS: The holmium:yttrium-aluminum-garnet (YAG) laser, one of the most significant lasers in the field of urology, has recently been improved with pulse modulating technology (Moses™ technology). New thulium:YAG technology allows both pulsed and continuous wave modes. The thulium fiber laser is one of the newer lasers to come to market and has been shown to have effective and safe outcomes. GreenLight™ lasers are predominantly used in photovaporization procedures and have also been studied extensively, although less in recent years. The modern urologist is fortunate to have many high-quality lasers and a wide variety of surgical techniques to choose from when treating BPH. Understanding the basic laser principles and applications will help urologists to select the best treatment options for their patients with BPH.

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).

Simultaneously combining a thulium fiber laser and holmium:YAG laser in vacuum-assisted mini-endoscopic combined intrarenal surgery on a complex renal calculus: A case report.

Employing percutaneous nephrolithotomy to manage a complex renal calculus has always been challenging due to the blood transfusion requirement and the frequent necessity of using multiple access tracts. We report a novel treatment modality in the case of a 65-year-old male with a complex, large-volume renal calculus who was successfully treated by vacuum-assisted miniaturized endoscopic combined intrarenal surgery using the combination of a thulium fiber laser in retrograde fashion with a holmium:YAG laser in antegrade fashion. The kidney stone was entirely cleared, and the patient fully recovered with no adverse event.

Initial experience with thulium fiber laser for prostate enucleation: Analysis of the intraoperative and short-term outcomes in a prospective, multicenter cohort.

INTRODUCTION: Holmium laser enucleation of the prostate has rapidly become the gold standard for the surgical treatment of benign prostate hyperplasia, although thulium fiber laser (TFL) has also been postulated as an effective and safe alternative for prostate enucleation. The aim of this study is to describe our initial experience with the TFL for endoscopic enucleation of the prostate. MATERIAL AND METHODS: All patients proposed to TFL prostate enucleation were included in the analysis, regardless their prostate volume, catheter status and severity of symptoms, in 3 centers. Preoperative characteristics, intraoperative times and functional 3-months follow-up variables were collected, along with complications. RESULTS: Fifty-six patients were available, with a mean age of 68.7 years. Enucleation and morcellation efficiencies were 2.04 and 7.47 g/min, respectively. Median hospital stay was one day. Comparable functional data, pre and 3-month post-surgery was: mean prostate volume 88.9 vs 21.3 g, maximum urinary flow 13.2 vs 27.3 ml/s, post-void residual volume 149 vs 7.8 ml, prostatic specific antigen level 11.2 vs 1 ng/ml, and International Prostate Symptom Score 20.75 vs 3.96. Fourteen out of 56 (25%) patients presented with complications grade ≤2, according to the Clavien-Dindo classification. DISCUSSION: With wider evidence for other urological indications, very recent evidence about the suitability of TFL for prostate enucleation has arisen, since the first case described in 2021. Our results seem to back up these previous successful experiences as long as we obtained good intraoperative and short term follow-up functional results. However, there is still a need of longer follow-up data. CONCLUSIONS: TFL represents a novel technology for prostate enucleation, with a good intraoperative and short follow-up functional results, and a safety profile similar to the observed for those techniques that have been wider used for this indication. Further studies with longer follow-up periods and comparative with these other techniques are necessary.

Seguridad, consejos y límites para el uso del láser en la cirugía retrógrada intrarrenal / Laser safety, warnings, and limits in retrograde intrarenal surgery

Objetivo Analizar la información actual sobre la seguridad del láser en la cirugía retrógrada intrarrenal (CRIR), centrándonos en las dos principales tecnologías láser que utilizamos en urología, el láser de holmio:itrio-aluminio-granate (Ho:YAG) y el láser de fibra de tulio (TFL). Métodos Revisión narrativa de los artículos más relevantes publicados en las bases de datos Medline y Scopus sobre este tema. Resultados Los láseres TFL y Ho:YAG con ajustes similares (0,2 J/40 Hz) tienen un aumento de temperatura promedio por volumen similar y la tasa de calentamiento promedio aumenta proporcionalmente a la potencia del láser, especialmente cuando se utilizan frecuencias altas. Datos preclínicos recientes que comparan ambas tecnologías láser con diferentes ajustes del láser coinciden en que cuando la energía suministrada aumenta a expensas de frecuencias más altas, el daño térmico también aumenta. Las frecuencias más altas, a pesar del aumento de temperatura en el medio de irrigación, pueden causar lesiones térmicas accidentales por láser. Conclusiones El uso de ajustes de baja frecuencia y una irrigación adecuada es fundamental para evitar lesiones térmicas en la litotricia endoscópica con láser (LEL). Además, se recomienda el uso de gafas de seguridad láser en la LEL con Ho:YAG y TFL. (AU)

Objective To analyze the current information about laser safety in retrograde intrarenal surgery (RIRS), focusing on the two main laser technologies that we use in urology, the holmium:yttrium-aluminum-garnet (Ho:YAG) laser, and the thulium fiber laser (TFL). Methods Narrative overview of the most relevant articles published in Medline and Scopus databases about this subject. Results TFL and Ho:YAG laser at similar settings (0.2 J/40 Hz) have similar volume-averaged temperature increase and the average heating rate increase proportionally to laser power, especially when high frequencies are used. Recent preclinical data, comparing both laser technologies at different laser settings, agreed that when the delivered energy increases in expenses of higher frequencies, the thermal damage increases too. Higher frequencies, despite of the rise of temperature in the irrigation medium, can cause accidental thermal lasering lesions. Conclusions The use of low frequency settings and a proper irrigation is critical to avoid thermal injury in endoscopic laser lithotripsy (ELL). In addition, the use of laser safety eyeglasses is recommended in Ho:YAG and TFL ELL. (AU)