Evaluating the clinical outcomes of thulium fiber laser (TFL) in comparison to holmium laser in the treatment of urinary tract stones – A systematic review

Abstract

Holmium:Yttrium-Aluminum-Garnet (Ho:YAG) had been considered the gold standard for treating urinary tract stones. However, advancements in laser technology have introduced thulium fiber laser (TFL) as a potential alternative. Preliminary studies have indicated that TFL may have certain advantages over Ho:YAG laser in lithotripsy. This systematic review compared the clinical outcomes of TFL and Ho:YAG laser for urinary tract stone treatment, focusing on operating time, stone-free rate (SFR), retropulsion, and complications. A systematic search was conducted on PubMed and ScienceDirect for original articles published within the last 5 years, comparing the clinical outcomes of Ho:YAG and TFL in lithotripsy. Inclusion criteria were English-language studies focusing on Ho:YAG and TFL laser energy for urinary tract stones, with accessible full-text articles comparing clinical outcomes. Excluded were studies discussing lasers for conditions other than urinary tract stones or using lasers other than TFL and Ho:YAG. Four studies (544 procedures) met the criteria and underwent risk of bias assessment using Risk of Bias 2 (ROB-2) for randomized trials and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) for cohort studies. The data were presented in tables and charts. In this review, TFL demonstrated a shorter operating time compared to Ho:YAG (and higher stone-free rates in two studies. TFL also had a lower incidence of stone retropulsion. Intra-operative complication rates varied between the groups for ureterorenoscopy (URS) and retrograde intrarenal surgery (RIRS) procedures, while TFL had a higher rate of prolonged haematuria during mini percutaneous nephrolithotomy (PCNL) procedures. Postoperative complications were similar in both groups. Limitations of this review include procedural and laser setting heterogeneity, a small number of studies, and the lack of registration and protocols. In conclusion, TFL is an effective and safe alternative to Ho:YAG laser for lithotripsy, offering shorter operation time, higher stone-free rates, and reduced stone retropulsion.