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

Abstract

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.