The Holmium:Yttrium Aluminum Garnet (Ho:YAG) laser has been the standard energy source for endoscopic lithotripsy for over two decades; however, limitations such as inefficient energy transmission, strong retropulsion, and large fiber diameters have prompted the development of newer laser technologies. Pulse-modulated Ho:YAG platforms (e.g., Moses™ (Boston Scientific, Marlborough, USA), Virtual Basket™ (Quanta System, Milan, Italy), Magneto™ (Quanta System, Milan, Italy)) and the Thulium Fibre Laser (TFL) were introduced to improve energy coupling, fragmentation efficiency, and surgical precision. This systematic review aims to evaluate and compare the clinical efficacy and safety of TFL and pulse-modulated Ho:YAG systems in the management of urolithiasis. A systematic search of PubMed, Cochrane Library, and Embase was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing TFL and pulse-modulated Ho:YAG lasers in ureteroscopy (URS), retrograde intrarenal surgery (RIRS), or mini-percutaneous nephrolithotomy (mini-PCNL) were included. Data on stone-free rate (SFR), operative and lasering times, retropulsion, visibility, complications, and safety were extracted. Due to heterogeneity in definitions and study design, a qualitative synthesis without meta-analysis (SWiM) was performed. Risk of bias was assessed using the Risk of Bias (RoB) 2.0 (The Cochrane Collaboration, London, UK) and ROBINS-I (The Cochrane Collaboration, London, UK), and evidence certainty was graded with Grading of Recommendations Assessment, Development and Evaluation (GRADE). Eight studies, including two randomized controlled trials and six observational studies, were included in the review. Across most studies, TFL achieved similar or slightly higher SFRs (82-98%) compared with pulse-modulated Ho:YAG (56-95%). Operative and lasering times were comparable, while TFL demonstrated less retropulsion, superior endoscopic visibility, and an equivalent complication profile. No clinically significant differences in thermal safety or re-hospitalization were observed. In summary, TFL provides comparable or marginally superior performance to pulse-modulated Ho:YAG lasers for endoscopic stone surgery. It offers consistent safety and improved intraoperative control, suggesting an emerging role as a preferred next-generation lithotripsy platform pending further multicenter randomized trials.
Cureus. 2025 Nov 17*** epublish ***
Maanya Bhardwaj, Abhinav Singhal, Gaurika Bhardwaj, Layla Sultan, Maitrey Darrad
Urology, Cambridge University Hospital NHS Foundation Trust, Cambridge, GBR., Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR., Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, GBR., Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR., Urology, University Hospitals Birmingham NHS Foundation Trust, Birmimgham, GBR.