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JU INSIGHT: Pulse-modulated Holmium: YAG Laser vs the Thulium Fiber Laser for Renal and Ureteral Stones
By: Christopher R. Haas, MD; Margaret A. Knoedler, MD; Shuang Li, PhD; Daniel R. Gralnek, MD; Sara L. Best, MD; Kristina L. Penniston, PhD; Stephen Y. Nakada, MD | Posted on: 02 Feb 2023
Haas CR, Knoedler MA, Li S, et al. Pulse-modulated holmium: YAG laser vs the thulium fiber laser for renal and ureteral stones: a single-center prospective randomized clinical trial. J Urol. 2023;209(2):374-383.
Study Need and Importance
Numerous preclinical data on the thulium fiber laser (TFL) have shown great promise for potential improvement over the gold standard of Ho:YAG (holmium:yttrium-aluminum-garnet) lithotripsy. Prior randomized trials suggest an improvement in operative time using the TFL compared to Ho:YAG; however, none used the latest high-powered pulse-modulated Ho:YAG technology with similar fiber diameters for comparison.
What We Found
A total of 108 patients were included in this randomized trial for routine outpatient ureteroscopy of nonstaghorn stones <2 cm. The pulse-modulated Ho:YAG with Moses 2.0 technology (Lumenis/Boston Scientific) and the SOLTIVE Premium SuperPulsed Laser System (Olympus) groups were well balanced with similar stone characteristics. Similar 200 µm-core laser fibers and similar starting laser parameters for fragmentation (0.8 J and 8 Hz) and for high-powered dusting (0.3 J and 80 Hz) were employed for both lasers. We found no significant difference in ureteroscope time between the pulse-modulated Ho:YAG (mean 21 minutes) and TFL lasers (mean 19.9 minutes, see Figure). Subset analysis comparing ureteroscope times subdivided by stone size, greater than or less than the median Hounsfield units of 1,023, and stone location also showed no significant differences. No differences were detected in stone-free rates or complications.
Limitations
While the laser settings were set at standard starting settings, further adjustments were left to the discretion of the surgeon. As the TFL is a newer technology, it is likely that the optimal laser settings are not equivalent to the Ho:YAG laser and require further investigation.
Interpretation for Patient Care
The results of this randomized trial of the high-powered pulse-modulated Ho:YAG laser vs the TFL showed no significant clinical advantage of one technology over the other in ureteroscope time, stone-free rates, or complications. Patients and surgeons can be assured that either platform yields excellent results in skilled hands.
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