Thulium Fiber Laser: Bringing Lasers to a Whole New Level

The safety and efficacy of five surgical treatments in prostate enucleation: a network meta-analysis

PURPOSE

The aim of our study was to investigate the comparative outcomes of five different energy types on surgical efficacy and postoperative recovery in patients with benign prostate hyperplasia.

METHODS

The literature was systematically reviewed on December 1st, 2023, encompassing studies retrieved from PubMed, Embase, Web of Science, and The Cochrane Library databases that incorporated clinical studies of holmium laser enucleation of the prostate (HoLEP), Thulium:YAG laser enucleation of the prostate (ThuLEP), transurethral plasmakinetic enucleation of prostate (PKEP), diode laser enucleation of the prostate (DiLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP) in the treatment of prostatic hyperplasia. Two independent reviewers extracted study data and conducted quality assessments using the Cochrane Collaboration's Risk of Bias tool and Newcastle-Ottawa Scale (NOS). Network meta-analysis (NMA) was employed to indirectly analyze the outcomes of endoscopic enucleation of the prostate (EEP) techniques.

RESULTS

The study included a total of 38 studies, comprising 21 non-randomized controlled trials (nRCTs) and 17 randomized controlled trials (RCTs), incorporating five distinct techniques: holmium laser, Thulium:YAG laser, bipolar plasma, diode laser and thulium fiber laser. In comparing treatment durations, ThuLEP and HoLEP had shorter overall hospital stays than PKEP, while the enucleation time of ThuLEP and HoLEP was shorter than that of ThuFLEP. Moreover, the enucleation tissue weight of both thulium fiber laser and holmium laser was heavier than bipolar plasma. However, the analysis did not reveal any statistically significant variation in complications among the various types of enucleation. In postoperative follow-up, the IPSS at 3 months post-operation was superior in the Thulium:YAG laser group compared to the holmium laser group. The thulium fiber laser technique demonstrated significant advantages over other enucleation methods in terms of QoL and PVR at 12 months after surgery.

CONCLUSION

Theoretical properties may vary among different energy sources; however, there are no discernible clinical differences in operation-related parameters, postoperative complications, and postoperative follow-up. Therefore, the choice of laser does not significantly impact the outcome. However, due to the limited number of included studies, future research should focus on larger sample sizes and multicenter investigations to further validate the findings of this study.

Comparison of HoLEP, ThuLEP and ThuFLEP in the treatment of benign prostatic obstruction: a propensity score-matched analysis

PURPOSE

To compare the efficacy and safety of Holmium laser enucleation of the prostate (HoLEP), Thulium laser enucleation of prostate (ThuLEP) and Thulium fibre laser enucleation of prostate (ThuFLEP) by performing propensity score matched analysis (PSM).

METHODS

We retrospectively analysed the patients who underwent HoLEP (Group 1, n = 696), ThuLEP (Group 2, n = 146) and ThuFLEP (Group 3, n = 193) surgery because of benign prostatic obstruction (BPO). A 1:1:1 HoLEP: ThuLEP: ThuFLEP group matching was performed using PSM analysis. Perioperative, postoperative functional outcomes and complications were analysed and compared.

RESULTS

We observed significant improvement in functional parameters regarding IPSS, Qmax, PVR and quality of life in all groups compared to baseline values at the 1st, 6th and 12th postoperative months. There was no significant difference between different laser types in terms of urge (UUI) and stress urinary incontinence (SUI) at 1st postoperative month. In all three groups, no patient had postoperative SUI or UUI at 6th and 12th postoperative months. In addition, no significant difference was observed between laser types in terms of postoperative complications.

CONCLUSION

HoLEP, ThuLEP and ThuFLEP are safe and effective LEP methods with improvement in functional parameters and low complication rates. Similar results in terms of functional outcomes and complications clearly show that these surgeries are alternatives to each other for the patients with BPO. Experts' opinions, practices and enucleation techniques should also be taken into consideration when choosing a laser for BPO surgery.

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.

Thulium fiber laser enucleation of the prostate: a systematic review of the current outcomes

INTRODUCTION

One recent addition to different lasers used for endoscopic enucleation of the prostate is the thulium fiber laser (TFL). The purpose of this systematic review is to present the feasibility, safety and efficacy of TFL Enucleation of the Prostate (ThuFLEP).

EVIDENCE ACQUISITION

PubMed®, Scopus® and Cochrane® primary databases were systematically screened. The search strategy used the PICO (Patients, Intervention, Comparison, Outcome) criteria. Patients should be adults with benign prostatic obstruction (BPO) undergoing ThuFLEP. While comparative studies reporting comparison of ThuFLEP to other BPO treatments were included, cohort studies with no comparison group were also accepted. Outcomes including enucleation time and complication rates were reported.

EVIDENCE SYNTHESIS

Twelve studies met all the predefined criteria and were included in the final qualitative synthesis. Mean operative time and enucleation time ranged from 46.6±10.2 to 104.5±33.6 and from 38.8±17.9 to 66.0±24.9 minutes, respectively. Most of the complications were Grade I or Grade II ones. Although TFL was found to present some advantages over older BPO treatments, its outcomes were comparable with other endoscopic enucleation approaches.

CONCLUSIONS

ThuFLEP seems to be a feasible, safe and efficient approach for BPO symptoms management. Limited evidence showed that although ThuFLEP was associated with a reduced total operative time, it was also associated with worse IPSS improvement at 1-year follow-up, when compared with MOSESTM Holmium Laser Enucleation of the Prostate (HoLEP). These findings confirm the well-established opinion that the enucleation technique itself is more important than the technology which is used.

Experts' recommendations in laser use for the treatment of bladder cancer: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training and Research in Urological Surgery and Technology (TRUST)-Group

PURPOSE

To identify laser settings and limits applied by experts during laser vaporization (vapBT) and laser en-bloc resection of bladder tumors (ERBT) and to identify preventive measures to reduce complications.

METHODS

After a focused literature search to identify relevant questions, we conducted a survey (57 questions) which was sent to laser experts. The expert selection was based on clinical experience and scientific contribution. Participants were asked for used laser types, typical laser settings during specific scenarios, and preventive measures applied during surgery. Settings for a maximum of 2 different lasers for each scenario were possible. Responses and settings were compared among the reported laser types.

RESULTS

Twenty-three of 29 (79.3%) invited experts completed the survey. Thulium fiber laser (TFL) is the most common laser (57%), followed by Holmium:Yttrium-Aluminium-Garnet (Ho:YAG) (48%), continuous wave (cw) Thulium:Yttrium-Aluminium-Garnet (Tm:YAG) (26%), and pulsed Tm:YAG (13%). Experts prefer ERBT (91.3%) to vapBT (8.7%); however, relevant limitations such as tumor size, number, and anatomical tumor location exist. Laser settings were generally comparable; however, we could find significant differences between the laser sources for lateral wall ERBT (p = 0.028) and standard ERBT (p = 0.033), with cwTm:YAG and pulsed Tm:YAG being operated in higher power modes when compared to TFL and Ho:YAG. Experts prefer long pulse modes for Ho:YAG and short pulse modes for TFL lasers.

CONCLUSION

TFL seems to have replaced Ho:YAG and Tm:YAG. Most laser settings do not differ significantly among laser sources. For experts, continuous flow irrigation is the most commonly applied measure to reduce complications.

Thulium fiber laser vs. holmium laser enucleation of the prostate: results of a prospective randomized non-inferiority trial

PURPOSE

Holmium laser enucleation of the prostate (HoLEP) represents the current standard procedure for size-independent surgical therapy of benign prostatic obstruction (BPO). With advent of the novel laser technology thulium fiber laser (TFL), we hypothesized that the functional outcome of TFL enucleation of the prostate (ThuFLEP) is non-inferior compared to HoLEP.

METHODS

From October 2021 to October 2022, 150 patients with BPO were recruited for the prospective randomized trial in accordance with CONSORT. Stratified randomization into the arms ThuFLEP (n = 74) or HoLEP (n = 76) was carried out. The primary endpoint was non-inferior international prostate symptom score (IPSS) and quality of life (QoL) at three months after treatment. Secondary endpoints were rates of complications, peak flow, residual urine and operation times.

RESULTS

Preoperative characteristics showed no significant differences. Overall IPSS and QoL improved from 21 to 8 and 4 to 1.5, respectively, after three months of follow-up. No statistically significant differences between ThuFLEP and HoLEP were observed regarding median postoperative IPSS (8.5 vs. 7, p > 0.9), QoL (1 vs. 2, p = 0.6), residual urine (48 vs. 30ml, p = 0.065) and peak flow (19 vs. 17ml/s, p > 0.9). Similarly, safety profile was comparable with no statistically significant differences regarding rate of major complications (5.3 vs. 5.4%, p = 0.5), laser hemostasis time (3 vs. 2min, p = 0.2), use of additive electric coagulation (74 vs. 87%, p = 0.06) or electric coagulation time (8 vs. 8min, p = 0.4).

CONCLUSIONS

In this prospective, randomized trial ThuFLEP showed non-inferior results compared to HoLEP in terms of functional outcomes measured by IPSS and QoL as primary endpoint.

TRIAL REGISTRATION NUMBER

DRKS00032699 (18.09.2023, retrospectively registered).

Comparison Between Thulium Fiber Laser and High-power Holmium Laser for Anatomic Endoscopic Enucleation of the Prostate: A Propensity Score-matched Analysis from the REAP Registry

BACKGROUND

Different lasers have been developed for treatment of benign prostatic hyperplasia, with no definitively superior technique identified to date.

OBJECTIVE

To compare surgical and functional enucleation outcomes in real-world multicentre practice using high-power holmium laser (HP-HoLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP) for different prostate sizes.

DESIGN, SETTING, AND PARTICIPANTS

The study included 4216 patients who underwent HP-HoLEP or ThuFLEP at eight centers in seven countries between 2020 and 2022. Exclusion criteria were previous urethral or prostatic surgery, radiotherapy, or concomitant surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

To adjust for the bias arising from different characteristics at baseline, propensity score matching (PSM) was used to identify 563 matched patients in each cohort. Outcomes included the incidence of postoperative incontinence, early complications (30-d), and delayed complications, and results for the International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and postvoid residual volume (PVR).

RESULTS AND LIMITATIONS

After PSM, 563 patients in each arm were included. Total operative time was similar between the arms, but enucleation and morcellation times were significantly longer for ThuFLEP. The rate of postoperative acute urinary retention was higher in the ThuFLEP arm (3.6% vs 0.9%; p = 0.005), but the 30-d readmission rate was higher in the HP-HoLEP arm (22% vs 8%; p = 0.016). There was no difference in postoperative incontinence rates (HP-HoLEP:19.7%, ThuFLEP:16.0%; p = 0.120). Rates of other early and delayed complications were low and comparable between the arms. The ThuFLEP group had higher Qmax (p < 0.001) and lower PVR (p < 0.001) than the HP-HoLEP group at 1-yr follow-up. The study is limited by its retrospective nature.

CONCLUSIONS

This real-world study shows that early and delayed outcomes of enucleation with ThuFLEP are comparable to those with HP-HoLEP, with similar improvements in micturition parameters and IPSS.

PATIENT SUMMARY

As lasers become readily available for the treatment of enlarged prostates causing urinary bother, urologists should focus on performing good anatomic removal of prostate tissue, with the choice of laser not as important for good outcomes. Patients should be counseled about long-term complications, even when the procedure is being performed by an experienced surgeon.

Experts' recommendations in laser use for the endoscopic treatment of prostate hypertrophy: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group

PURPOSE

To identify expert laser settings for BPH treatment and evaluate the application of preventive measures to reduce complications.

METHODS

A survey was conducted after narrative literature research to identify relevant questions regarding laser use for BPH treatment (59 questions). Experts were asked for laser settings during specific clinical scenarios. Settings were compared for the reported laser types, and common settings and preventive measures were identified.

RESULTS

Twenty-two experts completed the survey with a mean filling time of 12.9 min. Ho:YAG, Thulium fiber laser (TFL), continuous wave (cw) Tm:YAG, pulsed Tm:YAG and Greenlight™ lasers are used by 73% (16/22), 50% (11/22), 23% (5/22), 13.6% (3/22) and 9.1% (2/22) of experts, respectively. All experts use anatomical enucleation of the prostate (EEP), preferentially in one- or two-lobe technique. Laser settings differ significantly between laser types, with median laser power for apical/main gland EEP of 75/94 W, 60/60 W, 100/100 W, 100/100 W, and 80/80 W for Ho:YAG, TFL, cwTm:YAG, pulsed Tm:YAG and Greenlight™ lasers, respectively (p = 0.02 and p = 0.005). However, power settings within the same laser source are similar. Pulse shapes for main gland EEP significantly differ between lasers with long and pulse shape modified (e.g., Moses, Virtual Basket) modes preferred for Ho:YAG and short pulse modes for TFL (p = 0.031).

CONCLUSION

Ho:YAG lasers no longer seem to be the mainstay of EEP. TFL lasers are generally used in pulsed mode though clinical applicability for quasi-continuous settings has recently been demonstrated. One and two-lobe techniques are beneficial regarding operative time and are used by most experts.

Experts' recommendations in laser use for the treatment of upper tract urothelial carcinoma: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training Research in Urological Surgery and Technology (T.R.U.S.T.) group

PURPOSE

To highlight and compare experts' laser settings during endoscopic laser treatment of upper tract urothelial carcinoma (UTUC), to identify measures to reduce complications, and to propose guidance for endourologists.

METHODS

Following a focused literature search to identify relevant questions, a survey was sent to laser experts. We asked participants for typical settings during specific scenarios (ureteroscopy (URS), retrograde intrarenal surgery (RIRS), and percutaneous treatment). These settings were compared among the reported laser types to find common settings and limits. Additionally, we identified preventive measures commonly applied during surgery.

RESULTS

Twenty experts completed the survey, needing a mean time of 12.7 min. Overall, most common laser type was Holmium-Yttrium-Aluminum-Garnet (Ho:YAG) (70%, 14/20) followed by Thulium fiber laser (TFL) (45%, 9/20), pulsed Thulium-Yttrium-Aluminum-Garnet (Tm:YAG) (3/20, 15%), and continuous wave (cw)Tm:YAG (1/20, 5%). Pulse energy for the treatment of distal ureteral tumors was significantly different with median settings of 0.9 J, 1 J and 0.45 J for Ho:YAG, TFL and pulsed Tm:YAG, respectively (p = 0.048). During URS and RIRS, pulse shapes were significantly different, with Ho:YAG being used in long pulse and TFL in short pulse mode (all p < 0.05). We did not find further disparities.

CONCLUSION

Ho:YAG is used by most experts, while TFL is the most promising alternative. Laser settings largely do not vary significantly. However, further research with novel lasers is necessary to define the optimal approach. With the recent introduction of small caliber and more flexible scopes, minimal-invasive UTUC treatment is further undergoing an extension of applicability in appropriately selected patients.

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

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.