Thulium Fibre Laser - Is it game changer for renal stones?

Renal stones disease, affecting around 10% of the population, causes significant morbidity and increases healthcare costs.(1) For past 2 decades, Holmium:YAG laser lithotripsy has been the workhorse of endoscopic stone surgery.(2) Thulium Fibre Laser (TFL) has recently emerged as a promising alternative. TFL operates at a wavelength of 1940 nm. This aligns more closely with the peak water absorption coefficient than Holmium:YAG’s 2120 nm. This results in enhanced stone fragmentation efficiency.(3) Additionally, TFL’s ability to utilize smaller, more flexible fibres (150 micron or even 50 micron) improves maneuverability within the renal collecting system.(4)

TFL’s efficacy in renal stone management is supported by evidence. Korolev et al. demonstrated successful outcomes using SuperPulse TFL in retrograde intrarenal surgery (RIRS) for small lower pole renal stones. Dymov et al. reported effective fragmentation for larger stones exceeding 2 cm, during RIRS. A meta-analysis by Enikeev et al. further confirmed TFL’s effectiveness across ureteral and renal stones.(5) Keller et al. reported that TFL had higher ablation rates and smaller fragment sizes compared to Holmium:YAG in dusting mode.(6)

TFL exhibits a favourable safety profile. Enikeev et al. reported complication rates which were comparable to or lower than those of Holmium:YAG. They attributed this to TFL’s adjustable pulse settings, which minimize thermal damage to adjacent tissues.(5)

TFL has a SuperPulse mode, which enhances stone dusting. It produces fine fragments that facilitate natural expulsion.(7) Additionally, Hall et al. explored an automated vibrating fibre system, improving precision and reducing operative times.(8)

Thulium Fibre Laser offers superior efficacy, safety, and precision in renal stone management. It generates finer dust as compared to Ho:Yag laser, can be used with smaller diameter fibres, leads to faster lithotripsy and on table complete stone clearance in many cases. TFL in future will lead to expansion of the scope of RIRS including larger stones and higher percentage of primary RIRS.

Written by Dr Kumar Saurav, Sant Parmanand, New Delhi