Laser applications in endourology: Endocorporeal laser lithotripsy during ureteroscopy

Laser energy has become the preferred option to treat urinary stones during ureteroscopy (URS), rigid or flexible (FURS). Tis review aimed to report the outcomes of endocorporeal laser lithotripsy (ELL) during URS, as well as laser settings.

A literature review was conducted up to April 2025 with no time limit on PubMed/MEDLINE, Scopus, and Cochrane databases. A narrative synthesis is presented for clarity.

Only pulsed Holmium:YAG (Ho:YAG), Thulium Fiber (TFL), and Thulium:YAG (p-Tm:YAG) lasers are effective for ELL during URS. They present similar stone-free rates (SFR, residual fragments<3mm) during FURS. TFL is associated with the best zero-fragment rates (ZFR, residual fragments<1mm). Technological nuances need to be addressed to explain the variations in surgical technique and outcomes: TFL has a low peak power (500W max) and 150μm fibers providing finer dusting abilities than Ho:YAG and p-Tm:YAG. Conversely, Ho:YAG offers excellent fragmentation abilities, useful for hard stones such as cystine ones. p-Tm:YAG represents a compromise enabling both dusting and fragmentation of all stone types. Laser settings should be individualized beginning with treatment objective, and peak power. A low-energy (0.5J)-low-frequency (5Hz) test then allows adjustment of fracture level via energy and treatment speed via frequency (≤10Hz/W in ureter, ≤30Hz/W in renal cavities).

Ho:YAG, TFL, and more recently p-Tm:YAG are indispensable tools for ELL during URS, with similar SFR. However, TFL has reported the best ZFR. The development of suction devices is expected to revolutionize ELL in URS.