Which is the best laser for ureteroscopy? A Comprehensive Review

Area of Science:

• Urology
• Laser Technology
• Nephrolithotripsy

Background:

• Ureteroscopy laser technology has rapidly evolved, introducing new options beyond standard Holmium:YAG (Ho:YAG) lasers.
• Thulium Fiber Laser (TFL) and hybrid systems (Magneto/Tm:YAG) present new choices, causing uncertainty in clinical decision-making.

Purpose of the Study:

• To analyze the physical principles, safety, and clinical outcomes of various ureteroscopy lasers.
• To propose a framework for selecting the appropriate laser technology based on clinical context.

Main Methods:

• A comprehensive literature review of PubMed and Embase databases from 2014-2025.
• Selection of 14 high-quality studies focusing on ablation efficiency, stone-free rates (SFR), complications, and cost-effectiveness.

Main Results:

• Thulium Fiber Laser (TFL) shows faster ablation and better dusting than standard Ho:YAG, with similar safety profiles.
• High-Power Ho:YAG remains versatile for complex stones, while emerging hybrid lasers require further validation.
• TFL and High-Power systems involve higher initial costs compared to Low-Power lasers.

Conclusions:

• No single laser is universally superior; selection should be context-dependent.
• A framework is proposed: Low-Power Ho:YAG for cost-sensitive centers, High-Power Ho:YAG for complex cases, TFL for efficiency, and hybrid technologies for innovation.
• Standardized reporting in future studies is crucial for robust evidence.