Professor Institute for Urology and Reproductive Health, Sechenov University, Moscow
Introduction: A new thulium fiber laser (TFL) has been recently developed as a novel surgical tool with multiple applications in urology. The latest modification of the device incorporates two modes for surgery – quasi-continuous (QCW, for soft tissue surgery) and SuperPulsed (SP, for lithotripsy). Evaluation of the utility of the novel device began with in-vitro comparison of TFL with conventional Ho:YAG. After clinical approval, device efficacy was assessed for soft tissues (BPH, NMIBC) and stones.
Methods: This prospective clinical trial started following local IRB approval. For TFL enucleation of the prostate (ThuFLEP), TFL (NTO IRE-Polus, Russia) in QCW mode with 600-µm laser fiber and 26 Ch resectoscope (Karl Storz, Germany) with continuous irrigation (0.9% saline) was used. TFL en bloc resection of bladder tumor (TFL-ERBT) was performed using the following settings: QCW; 1.0 J; 10 W. Lithotripsy was performed with TFL using 200-, 400- and 600-µm fibers in SP mode. Stone-free rate (SFR) was assessed with low-dose computed tomography 3 months after.
Results: ThuFLEP was performed in 1392 patients, TFL-ERBT in 118 cases, and TFL lithotripsy (PCNL, RIRS, URS, bladder) was performed in 321 patients. In the ThuFLEP group median prostate volume was 80 (IQR 60; 105) cc. Qmax and IPSS before surgery were 9.6±2.6 and 22.9±1.8, respectively. Mean surgery duration was 70.5±31.0 min, whereas the mass of resected tissue was 69.8±34.7 g. Mean catheterization time was 1.7±0.8 days; mean hospital stay was 3.7±1.0 days. PVR, Qmax, IPSS and QOL all significantly improved at 3 months after surgery (p <0.001). TFL-ERBT was performed in 118 patients with detrusor rate of 91.6%. RFS at 6 months was 91.5%. Of 321 patients with urinary calculi treated with TFL, 153 had kidney stones (median stone volume – 279.6 (IQR, 139.4–615.8) mm3, mean density – 1020±382 HU), 149 had ureter stones (median stone volume - 179 (IQR, 94–357) mm3, mean density – 985±360 HU) and 19 had bladder stones (mean size 22.2 mm, mean density – 1050 HU). Stone-free rate was 92%.
Conclusions: TFL shows high efficiency and acceptable safety profile in the treatment of urinary stones, NMIBC and BPH. The combination of SuperPulsed and quasi-continuous modes within a single device allowed for developing a universal tool for urologic surgery. However, further studies are necessary to assess the comparative efficacy of this surgical modality with standard options offered by guidelines.