This document discusses different laser options for treating urological conditions, including the Holmium:YAG laser, Thulium:YAG laser, and Thulium Fiber Laser. It provides details on the wavelength emissions and tissue penetration depths of each laser. The document compares the lasers' performance characteristics, costs, learning curves, and safety and efficacy outcomes for procedures like prostatectomy. While the Thulium:YAG laser may have advantages over Holmium, the Thulium Fiber Laser is noted to have limitations like poorer coagulation ability and ablation speed due to its more superficial tissue penetration depth.

1. Dr. Prem Kumar
Consultant Urologist
Ranchi Urology Centre

2.  Rare earth element
 Neighbours of Holmium in periodic table
Ranchi Urology Centre

3. TFL
TFL emits at a wavelength of 1940 nm, near absorption peak of water.
Thulium:YAG emission is at 2010 nm
Holmium: YAG emission is at 2123 nm. Because the water absorption coefficient of the TFL is
nearly 2 times higher than Thulium:YAG laser, its tissue penetration is half :
TFL~100 µm penetration
Th-YAG~200 µm penetration
Ho-YAG ~ 400 µm penetration
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4. Thulium : YAG Laser Thulium Fibre Laser
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5. Laser Issues
Holmium : YAG,
100 W
 4 laser heads (each with 1-laser rod
2 mirrors and a pumping chamber)
1 Lens hence with increased wear-n-tear, maintenance
cost and output
Thulium : YAG  Laser Rod (Solid state)
 Diode Pump (Through crystal) into Fiber Complex
Thulium Fiber
Laser
 Diode Pump
 Thulium doped , 10-20 μm diameter, 10-30 m long Silica
fibre
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6. Laser Cost Fiber / Running Cost
(50000-55000)
Holmium 60 W 55 L
Enucleation @40cases/fibre= Rs. 1000 – 1500 /case.
Holmium 100 W 90 L
Thulium 150 W 80 L
100 cases/ 3 fibre= Rs.2000- 2500 /case
Same fibre can be used for holmium laser for stones subsequently.Thulium 200 W 90 L
Thulium Fibre Laser 60W 45 L Enucleation @40cases/fibre= Rs. 1000 – 1500 /case.
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 Currently no comparative cost studies investigating thulium laser.
 In contrast to other laser systems, the bare ended quartz fibre of the thulium laser can be
reused many a times leading to almost negligible running cost
Yana Barbalat et al, Evidence of the efficacy and safety of the thulium laser in the treatment of men with benign prostatic obstruction, Ther Adv Urol2016, Vol.8(3) 181-191
Szlauer,et al. (2009) Endoscopic vaporesection of the prostate using the continuous-wave 2-microm thulium laser: outcome and demonstration of the surgical technique. Eur Urol 55: 368–375.

7. Ranchi Urology Centre

8. Ranchi Urology Centre
Technique Basic Principle Consensus Nomenclature
Vaporization Destruction Thulium:YAG Vaporization of
prostate (ThuVAP)
Vaporesection Resection into small tissue
chips
Thulium:YAG Vaporesection of
Prostate (ThuVARP)
Vapoenucleation Enucleation in combination
with vaporization of the
median & lateral lobe
Thulium:YAG Vapoenucleation
of Prostate (ThuVEP)
Enucleation Blunt enucleation with laser
support
Thulium:YAG Laser enucleation
of Prostate (ThuLEP)
Ref: Bach T etal, Thulium YAG 2 μm cw laser prostatectomy: where do we stand? World J Urol. 2010: 28 (2)

9. Modalities Holmium Thulium :YAG Thulium Fiber
Laser
Resection
Vaporisation Poor Poor
Coagulation Poor Poor
Power Supply Dedicated high
amperage power
outlet
Standard/ house hold
power outlet
Standard/ house
hold power outlet
Pulse Energy
Pulse frequency
0.2- 6 J
Upto 100 Hz
0.025- 6 J
5-2200 Hz
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10.  Excellent Hemostasis and Coagulation
 Perform smoother incision & excellent tissue
vaporization
 Greater accuracy
 Allows uncomplicated correction of the layer of
enucleation
 Size independent
 Well tolerated and effective
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11.  Minimal collateral damage
 Low peri-operative morbidity
 Excellent long term results
 PSA reduction rate of 77.1% at 5 year follow up
 Energy efficiency
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12. Ranchi Urology Centre
Laser Learning Curve
Holmium more
Thulium less
 ThuVEP has an easier learning curve ( 8 -16 cases ) than HoLEP
thulium laser allows for instant conversion to vaporisation with the same end fibre
HoLEP demand a greater learning curve, with 40-60 cases required to become
proficient, during the initial learning curve, it is often difficult to discern the level of the
plane between the adenoma and surgical capsule when deepening the groove.
Yana Barbalat et al, Evidence of the efficacy and safety of the thulium laser in the treatment of men with benign prostatic obstruction, Ther Adv Urol2016, Vol.8(3) 181-191
Brunckhorst, O., Ahmed, K., Nehikhare, O.,Marra, G., Challacombe, B. and Popert, R. (2015),Evaluation of the learning curve for holmium laser enucleation of the prostate using multiple
outcome measures. Urology 86: 824–829.
Ramsay L Kuo et al, Holmium Laser Enucleation of the Prostate (HoLEP): A Technical Update, World Journal of Surgical Oncology 2003, 1:6
 TFL also has a longer learning curve

13. Ranchi Urology Centre
Laser Blood loss
Drop in Hb%
Patient requiring transfusion
HoLEP 1.2 ± 0.6 gm/dl # 2 % **
ThuVEP 0.8 ± 0.42## 0.6- 1.7 % *
##P. Vartak Ketan and H. Salvi Prashant, Thulium laser enucleation of the prostate is a safe and a highly effective modality for the treatment of benign prostatic hyperplasia -
Our experience of 236 patients, Urol Ann. 2016 Jan-Mar; 8(1): 76–80.
# Myeong Jin Woo, et al, Comparison of Surgical Outcomes Between Holmium Laser Enucleation and Transurethral Resection of the Prostate in Patients With Detrusor
Underactivity, Int Neurourol J. 2017 Mar; 21(1): 46–52.
*Yana Barbalat et al, Evidence of the efficacy and safety of the thulium laser in the treatment of men with benign prostatic obstruction, Ther Adv Urol2016, Vol.8(3) 181-191
**Ilter Alkan et al, Holmium laser enucleation of the prostate: surgical, functional, and quality-of-life outcomes upon extended follow-up, Int Braz J Urol. 2016; 42: 293-301

14. Ranchi Urology Centre

16. Ranchi Urology Centre
*P. Vartak Ketan and H. Salvi Prashant, Thulium laser enucleation of the prostate is a safe and a highly effective modality for the treatment of benign prostatic hyperplasia -
Our experience of 236 patients, Urol Ann. 2016 Jan-Mar; 8(1): 76–80.
Parameter ThuVEP * HoLEP**
Operation time (min) 56 60-97
Enucleation time(min) 32.5 49.88
Morcellation time (min) 11 17.8
Morcellation efficiency (gm/min) 2.6 2.62
Hemoglobin decrease(gm/dl) 0.8+4.2 0.8(0-2.4)
Catheterisation time(days) 2 1-3
Hospitalisation (days) 4 1.5-4
Recatheterisation rate 1.27 % 3.9%
•# Hemendra N. Shah et al, Peri-operative complications of holmium laser enucleation of the prostate: experience in the first 280 patients, and a review of literature,
BJUI, Volume 100, Issue 1 July 2007 Pages 94–101
Prostate Size: 40- 50gm

17. Parameter Thu:Yag** Hol:Yag*
Post op dysuria Less 1.2(0-10)%
Morcellation injury 1.4 % cases 1-3%
Stress incontinence 0.1-0.5% 0.9(0-3)%
Urge incontinence 6.7% 5.6%
UTI 3.1% 0-4.9
Capsular perforation 2.1 % 2-9.6% #
Extra peritoneal fluid collection 1.5%
Superficial bladder injury 15 % 3.9%
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*Yakup Bostanci et al.. Laser Prostatectomy: Holmium Laser Enucleation and Photoselective Laser Vaporization of the Prostate Rev Urol. 2013;15(1):1-10 doi:
10.3909/riu0553
•Ilter Alkan et al, Holmium laser enucleation of the prostate: surgical, functional, and quality-of-life outcomes upon extended follow-up, Int Braz J Urol. 2016; 42: 293-
301
•# Hemendra N. Shah et al, Peri-operative complications of holmium laser enucleation of the prostate: experience in the first 280 patients, and a review of literature,
BJUI, Volume 100, Issue 1 July 2007 Pages 94–101
**Yana Barbalat et al, Evidence of the efficacy and safety of the thulium laser in the treatment of men with benign prostatic obstruction, Ther Adv Urol2016, Vol.8(3)
181-191

18. Ranchi Urology Centre
Recommendations LE GR
ThuVARP is an alternative to TURP for small- and medium-sized
prostates.
1b A
ThuVEP can be offered as an alternative to TURP, to HoLEP and OP for
large size prostates.
1b,2b B

20. Ranchi Urology Centre
Treatment Laser Settings
Urethrotomy
(urethral strictures)
10 W - CW or PW
(200-365μm fiber)
Endoureterotomy
(ureteral strictures)
5-15 W CW
(272-365μm fiber)
Ablation of
UUT carcinoma
10 W (direct contact),
15-20W (distant)
(200-600μm fiber)
Resection of superficial Bladder
Carcinoma (ThuLRBT)
5–15 W (200-550 μm fiber)
30–50 W (550 μm fiber)
BNI 24 W, up to 100 W
(550μm side and bare fiber)
Penile Cancer
excision/ablation
15-20 W
(365μm fiber)
Partial Nephrectomy 10-40 W

21. Limited Studies available to validate safety & efficacy

22. 2010nm
1940nm
TFL closes only
small vessels, poorer
coagulation
Biopsy taken
after
Thulium:YAG
2010nm
enucleation
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23. 1. No CE approval
2. FDA recently approved [Olympus]
3. 3 models
a) 35W TFL
b) 55W – 60 W- TFL Superpulsed
c) 120W TFL
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Less cutting/ablation/coagulation because more superficial effect than THULIUM –YAG (TFL
~ 100µm vs Th-YAG ~ 200µm penetration)
Not suitable for vaporization: too low power to use large fibers; too superficial effect
(1900nm wavelength)

24.  A lower tissue penetration depth may diminish safety of TFL
regarding
1. Coagulation capability-
 Soft tissue superficial effect
 less coagulative,
 difficult to close larger vessels.
2. Ablation speed- depends on penetration depths into tissue
3. Poor vaporization
4. Duty cycle to avoid over heating: 20 minutes off after 60 minutes
usage
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29. ThuVARP ThuFLP

30.  Limited studies to prove its efficiency for
prostatectomy.
 Results likely to be similar to HoLEP but probably
slower and less hemostatic.
 Higher learning curve.