Which is the best laser for ureteroscopy? A Comprehensive Review.

PURPOSE: The landscape of ureteroscopy has been transformed by rapid advancements in laser technology. The transition from the standard Holmium:YAG (Ho:YAG) to Thulium Fiber Laser (TFL) and emerging hybrid technologies (Magneto/Tm:YAG) creates decisional uncertainty. This review analyzes the physical principles, safety, and clinical outcomes of available lasers, proposing a context-based decision-making framework. MATERIALS AND METHODS: A literature review using PubMed and Embase (2014-2025) yielded 1,902 records. Search terms included "holmium laser nephrolithotripsy," "thulium fiber laser," and "ureteroscopy laser." Fourteen seminal high-quality studies were selected for expert narrative synthesis, focusing on ablation efficiency, stone-free rates (SFR), complications, and cost-effectiveness. RESULTS: Literature heterogeneity, particularly inconsistent SFR definitions and imaging modalities, challenges comparative analysis. Clinically, TFL demonstrates superior ablation speeds and dusting capabilities compared to standard Ho:YAG, with equivalent safety. However, High-Power Ho:YAG remains unmatched in versatility for complex stones. Emerging pulsed Tm:YAG and Magneto Cyber Ho systems theoretically combine peak power with dusting efficiency but require further validation. Economically, TFL and High-Power systems demand significantly higher capital investment than Low-Power alternatives. CONCLUSIONS: No universally superior laser exists; selection must be guided by institutional context. We propose a four-scenario framework: (1) Low-Power Ho:YAG is ideal for cost-sensitive, low-volume centers; (2) High-Power Ho:YAG is the standard for high-volume centers treating complex cases; (3) TFL is the choice for maximizing operative efficiency and dusting; and (4) Emerging Hybrid Technologies suit academic centers driving innovation. Future studies must prioritize standardized reporting to solidify the evidence base.