Smart Lithotripsy: Lasers, Energy Sources and Efficiency

Abstract

PURPOSE OF REVIEW: To examine the evidence on contemporary lasers and provide a practical framework for platform selection, parameter optimization, and thermal safety based on the principles of smart lithotripsy. RECENT FINDINGS: Holmium: yttrium-aluminum-garnet (Ho:YAG) remains versatile for fragmentation and dusting, whereas thulium fiber laser (TFL) provides efficient fine-particle dusting with limited retropulsion. Pulsed thulium: YAG (p-Tm:YAG) shows an intermediate profile between Ho:YAG and TFL, but clinical evidence on lithotripsy outcomes is limited. Higher power settings with Ho:YAG may accelerate ablation, but have to be used carefully with high flow rates and access sheaths. For TFL, high-power settings have not been shown to shorten operative time or improve stone-free outcomes and may increase thermal risk. Future systems may incorporate stone recognition, composition prediction, and tissue protection. There is no ideal laser for every clinical scenario. Urologists should match the platform, settings, and treatment strategy to the intended endpoint, whether fragmentation with active extraction or dusting with passive clearance.