My Laser is Better: TFL

How to cite: Sheetz TJ. “My Laser is Better: TFL.” Grand Rounds in Urology. November 13, 2025. Accessed Apr 2026. https://grandroundsinurology.com/my-laser-is-better-tfl/

Summary

Tyler J. Sheetz, MD, 2023-25 Kaiser Endourology Fellow, University of California, San Diego, San Diego, California, argues that the thulium fiber laser (TFL) is the most versatile and practical laser platform currently available for urologic stone surgery. He asserts that TFL improves nearly every dimension of laser lithotripsy, including physics, ablation efficiency, retropulsion, fiber size, operating room logistics, portability, and energy efficiency.

Dr. Sheetz opens with a brief history of laser lithotripsy, noting that Holmium:YAG has served as the gold standard for decades due to its effectiveness across stone types. However, limitations related to device size, electrical requirements, and efficiency prompted the development of newer technologies. TFL, introduced in 2005 and approved by the US Food and Drug Administration in 2020, is presented as a direct response to these shortcomings.

Laser physics is emphasized as a key differentiator. TFL offers a broader range of pulse energy, dramatically higher maximum frequency, and a more uniform pulse profile compared with Holmium:YAG. These characteristics allow surgeons to finely tune fragmentation and dusting strategies. Ablation data from bench and translational studies demonstrate up to fourfold greater ablation volume with TFL, along with consistently smaller dust particles that are more easily evacuated.

Reduced retropulsion is highlighted as a major clinical advantage, allowing stones to remain stable during treatment and improving efficiency. Fiber size is another core benefit. TFL supports fibers as small as 50 microns, improving scope deflection, visibility, irrigation, and access in challenging anatomy while enabling miniaturization of ureteroscopic and percutaneous techniques.

Dr. Sheetz also focuses on operating room logistics. Compared with Holmium:YAG systems that can weigh several hundred pounds and require specialized electrical outlets, TFL units are compact, lightweight, and compatible with standard outlets. These features improve scheduling flexibility and portability, including potential use in global outreach settings.

Dr. Sheetz emphasizes that TFL systems demonstrate substantially higher energy efficiency and lower power consumption per case, positioning them as a more sustainable option for modern operating rooms. Together, these features position the thulium fiber laser as a compelling option for modern endourology.

About the 32nd Annual Perspectives in Urology: Point Counterpoint conference: Presented by Program Chair and Grand Rounds in Urology Editor-in-Chief E. David Crawford, MD, this conference brought together leading experts in urology, medical oncology, and radiation oncology to discuss and debate the latest topics in genitourinary cancers, primarily prostate cancer and bladder cancer. This interactive conference offered topical lectures, pro/con debates, interesting-case presentations, interactive panel discussions, and interactive audience and faculty networking.