How to cite: Bechis SK. “My Laser is Better Than Yours: Thulium:YAG.” Grand Rounds in Urology. November 13, 2025. Accessed Feb 2026. https://grandroundsinurology.com/my-laser-is-better-than-yours-thuliumyag/
Summary
Seth K. Bechis, MD, MS, Associate Professor of Urology, University of California, San Diego, San Diego, California, argues that pulsed Thulium:YAG represents the most balanced and versatile laser platform in modern endourology, combining the strengths of Holmium:YAG and thulium fiber laser (TFL) while minimizing their respective limitations. He presents the case that Thulium:YAG occupies a “middle ground” that delivers high peak power for fragmentation, fine dust production for suction-based evacuation, and favorable thermal and coagulation properties.
Dr. Bechis reviews laser physics, emphasizing photothermal and photomechanical mechanisms and how wavelength-dependent water absorption affects fragmentation efficiency, dust size, and tissue heating. Thulium:YAG is shown to be approximately twice as absorbed by water as Holmium:YAG, but substantially less absorbed than TFL, resulting in efficient energy transfer without excessive thermal buildup.
Peak power characteristics are reviewed in detail. Compared with TFL, pulsed Thulium:YAG achieves significantly higher peak power at similar pulse energies, enabling more effective fragmentation of hard stones while still producing fine dust. Bench and human stone studies are presented demonstrating that Thulium:YAG consistently generates dust well below 250 microns, making it well-suited for suction-assisted techniques, such as flexible, navigable suction sheaths.
Clinical and experimental data comparing laser platforms across multiple stone compositions are reviewed. Thulium:YAG performs at or near the top tier for synthetic stones and demonstrates intermediate but reliable performance for human stones. Importantly, it avoids the stone charring and melting effects reported with high-frequency TFL settings.
Beyond stone surgery, the presentation highlights versatility in benign prostatic hyperplasia (BPH) treatment. Thulium:YAG supports vaporization, fragmentation, and mechanical enucleation with good hemostasis and minimal charring. Comparative data suggest shorter operative times, reduced hospital stay, and lower postoperative pain compared with Holmium laser enucleation for large prostates.
Dr. Bechis argues that pulsed Thulium:YAG offers the best combination of fragmentation power, fine dusting, safety, versatility, and operating room practicality, positioning it as a compelling all-around laser platform.
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.
ABOUT THE AUTHOR
Seth K. Bechis, MD, MS, is an Associate Professor of Urology at the University of California, San Diego. Dr. Bechis specializes in all procedures of the prostate, including minimally invasive procedures such as Rezum water vapor therapy and UroLift, as well as robotic surgery and GreenLight Laser photoselective vaporization of the prostate. His current research focuses on improving surgical techniques and clinical outcomes in stone disease, as well as tools for stone diagnosis and opiate-sparing pathways for managing pain.
Dr. Bechis earned his Master’s of Science in Biomedical Sciences and his medical degree from the University of California, San Francisco. He completed his residency at Harvard University in Boston, Massachusetts. Dr. Bechis then completed a fellowship in Laparoscopy/Robotics and Endourology at the University of California, San Francisco.
Dr. Bechis is a member of several professional medical organizations, including the American Urological Association (AUA), the Endourological Society, and the Western Section of the AUA. He has won numerous awards and honors over the years, including the Whitehill Award for Excellence in Clinical Teaching in 2019, Plenary Address for Best Abstract from the American Urological Association in 2015, and first place in the 2014 Max K. Willscher Resident Research Award Competition. Dr. Bechis has been invited to speak nationally and internationally at conferences on topics including benign prostatic hyperplasia and stone disease. His research has been featured in peer-reviewed medical journals, including Journal of Urology, Journal of Endourology, and World Journal of Urology. Additionally, Dr. Bechis was editor of First Aid Q&A for the USMLE Step 1, Second Edition, and has authored chapters for university handbooks.
