632429

research-article2016
TAU0010.1177/1756287216632429Therapeutic Advances in UrologyY. Barbalat et al.

Therapeutic Advances in Urology Review

Evidence of the efficacy and safety of the

Ther Adv Urol

1­–11

thulium laser in the treatment of men with DOI: 10.1177/

1756287216632429

benign prostatic obstruction

© The Author(s), 2016.
Reprints and permissions:
http://www.sagepub.co.uk/
journalsPermissions.nav

Yana Barbalat, Marissa C. Velez, Christopher I. Sayegh and Doreen E. Chung

Abstract:  In 2005, the high power thulium laser was introduced for the surgical treatment of
benign prostatic obstruction. It has several properties that confer theoretical advantages over
other lasers used for the same indication, such as technical versatility and a relatively small
zone of thermal damage. Studies using the 70–150 W thulium laser systems demonstrate
good efficacy of these procedures with low morbidity and few complications even in higher risk
patients. Different techniques have been employed to treat the prostate with this technology,
including enucleation, vapoenucleation, vaporization and resection. Comparative studies have
been published comparing thulium laser prostatectomy to monopolar transurethral resection
of prostate (TURP), bipolar TURP and holmium laser enucleation of prostate (HoLEP). In
this review we discuss the current literature on the safety and efficacy of various thulium
techniques for the treatment of benign prostatic hyperplasia and examine comparative
studies.

Keywords:  laser therapy, prostatic hyperplasia, thulium

Introduction analyzed practice patterns and found that, by Correspondence to:

Doreen E. Chung, MD
According to the Urologic Diseases in America 2005, traditional TURP accounted for 39% of Columbia University
project, benign prostatic hyperplasia (BPH) surgical interventions for BPH while laser proce- Medical Center, 161 Fort
Washington Avenue, HIP
affects 70% of men in the US aged 60–69 and dures accounted for 57% [Yu et al. 2008]. There 11th Floor, New York, NY
80% of those aged 70 or older [Wei et al. 2005]. are several different types of minimally invasive 10032, USA
dec2154@cumc.columbia.
The Rancho Bernardo study, a longitudinal pop- laser procedures including enucleation, vaporiza- edu
ulation-based study, found that 56% of men aged tion, vapoenucleation and resection. Yana Barbalat, MD
50–79, 70% of men aged 80–89 and 90% of men Marissa C. Velez, MD
Christopher I. Sayegh, BSc
aged 90 or older reported experiencing lower uri- The high power thulium laser was first introduced Columbia University
nary tract symptoms (LUTS) [Parsons et  al. in 2005 for the treatment of BPH [Xia et  al. Medical Center, New York,
NY, USA
2008]. Multiple surgical options are available for 2005]. Similar to holmium technology, at
the treatment of BPH and its associated symp- 2010 nm, the wavelength of the thulium laser is
toms, with transurethral resection of the prostate very close to the peak for absorption in water,
(TURP) remaining the gold standard surgical which is 1940 nm. However, unlike the pulsed
treatment with the longest follow-up data availa- wave holmium laser, this high density energy is
ble. Although traditional TURP is both efficient delivered in a continuous wave. This theoretically
and effective, it is associated with significant mor- translates to more efficient vaporization and shal-
bidity from bleeding and fluid shifts, including a lower depth of penetration in tissue, which has
2–8% transfusion rate [Mebust et  al. 1989; been reported to be 0.2 mm as compared with
Rassweiler et al. 2006]. TURP rates have declined 0.4 mm for holmium lasers [Fried and Murray,
over the past two decades due to the significant 2005]. This property likely also results in a smaller
benefits of medical therapy and the proliferation zone of thermal damage, which in turn may help
of alternative surgical techniques that include to decrease postoperative dysuria, an adverse
laser therapies for BPH. Yu and colleagues effect that is commonly associated with

http://tau.sagepub.com 1

Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016

Therapeutic Advances in Urology 
transurethral laser prostate surgery [Rieken et al.
2010]. The fiber is diode pumped which gives it
the capability of operating in either a pulsed mode
or a continuous wave mode. The continuous
wave mode is more suitable for hemostasis and
coagulation of tissue, whereas the pulsed mode
for is more suited for lithotripsy [Hardy et  al.
2014].
Studies using the 70–150 W thulium laser sys-
tems demonstrate good short-term efficacy with
low morbidity and few complications [Gross et al.
2012]. This paper reviews the current evidence of
safety and efficacy of the various thulium laser
techniques for the treatment of BPH and the
comparative studies.
Methods
A PubMed search for papers from 2005 to 2015
was conducted using the words ‘thulium laser
prostate’. A total of 112 papers were obtained.
After case reports, abstracts only and papers not in
English were excluded, 98 articles remained. We
reviewed all case series, review papers, cohort stud-
ies, and retrospective and prospective studies rele-
vant to the topic covered in this review. We then
scanned the references of the articles used to cap-
ture any additional relevant papers which would
make this manuscript more comprehensive.
Surgical techniques
Several techniques using the thulium laser have
been described for laser prostatectomy including
thulium vapoenucleation (ThuVEP) and thulium
laser resection of the prostate (TmLRP) (the ‘tan-
gerine’ technique), thulium laser enucleation
(ThuLEP) and thulium vaporization (ThuVP)
(Table 1). In the authors’ opinion, for smaller
prostates all techniques are similarly efficient and
feasible. The end-fire fiber in combination with
effective vaporization of the thulium laser system
lends itself to both vaporization and enucleation.
Hence, the choice of technique in smaller pros-
tates is mostly driven by surgeon preference. For
larger prostates (i.e. size >100 ml), enucleation
techniques are more efficient and effective.
ThuVEP and ThuLEP are almost identical tech-
niques in description. There may be a greater
proportion of mechanical, as opposed to laser,
enucleation in the ThuLEP technique.
There are two main high power thulium laser sys-
tems: the CyberTM (Quanta System, Solbiate
2 http://tau.sagepub.com
Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016
Olona, Italy; 150W, 200W) and the Revolix®
(Lisa Laser, Katlenburg-Lindau, Germany; 30W,
70W, 120W and 200W systems). The authors
have used both systems at the same power level
and there does not appear to be a noticeable dif-
ference in vaporization efficiency.
Vapoenucleation (ThuVEP)
Vapoenucleation is the most commonly described
technique and involves trilobar enucleation using
a combination of laser and mechanical energy fol-
lowed by intravesical morcellation, similar to hol-
mium laser enucleation of prostate (HoLEP)
[Bach et al. 2009a, 2009b]. The continuous wave
of the thulium laser leads to a very different inter-
action with prostate tissue compared with the
pulsed holmium laser, which is the reason the
technique has been coined ‘vapoenucleation’.
The majority of studies are short term and there is
large heterogeneity in patient populations making
the studies difficult to compare.
The first studies were performed in small pros-
tates where the tissue chip size was small enough
to avoid the need for morcellation. Bach and col-
leagues reported on a single surgeon feasibility
series of 54 men with a mean prostate volume
30.3 (range 12–38) cm3 who underwent vapore-
section of the prostate with the 70W RevoLix®
(Lisa Laser Products, Katlenburg-Lindau,
Germany) laser system with a wavelength of
2013 nm [Bach et al. 2007]. Improvements were
seen in mean International Prostate Symptom
Score (IPSS) (19.8 to 6.9), maximum flow rate
(Qmax) (4.1–20.1  ml/s) and postvoid residual
(PVR) (86–12 ml) compared with preoperative
paramaters. No patients required transfusion or
rehospitalization. A total of six (11%) patients
developed a symptomatic urinary tract infection
(UTI) requiring antibiotic therapy.
Following this feasibility study, this same group
of authors investigated the feasibility and efficacy
of thulium:YAG (Tm:YAG) laser vapoenuclea-
tion of the prostate in larger prostates [Bach et al.
2009b]. In this short-term study, with follow up
to discharge, 88 patients with a prostate volume
of 61.3 ± 24.0 cm3 underwent vapoenucleation of
the prostate with the 70W RevoLix® Tm:YAG
laser. In contrast to the previous study, morcella-
tion was performed in all patients following
enucleation. The complication rate was 16.6%,
with 12 patients having complications: two
(2.2%) patients required blood transfusions for
 Y Barbalat, MC Velez et al.

Table 1.  Thulium non-comparative observational studies.

Reference Thulium No. of Mean prostate Operative time Anticoagulation Follow up Complications
technique patients size (g) (min) (% patients) (months)
Iacono ThuLEP 148 108.08 ± 24.23 70.03 ± 25.87 N/A 12 UTI (12.8%)
et al. [2012] Bladder injury
(2.7%)
Transfusion
(2.7%)
Rausch ThuLEP 234 84.8 ± 34.99 102 ± 37 ASA/clopidogrel 24 UTI (3%)
et al. [2015] held (except for Transfusion
high risk patients) (0.9%)
(5.1%) Stricture (2.1%)
Gross et al. ThuVEP 1080 51* 56 (40-80) Continued (28.7%) 1 UTI (8.4%)
[2012] Transfusion
(1.7%)
Netsch ThuVEP 56 50* 61.5 (40–100.75) Continued (100%) 24 Transfusion
et al. [2013] (7.1%)
Sun et al. TmLRP 2216 66* 64 (48–85) Continued (10.3%) 8 year UTI (3.1%)
[2015] Transfusion
(0.6%)
Pariser ThuVP 59 57 ± 30.2 35 ± 18 (laser Warfarin bridged 3 UTI (10%)
et al. [2014] time) to enoxaparin or Transfusion
heparin. ASA/ (0%)
clopidogrel held
or continued
based on
cardiology
recommendation.
(47%)
Vargas ThuVP 55 42.53 ± 17.41 51.62 ± 19.76 Excluded 6 UTI (3.6%)
et al. [2014] Transfusion
(0%)
*Reported as median value.
ASA, acetylsalicylic acid; ThuLEP, thulium laser enucleation; ThuVP, thulium vaporization; TmLRP, thulium laser resection of the prostate; UTI,
urinary tract infection.

postoperative bleeding; six (6.8%) patients devel-
oped symptomatic UTIs; three (3.4%) patients
experienced intra- or postoperative bleeding; and
two (2.2%) underwent a second-look procedure
during the same hospital stay due to inability to
void. Significant improvements were seen at dis-
charge in Qmax (3.5 ± 4.7–19.8 ± 11.6 ml/s) and
PVR (121 ± 340–22 ± 33 ml).
This same group reported on complications and
early postoperative outcomes of ThuVEP per-
formed by 11 surgeons at a single institution in an
impressively large series of 1080 patients using
various generations of the thulium laser between
70W and 200W [Gross et  al. 2012]. This was
a short-term analysis examining preoperative
characteristics, surgical details and immediate
outcomes.
Median age at surgery was 71 years and prostate
size was 52 ml [interquartile range (IQR) 36–79]
with a median operation time of 56 minutes. A
total of 22% of patients were in retention prior to
surgery. Median enucleation time was 33 minutes
(IQR 22–50) and median resected tissue weight
was 30 g (IQR 36–78). Significant changes were
seen after surgery in median maximum flow rate
(8.9 versus 18.4 ml/s, p < 0.001) and PVR (120
versus 20 ml, p < 0.001) compared with before
surgery. Median catheterization time was 2 days
(IQR 2–2) and median hospital stay was 4 days
(IQR 3–5).
The overall immediate morbidity rate was 16.9%.
Minor complications (Clavien class 1 and 2)
occurred in 262 (24.6%) patients. Within 4
weeks, 71 (6.6%) patients required intervention

http://tau.sagepub.com 3

Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016

Therapeutic Advances in Urology 
(Clavien 3a: 0.6%; Clavien 3b: 6%). One patient
had a Clavien 4a complication and had an acute
myocardial infarction. No mortalities were seen.
The most frequently reported complications were
urinary retention after catheter removal (9%),
UTI without bacteremia (6.9%), clot retention
without surgical revision (3.5%), residual pros-
tate tissue requiring reoperation (2.7%), capsular
perforation (2.1%), hemorrhage requiring reop-
eration (2%), bleeding requiring blood transfu-
sion (1.7%), UTI with signs of bacteremia
(1.5%), extraperitoneal fluid collection (1.5%),
superficial bladder injury due to morcellation
(1.4%), ureteral orifice injury (0.7%) and hydro-
nephrosis due to ureteric orifice injury (0.6%).
The overall reoperation rate was 4.7% and the
readmission rate was 4.1%.
A subanalysis was performed and patients were
stratified by prostate size. Group A had a prostate
size <40 ml (28%), Group B had a prostate size
40–79 ml (47%) and Group C had a prostate size
⩾80 ml (25%). No differences were seen in com-
plications rates between the groups.
The complication rate using the Clavien classifi-
cation system (CCS) were then compared with
those in published series of HoLEP, photoselec-
tive vaporization of the prostate (PVP), TURP
and open prostatectomy. Overall in this large
series, immediate outcomes and complication
rates for ThuVEP were similar to those in large
series of HoLEP and PVP and lower than in
TURP and open prostatectomy. This large series
confirmed that ThuVEP is a safe and effective
procedure for the treatment of symptomatic BPH
with low perioperative morbidity.
There are many strengths of this large series of
patients including adequate power, multiple sur-
geons and use of standardized reporting methods
for complications. However, the fact that it was a
single center study and that various generations of
the thulium laser were used may not make the
results generalizable to some populations.
Studies support the use of ThuVEP in medically
complex patients, such as high risk cardiopulmo-
nary patients on oral anticoagulation, with few
perioperative complications. Macchione and col-
leagues investigated the safety and efficacy of
ThVEP using the 120-W Tm:YAG laser (Revolix
Duo) in 76 patients who were taking oral anti-
platelet or anticoagulation. In 41 patients (group
4 http://tau.sagepub.com
Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016
A), the procedure was performed while patients
continued oral anticoagulation and, in 35 patients
(group B), oral anticoagulation was discontinued
10 days prior to surgery and patients were bridged
with low molecular weight heparin (LMWH) for
2 weeks, with 3 (8%) patients from this group
taking warfarin [Macchione et al. 2013].
In group A, 5 (12%) patients were taking warfa-
rin, 20 (48%) acetylsalicylic acid (ASA), 12
(29%) ticlopidine, and 4 (10%) ASA and clopi-
dogrel. In group B, 3 (8%) patients were taking
warfarin, 15 (42%) ASA, 11 (31%) ticlopidine
and 6 (17%) ASA and clopidogrel. All procedures
were performed by a single surgeon. The decision
to discontinue oral anticoagulation was made by
the consultant cardiologist. In both groups, mean
age was similar (69 ± 7 for both) as well as mean
prostate size (65 ml for both). Median ASA for
both groups was 3. Operative times (48  ± 8,
47 ± 5 minutes), catherization time (1.5  ± 6,
1.6 ± 6 days), hospital stay (2.3 ± 0.9 and 2.4 ± 9
days), mean drop in sodium (0.52  ± 2.0 and
1.34 ±  1.1 g/L) and mean hemoglobin drop
(0.35 ±  0.2 and 0.85  ± 0.2 g/l) were similar
between groups A and B. Only one patient in
group A required a transfusion. A total of three
(4%) patients overall required continuous blad-
der irrigation for postoperative hematuria.
Significant improvements were seen compared to
baseline in Qmax, IPSS, PVR and quality of life
(QoL) at 3 and 6 months postoperative.
Thulium laser resection of prostate (TmLRP)
TmLRP was initially applied in 2004 by Xia and
colleagues in the treatment of BPH [Xia et  al.
2005]. Described as the ‘tangerine technique’,
resection is carried out by dissection of whole
prostatic lobes off the surgical capsule similar to
that of peeling a tangerine. Tissue is vaporized
sufficiently so that small pieces may be removed
via a resectoscope without requiring use of a mor-
cellator [Xia, 2009]. Several studies with short-
term follow up have demonstrated excellent safety
and efficacy of this technique [Xia et al. 2008; Fu
et al. 2010].
In 2014, Sun and colleagues evaluated the long-
term durability and complication rates after
TmLRP through a large, prospective, multicenter
study [Sun et al. 2015]. A total of 2016 patients
were treated with TmLRP at four medical centers
and were followed for up to 8 years (61.1% fol-
lowed for 5 years, 24.4% followed for 8 years). A

Tm:YAG laser was used with a laser power level
at 50W, 70W or 120W in all patients.
IPSS, QoL, Qmax and PVR were all significantly
improved at 3 months after surgery and remained
significantly improved during the entire follow-up
period. IPSS and QoL decreased by 72.3% and
75%, respectively; Qmax had increased by 178%
and PVR had decreased by 81.8% by the end of
follow up. At 3 months, 1 year and 8 years post-
operatively, median IPSS was 7, 6 and 6, respec-
tively; median QoL was 1, 1 and 1; median Qmax
was 21.7, 22.3 and 19.2 ml/s, respectively; and
PVR was 22, 18 and 20 ml. These results showed
sustained long-term improvement in all urinary
parameters post TmLRP. Short-term Clavien 1
and 2 complications occurred in 23.7% of the
patients. A total of 9% patients had some type of
temporary urinary incontinence and only 3% of
patients were reported to have UTI. A total of 6%
of patients went into urinary retention requiring
catheterization and 3% had clot retention requir-
ing bladder irrigation. Blood transfusion was
required by 13 (0.6%) patients and eight (0.4%)
developed deep vein thrombosis and pulmonary
embolus. There was evidence of systemic infec-
tion in 29 (1.3%) patients. Clavien 3 complica-
tions, requiring re-intervention occurred in 2.2%
of the patients. Resection of residual tissue was
required in 11 (0.5%) patients and 37 (1.7%)
patients underwent cystoscopy for bleeding. In
the cohort of 556 patients with prostate size >80
g, there was no difference in overall, Clavien 1, 2
or 3 complications compared with the patients
with prostate size <80 g.
One unique aspect of this study was the reporting
of long-term complications. Urethral stricture
and bladder neck contractures occurred in 2.6%
and 1.6% of patient, respectively. Persistent stress
incontinence was found in two patients (0.1%).
Re-operation as a result of BPH recurrence was
required in 1.2% of patients over the course of up
to 8 years.
Of note, this study also included 228 patients
who were taking oral anticoagulants (aspirin and/
or clopidogrel) at the time of surgery. There was
no difference in overall, Clavien 1, 2 or 3 compli-
cations between those taking anticoagulants and
not. Additionally, there was no difference in peri-
operative bleeding between the two groups (1.3%
risk on anticoagulation versus 0.7% risk off anti-
coagulation, p = 0.41) This study offers a particu-
lar robust analysis given its prospective,
http://tau.sagepub.com 5
Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016
Y Barbalat, MC Velez et al.
multi-centered design, long-term follow up and
inclusion of a diverse patient profile including
varied prostate size and patients at higher risk of
cardiopulmonary or bleeding complications than
those on anticoagulation.
Thulium laser vaporization of the prostate
(ThuVP)
Although the thulium laser is well suited to vapor-
ization, it is only recently that the safety and effi-
cacy of ThuVP has been reported. Pariser and
colleagues reported short-term outcomes of
ThuVP using the 150W (Cyber™) thulium laser
in the US, which was the first study to be pub-
lished on outcomes on any technique for thulium
laser prostatectomy in a North American patient
population. A total of 59 patients with mean pros-
tate volume of 57 ± 30.2 ml underwent ThuVP;
47% of the patients were taking oral anticoagula-
tion at baseline with aspirin, clopidogrel, warfarin
or enoxaparin. The majority (78%) of patients
were discharged home the same day of surgery.
Although there was a significant change in hemo-
globin from baseline (13.1–12.4 g/dl), no patients
received blood transfusions and the drop was
similar to that seen in 532 nm laser studies [Pariser
et al. 2014].
At 3 months, mean Qmax and PVR were signifi-
cantly improved. Subjective measurements
(IPSS and QoL) also demonstrated significant
improvements from baseline at all follow-up
intervals. At 3 months, IPSS was 8.7 ± 6.5 com-
pared with 19.9 ± 8.0 at baseline and QoL was
2.1 ± 1.4 compared with 4.5 ± 1.1 at baseline
(p < 0.05). All 15 patients who presented in
retention were voiding spontaneously at the
time of their last follow up. The overall 30-day
complication rate was 20%, with all complica-
tions graded as Clavien 1 and 2. A total of 10%
of patients needed catheterization for urinary
retention (half of these were in retention prior to
surgery) and 10% developed symptomatic cul-
ture-proven UTIs. There were no immediate
higher grade complications. Between 30 and 90
days, 1 patient developed a urethral stricture
and 1 a bladder neck contracture. Both were
successfully managed endoscopically and repre-
sent the only Clavien grade 3 complications
[Pariser et al. 2014].
Around the same time, Vargas and colleagues
also published outcomes of 150W ThuVP with 6
months of follow up in 52 patients in Spain.
Therapeutic Advances in Urology 
Prostate size was comparatively smaller with
median 51 ml (IQR 36–78.7 ml) and patients on
anticoagulation were excluded. Patients were also
discharged home the same day of surgery.
Significant improvements were seen in Qmax
(mean improvement 9.33 ml/s) and mean IPSS
(reduction by 17 points). Immediate complica-
tions were recorded at 1 month follow up and
included acute urinary retention (one patient),
urinary tract infection (two patients) and gross
hematuria (two patients). The only late complica-
tion observed (assessed at the 6 month mark) was
bladder neck contracture, which was seen in one
patient. Again within 30 days, no Clavien grade 3
or higher complications were seen [Vargas et  al.
2014]. No comparative data are available for
ThuVP, although this technique appears to have
short-term complications similar to those
described after vaporization with other laser sys-
tems as well as TURP [Reich et al. 2008; Pereira-
Correia et al. 2012].
Thus far, early short-term studies on ThuVP
appear promising and outcomes appear similar to
those from 532 nm vaporization but further long-
term and comparative studies are needed.
Thulium laser enucleation of the prostate
(ThuLEP)
ThuLEP is extremely similar to ThuVEP except
that enucleation of the adenoma is done
mechanically without the use of energy. The ini-
tial cuts are still made with the laser [Kyriazis
et  al. 2012]. Due to the continuous pulse,
vaporization occurs whenever the laser is
employed. Indeed, in papers the description
between the two techniques is often indistin-
guishable [Bach et al. 2009a, 2009b].
Iacono and colleagues described a series of 148
men who underwent ThuLEP with large prostate
size (108 ± 24 ml) who underwent the procedure
using the 120W RevoLix laser with 12 months of
follow-up. Significant improvements were seen in
IPSS, QoL, and PVR [Iacono et  al. 2012].
Complications included UTI in 19 patients
(12.8%), postoperative urgency incontinence in
10 (6.7%), early recatheterization with residual
tissue at prostatic apex in four patients (2.7%),
blood transfusion in four patients (2.7%) and
bladder injury during morcellation in 2 patients
(1.3%). There was significant increase in IIEF
but the absolute difference in score was very small
(19.3 ± 8.2–20.3 ± 8.2, p < 0.05).
6 http://tau.sagepub.com
Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016
In a recent series, Rausch and colleagues per-
formed ThuLEP between 2008 and 2012 in 234
patients with a mean prostate size of 84.8 ± 34.9 ml
using the RevoLix (power not specified). Overall
the 30-day complication rate was 19.7%. In the
perioperative period, only 3% of patients experi-
enced a UTI, 6.8% required catheter replace-
ment and 0.9% required a blood transfusion. In
the postoperative period, 3% experienced urgency
incontinence and 2.1% experienced bladder neck
stricture [Rausch et  al. 2015]. Complications
occurring after 30 days included stress inconti-
nence in one patient (0.5%) and inability to void
requiring chronic catheterization in 19 (8.1%)
patients. Predictors of complications in univariate
and multivariate analysis were age >80 years and
prostate size <50 ml.
Very few studies have addressed sexual outcomes
in detail following any thulium laser prostatec-
tomy. In 2015, Carmignani and colleagues evalu-
ated sexual outcomes in 110 men undergoing
ThuLEP with the Cyber 150™ W laser in a pro-
spective study using validated instruments.
Patients were evaluated before surgery and at 3
and 6 months after ThuLEP with IPSS, IIEF-5
and ICIQ-Male Sexual Matters associated with
Lower Urinary Tract Symptoms (ICIQ-
MLUTSsex) [Carmignani et  al. 2015]. While a
significant and sustained improvement in the
scores evaluating urinary symptoms was observed,
there were no significant differences in erectile
function before and after surgery.
Comparative studies
Comparative studies to traditional TURP
Several comparative studies of thulium laser pros-
tatectomy and other transurethral techniques are
available (see Table 2), mostly originating in Asia.
Several studies have been published comparing
thulium laser prostatectomy with standard
monopolar TURP [Xia et al. 2008]. Using a 50W
continuous wave thulium laser (LISA Laser
Products OHG, Germany), Xia and colleagues
performed TmLRP and compared outcomes up
to 12 months with standard TURP. Patients in
urinary retention were excluded. A total of 52
patients were randomized to TmLRP and 48 to
TURP. Operative time for both procedures were
also similar for TmLRP and TURP (46 ± 16 and
50 ± 20 minutes, p = 0.28). There was a smaller
decrease in hemoglobin in the TmLRP group ver-
sus TURP (0.92 ± 0.82 versus 1.46 ± 0.65 g/dl,
 Table 2.  Comparative studies.

Reference Thulium Study design No. of Prostate Mean prostate Follow up Complications Operative time Hospital stay Hemoglobin
techniques patients size (g) size (g) decrease (g/dl)
compared

Xia et al. TmLRP Randomized 100 <100 59.2 ± 17.7 12 month No significant No significant TmLRP TmLRP versus
[2008] versus prospective trial TmLRP difference difference versus TURP TURP 0.92 ± 0.82
Traditional   55.1 ± 16.3 115.1 ± 25.5 versus
TURP TURP hours versus 1.46 ± 0.65
161.1 ± 33.8 (p = 0.0004)
hours
(p < 0.0001)
Cui et al. TmLRP Randomized 96 <150 51.2 ± 23.2 All 4 year No significant Unknown Unknown Unknown
[2014] versus prospective trial 48 ± 18.3 TmLRP difference
traditional 54.8 ± 27.4
TURP TURP
Chang ThuVEP Prospective, 59 Any 57.2 ± 25.1 12 month ThuVEP versus TURP Unknown No significant No significant
et al. versus nonrandomized ThuVEP Transfusion 13.8% difference difference
[2015] Traditional 64.7 ± 32.5 versus 26.7%
TURP TURP
Yang et al. ThuLEP Randomized 158 <100 72.4 ± 21.2 18 month No significant ThuLEP ThuLEP ThuLEP
[2013] versus prospective trial ThuLEP difference versus BiTURP versus BiTURP versus BiTURP
BiTURP 69.2 ± 23.1 65.4 ± 22.2 2.5 ± 1.4 days 0.15 ± 0.02
BiTURP m versus versus 4.6 ± 1.4 versus
47.4 ± 15.9 m days (p = 0.026) 0.30 ± 0.03
(p = 0.022) (p = 0.045)
Wei et al. TmLRP Randomized 90 >80 112.86 ± 28.36 18 month TmLRP versus BiTURP: No significant TmLRP versus TmLRP versus
[2014] versus prospective trial TmLRP Clavien 1: 13.33 versus difference BiTURP BiTURP
BiTURP 115 ± 39.45 20%; Clavien 2: 0 versus 3.8 ± 0.46 0.86 ± 0.42
BiTURP 2.22%; Clavien 3: 0 days versus versus

Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016

versus 0% 5.02 ± 0.54 days 1.34 ± 1.04
(p < 0.0001) (p = 0.006)
Peng TmLRP Randomized 100 Any 57.8 ± 11.9 3 month No significant TmLRP versus TmLRP versus No significant
et al. versus prospective trial TmLRP difference BiTURP BiTURP difference
[2013] BiTURP 61.2 ± 24.2 3.3 ± 0.8 days
m versus versus 4.1 ± 1.3
30.14 ± 5.9 m days (p < 0.05)
(p < 0.05)

BiTURP, bipolar transurethral resection of the prostrate; ThuLEP, thulium laser enucleation; ThuLRP, thulium laser resection of the prostate; ThuVEP, thulium vapoenucleation; TURP,
transurethral resection of the prostate.

http://tau.sagepub.com 7
Y Barbalat, MC Velez et al.
Therapeutic Advances in Urology 
p = 0.0004). Hospital stay (115  ± 24 versus
161 ± 34 hours, p < 0.0001) and catheterization
time (46 ± 26 and 87 ± 34 hours, p < 0.0001)
were also shorter in the TmLRP group compared
with TURP. At 1, 6 and 12 months follow up, no
significant differences were seen between groups
in IPSS, QoL, Qmax or PVR. No significant
changes in IIEF-5 scores were seen compared
with preoperative in either group [Xia et al. 2008].
Regarding adverse effects, there were two (4%)
transfusions required in the TURP group but
none required in the TmLRP group. No signifi-
cant differences were found with regard to rate of
transfusion, TURP syndrome or UTI. No differ-
ences were seen in either the rate of de novo stress
urinary incontinence or urethral strictures.
Overall, this study suggested that subjective and
objective improvements of this technique are sim-
ilar to TURP but with lower morbidity.
More recently, Cui and colleagues performed a
randomized trial comparing the safety and effi-
cacy of standard TURP compared with TmLRP
with outcomes to 4 years. Patients were rand-
omized to the TmLRP (49)and TURP (57)
groups. The authors found that the degree of
improvement in all micturition parameters
including IPSS, QoL, PVR and Qmax were near
comparable in both the TmLRP and the TURP
patients at every time point of follow up to 48
months. Details of the short-term complications
were not reported. Long-term re-operation rates
for BPH recurrence and rate of bladder neck con-
tracture were similar in the two groups, although
the study may be underpowered to look at these
parameters [Cui et al. 2014].
Chang and colleagues recently reported a study
that compared a high-power 150W CyberTM
ThuVEP with standard TURP with a 1-year fol-
low up. A total of 29 patients were assigned to
have ThuVEP and 30 to TURP. Voided volume,
Qmax, PVR and mean flow rate all improved sig-
nificantly in both groups and there were no differ-
ences in IPSS or QoL after 1 year of follow up.
The transfusion rate in this study was 13.8% in
the ThuVEP group and 26.7% in the TURP
group, which is higher than that reported in other
studies using the high power laser [Gross et  al.
2012; Pariser et al. 2014]. This may be due to a
lower threshold for transfusion in the older patient
population of this study (mean age: ThuVEP 76;
TURP 72). There was minimal change in hemo-
globin level before and after the operation
(ThuVEP: 0.5 ± 1.3 g/dl; TURP: 0.5 ± 1.1 g/dl)
8 http://tau.sagepub.com
Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016
[Chang et al. 2015]. Because operative time was
not reported and baseline patient characteristics
are very different to those in the previous studies,
it is difficult to make a conclusion in regard to the
benefit of the higher power laser compared with
the 50W laser used by Xia and colleagues in 2008.
A meta-analysis using nine trials to examine the
performance of TmLRP versus TURP indicated
TmLRP to be a safe, feasible and efficient alter-
native to TURP for treating patients with BPH
with reliable perioperative safety, fewer complica-
tions, and comparable efficacy in relation to
Qmax, PVP, QoL and IPSS. Patients undergoing
TmLRP experienced smaller declines in serum
sodium levels (p <  0.0001), hemoglobin levels
(p < 0.0001), shorter durations of catheterization
(p < 0.0001), shorter lengths of hospital stay
(p < 0.0001) and fewer total complications
(p < 0.0001) [Tang et al. 2014].
Comparative studies to bipolar transurethral
plasmakinetic prostatectomy (BiTURP)
Yang and colleagues published a comparative
study of 158 patients randomized to ThuLEP
with a 100W thulium laser and BiTURP, with all
patients returning for 18-month follow up.
Preoperative parameters were similar in both
groups. The authors found that ThuLEP required
a significantly longer operative time (65.4 versus
47.4 minutes, p  = 0.022) than BiTURP, but
resulted in a significantly shorter hospital stay
(2.4 versus 4.6 days, p = 0.026), shorter catheteri-
zation time (2.1 versus 3.5 days, p = 0.031) and
lower drop in hemoglobin (0.15 versus 0.30 g/dl).
Similar improvements were seen in IPSS, QoL,
Qmax and PVR [Yang et  al. 2013]. Short-term
and perioperative complications were not men-
tioned. No patients in any group developed ure-
thral strictures or bladder neck contractures.
Wei and colleagues compared the efficacy and
safety of TmLRP using the 120W Tm:YAG laser
to BiTURP in patients with prostate size >80 g. A
total of 45 patients were randomized to each group
and were evaluated at 1, 6, 12 and 18 months. The
mean prostate sizes (112.86 ± 28.36 ml TmLRP,
115 ± 39.45 ml BiTURP group) as well as other
perioperative parameters were similar in both
groups. Compared with the BiTURP group, the
TmLRP group had statistically lower hemoglobin
drop, shorter catheterization time and shorter hos-
pital stay. Both groups had significant postopera-
tive improvements in IPSS, QoL, Qmax and PVR,

with no differences observed between the two
groups. Both techniques showed a low periopera-
tive complication rate (TmLRP versus BiTURP:
Clavien 1: 13.33 versus 20%; Clavien 2: 0 versus
2.22%; Clavien 3: 0 versus 0%). One patient in the
BiTURP group required a blood transfusion peri-
operatively. Urethral stricture rate was equal (one
patient in each group) and one patient in BiTURP
group developed a bladder neck contracture.
Additionally, there were no significant reduction in
IIEF-5 scores during the follow-up period com-
pared with preoperative data and no statistically
significant difference was observed between the
two groups [Wei et al. 2014].
Peng and colleagues also sought to compare the
short-term efficacy and safety of TmLRP with a
100W thulium laser (LISA Laser products OHG,
Germany) to BiTURP. A total of 100 patients
were randomized to TmLRP or BiTURP.
Operative time was significantly longer in the
TmLRP group (61 ± 24 versus 30 ± 6 minutes,
p < 0.05), while catheterization time (1.8 ± 0.4
versus 3.2 ± 0.6 days, p < 0.05) and hospital stay
(3.3 ± 0.8 versus 4.1 ± 1.3 days, p < 0.05) were
significantly shorter. No transfusions were
required in either group. Significant improve-
ments were seen in both groups in subjective and
objective objectives at 1 and 3 months postopera-
tive. Short-term and perioperative complications
were not mentioned. Compared with BiTURP,
TmLRP was superior in safety, blood loss and
urethral stricture rate with similar improvements
in IPSS, Qmax and PVR [Peng et al. 2013].
Comparative studies to HoLEP
Zhang and colleagues randomized 133 consecu-
tive patients with BPH to either undergo ThuLEP
or HoLEP in order to compare the two tech-
niques. They used a 70W thulium laser system
and a 100W holmium laser system and rand-
omized 72 patients to the thulium group and 62
patients to the holmium group. For the ThuLEP
and HoLEP groups, mean prostate volume was
relatively small and similar (47  ± 25 and
44 ± 23 ml). Operative time was comparatively
longer for the ThuLEP group versus the HoLEP
group (72.4 versus 61.5 minutes), but resulted in
less blood loss (130.0  ml versus 166.6 ml).
However, catheterization time and decrease in
hemoglobin postoperatively were similar in both
groups. The authors concluded that the shorter
operative time of the HoLEP may be secondary
http://tau.sagepub.com 9
Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016
Y Barbalat, MC Velez et al.
to the ease of finding the correct capsular plane
with the holium:YAG laser. The physical charac-
ters of the pulsed holmium:YAG laser include a
‘scar-free’ feature on the prostatic surface with
precise incision and dissection simultaneous with
coagulation of small and medium-size vessels.
Hence, as the incision reaches the surgical cap-
sule, the transitional prostatic lobes burst from
this plane to make the enucleation easier. In con-
trast, the thulium:YAG laser energy is emitted in
a continuous wave and induces an ‘eschar-like’
effect on the surface of the incised tissue. Because
of worse visualization, a longer time may have
been spent to dissect in the correct plane. IPSS,
QoL, PVR and PSA were similar in both groups
at 1, 6, 12 and 18 months of follow up. No trans-
fusions were required in either group, and no
short or long term re-operations were mentioned
[Zhang et al. 2012].
Learning curve. Although the outcomes of the
Zhang series [Zhang et al. 2012] seem to be simi-
lar between the two laser technologies, HoLEP
has been shown to demand a great learning curve,
with 40–60 cases required to become proficient
[Brunckhorst et  al. 2015]. Gross and colleagues
addressed the learning curve of ThuVEP [Gross
et al. 2012] All the 1080 cases were divided into
consecutive groups of 216 patients each and com-
plication rates were analyzed in each subgroup.
Overall, complication rates decreased significantly
over time, with a 41.7% complication rate within
the first 216 cases and 19.4% within the last 216
cases (p < 0.001). ThuVEP may have an easier
learning curve than HoLEP because the thulium
laser allows for instant conversion to vaporization
with the same end-fire fiber, a technique that more
urologists are comfortable with.
Cost.  Currently no comparative cost studies have
been performed specifically investigating thulium
lasers. However, in 2001, a prospective, random-
ized trial investigating the cost effectiveness of hol-
mium lasers versus traditional TURP found
catheterization time, length of hospital stay, risk of
bleeding and incidence of untoward events
reduced while offering equivalent outcomes at 1
year postoperatively. In a cost effectiveness analy-
sis, these improvements represented a 24.5% cost
saving over TURP [Fraundorfer et al. 2001]. With
regard to the thulium laser, acquisition costs are
comparable with other laser modalities and the
laser fibers cost about €450 each. In contrast to
some other laser systems, however, the bare-ended
quartz fibers of the thulium laser can be reused
Therapeutic Advances in Urology 
many times, which leads to almost negligible run-
ning costs [Szlauer et al. 2009].
Conclusion
With reports from around the world, the thulium
laser prostatectomy represents a safe and effica-
cious procedure for benign prostatic obstruction.
Multiple techniques including laser resection,
vapoenucleation and vaporization have been
described and appear to safe and effective with
low morbidity. Overall, comparative studies with
the traditional TURP, BiTURP, and HoLEP
have demonstrated promising, noninferior data in
terms of safety and efficacy. Thulium seems to
provide better hemostasis, less overall morbidity,
shorter catheterization time and a shorter hospital
stay compared with the traditional TURP. Also,
its option for efficient vaporization in addition to
enucleation makes it an easier technology for the
average urologist to learn to use than the hol-
mium laser. Finally, due to the physical proper-
ties of the laser, thulium laser prostatectomy may
theoretically be associated with lower rates of
dysuria compared with PVP, although studies are
lacking. Further comparative studies are needed
to explore this promising and user-friendly
technology.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
Conflict of interest statement
The authors declare no conflicts of interest in
preparing this article.
References
Bach, T., Hermann, T., Ganzer, R., Burchardt, M.
and Gross, A. (2007) Revolix vaporesection of the
prostate: initial results of 54 patients with 1-year
follow-up. World J Urol 25: 257–262.
Bach, T., Hermann, T., Hacker, A., Michel, M. and
Gross, A. (2009a) Thulium:yttrium-aluminum-garnet
laser prostatectomy in men with refractory urinary
retention. BJU Int 104: 361–364.
Bach, T., Wendt-Nordahl, G., Michel, M., Hermann,
T. and Gross, A. (2009b) Feasibility and efficacy of
thulium:yag laser enucleation (vapoenucleation) of the
prostate. World J Urol 27: 541–545.
Brunckhorst, O., Ahmed, K., Nehikhare, O.,
Marra, G., Challacombe, B. and Popert, R. (2015)
10 http://tau.sagepub.com
Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016
Evaluation of the learning curve for holmium laser
enucleation of the prostate using multiple outcome
measures. Urology 86: 824–829.
Carmignani, L., Bozzini, G., Macchi, A.,
Maruccia, S., Picozzi, S. and Casellato, S. (2015)
Sexual outcome of patients undergoing thulium laser
enucleation of the prostate for benign
prostatic hyperplasia. Asian J Androl 17:
802–806.
Chang, C., Lin, T., Chang, Y., Huang, W., Lin,
A. and Chen, K. (2015) Vapoenucleation of the
prostate using a high-power thulium laser: a one-year
follow-up study. BMC Urol 15: 40.
Cui, D., Sun, F., Zhuo, J., Sun, X., Han, B., Zhao,
F. et al. (2014) A randomized trial comparing thulium
laser resection to standard transurethral resection
of the prostate for symptomatic benign prostatic
hyperplasia: four-year follow-up results. World J Urol
32: 683–689.
Fraundorfer, M., Gilling, P., Kennett, K. and
Dunton, N. (2001) Holmium laser resection
of the prostate is more cost effective than
transurethral resection of the prostate: results
of a randomized prospective study. Urology
57: 454–458.
Fried, N. and Murray, K. (2005) High-power thulium
fiber laser ablation of urinary tissues at 1.94 microm. J
Endourol 19: 25–31.
Fu, W., Zhang, X., Yang, Y., Hong, B., Gao, J., Cai,
W. et al. (2010) Comparison of 2-microm continuous
wave laser vaporesection of the prostate and
transurethral resection of the prostate: a prospective
nonrandomized trial with 1-year follow-up. Urology
75: 194–199.
Gross, A., Netsch, C., Knipper, S., Holzel, J.
and Bach, T. (2012) Complications and early
postoperative outcome in 1080 patients after thulium
vapoenucleation of the prostate: results at a single
institution. Eur Urol 63: 859–867.
Hardy, L., Wilson, C., Irby, P. and Fried, N. (2014)
Thulium fiber laser lithotripsy in an in vitro ureter
model. J Biomed Opt 19: 128001.
Iacono, F., Prezioso, D., Di Lauro, G., Romeo, G.,
Ruffo, A., Iliano, E. et al. (2012) Efficacy and safety
profile of a novel technique, ThuLEP (Thulium
laser enucleation of the prostate) for the treatment of
benign prostate hypertrophy. Our experience on 148
patients. BMC Surg 12(Suppl 1): S21.
Kyriazis, I., Swiniarski, P., Jutzi, S., Wolters,
M., Netsch, C., Burchardt, M. et al. (2012)
Transurethral anatomical enucleation of the
prostate with Tm:YAG support (ThuLEP): review
of the literature on a novel surgical approach in the
management of benign prostatic enlargement. World
J Urol 33: 525–530.

Macchione, L., Mucciardi, G., Gali, A., Di
Benedetto, A., Buttice, S. and Magno, C. (2013)
Efficacy and safety of prostate vaporesection using a
120-W 2-µm continuous-wave Tm:YAG (RevoLix
2) in patients on continuous oral anticoagulant or
antiplatelet therapy. Int Urol Nephrol 45: 1545–1551.
Mebust, W., Holtgrewe, H., Cockett, A. and Peters,
P. (1989) Transurethral prostatectomy: immediate
and postoperative complications. A cooperative study
of 13 participating institutions evaluating 3,885
patients. J Urol 141: 243–247.
Netsch, C., Bach, T., Herrmann, T., Neubauer,
O. and Gross, A. (2013) Evaluation of the learning
curve for Thulium VapoEnucleation of the prostate
(ThuVEP) using a mentor-based approach. World J
Urol 31: 1231–1238.
Pariser, J., Famakinwa, O., Pearce, S. and Chung,
D. (2014) High-power thulium laser vaporization
of the prostate: short-term outcomes of safety and
effectiveness. J Endourol 28: 1357–1362.
Parsons, J., Bergstrom, J., Silberstein, J. and Barrett-
Connor, E. (2008) Prevalence and characteristics of
lower urinary tract symptoms in men aged > or = 80
years. Urology 72: 318–321.
Peng, B., Wang, G., Zheng, J., Xia, S., Geng, J., Che,
J. et al. (2013) A comparative study of thulium laser
resection of the prostate and bipolar transurethral
plasmakinetic prostatectomy for treating benign
prostatic hyperplasia. BJU Int 111: 633–637.
Pereira-Correia, J., De Moraes Sousa, K., Santos,
J., De Morais Perpetuo, D., Lopes-Da-Silva, L.,
Krambeck, R. et al. (2012) Greenlight HPS™ 120-W
laser vaporization versus transurethral resection of the
prostate (<60 Ml): a 2-year randomized double-blind
prospective urodynamic investigation. BJU Int 110:
1184–1189.
Rassweiler, J., Teber, D., Kuntz, R. and Hofmann,
R. (2006) Complications of transurethral resection of
the prostate (TURP)–incidence, management, and
prevention. Eur Urol 50: 969–979; discussion 980.
Rausch, S., Heider, T., Bedke, J., Kruck, S.,
Schwentner, C., Fischer, K. et al. (2015) Analysis of
early morbidity and functional outcome of thulium:
yttrium-aluminum-garnet laser enucleation for benign
prostate enlargement: patient age and prostate size
determine adverse surgical outcome. Urology 85:
182–188.
Reich, O., Gratzke, C., Bachmann, A., Seitz, M.,
Schlenker, B., Hermanek, P. et al. (2008) Morbidity,
mortality and early outcome of transurethral resection
of the prostate: a prospective multicenter evaluation of
10,654 patients. J Urol 180: 246–249.
Rieken, M., Ebinger Mundorff, N., Bonkat, G.,
Wyler, S. and Bachmann, A. (2010) Complications of
http://tau.sagepub.com 11
Downloaded from tau.sagepub.com at SAGE Publications on March 8, 2016
Y Barbalat, MC Velez et al.
laser prostatectomy: a review of recent data. World J
Urol 28: 53–62.
Sun, F., Han, B., Cui, D., Zhao, F., Sun, X.,
Zhuo, J. et al. (2015) Long-term results of thulium
laser resection of the prostate: a prospective study at
multiple centers. World J Urol 33: 503–508.
Szlauer, R., Gotschi, R., Razmaria, A., Paras, L. and
Schmeller, N. (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.
Tang, K., Xu, Z., Xia, D., Ma, X., Guo, X., Guan,
W. et al. (2014) Early outcomes of thulium laser versus
transurethral resection of the prostate for managing
benign prostatic hyperplasia: a systematic review and
meta-analysis of comparative studies. J Endourol 28:
65–72.
Vargas, C., Garcia-Larrosa, A., Capdevila, S. and
Laborda, A. (2014) Vaporization of the prostate with
150-W thulium laser: complications with 6-month
follow-up. J Endourol 28: 841–845.
Wei, H., Shao, Y., Sun, F., Sun, X., Zhuo, J.,
Zhao, F. et al. (2014) Thulium laser resection versus
plasmakinetic resection of prostates larger than 80 Ml.
World J Urol 32: 1077–1085.
Wei, J., Calhoun, E. and Jacobsen, S. (2005)
Urologic diseases in America project: benign prostatic
hyperplasia. J Urol 173: 1256–1261.
Xia, S. (2009) Two-micron (thulium) laser resection
of the prostate-tangerine technique: a new method for
BPH treatment. Asian J Androl 11: 277–281.
Xia, S., Zhang, Y., Lu, J., Sun, X., Zhang, J., Zhu,
Y. et al. (2005) [Thulium laser resection of prostate-
tangerine technique in treatment of benign prostate
hyperplasia]. Zhonghua Yi Xue Za Zhi 85: 3225–3228.
Xia, S., Zhuo, J., Sun, X., Han, B., Shao, Y. and
Zhang, Y. (2008) Thulium laser versus standard
transurethral resection of the prostate: a randomized
prospective trial. Eur Urol 53: 383–390.
Yang, Z., Wang, X. and Liu, T. (2013) Thulium
laser enucleation versus plasmakinetic resection of
the prostate: a randomized prospective trial with
18-month follow-up. Urology 81: 396–401.
Yu, X., Elliott, S., Wilt, T. and Mcbean, A. (2008)
Practice patterns in benign prostatic hyperplasia
surgical therapy: the dramatic increase in minimally
invasive technologies. J Urol 180: 241–245;
discussion 245.
Zhang, F., Shao, Q., Hermann, T., Tian, Y. and
Zhang, Y. (2012) Thulium laser versus holmium
laser transurethral enucleation of the prostate: Visit SAGE journals online
http://tau.sagepub.com
18-month follow-up data of a single center. Urology
79: 869–874. SAGE journals