Endoscopic enucleation of the prostate with pulsed Thulium:YAG generators: a systematic review.

INTRODUCTION: Thulium:YAG laser generators have recently been developed, enabling pulsed energy delivery, further expanding the armamentarium of available laser devices for endoscopic enucleation of the prostate (EEP). The current systematic review summarizes all applications of pulsed Thulium:YAG generators during EEP. PATIENTS AND METHODS: In line with the PRISMA guidelines, the protocol of this systematic review was a priori registered to OSF database, while three different databases (PubMed, Scopus and the Cochrane Library) were carefully screened from database inception to 4 May 2026. A dedicated search string was applied for all three databases: (pulsed OR hybrid) AND (thulium:YAG OR tm:YAG). A manual search was also performed where appropriate. Both the search strategy and the inclusion criteria were guided by the PICO (Patients, Intervention, Comparison, Outcome) framework. RESULTS: Eight studies fulfilled the predefined criteria and were included in this systematic review. The purely pulsed Dornier Thulio generator was used in six studies, while the hybrid LISA RevoLix HTL generator was used in two studies. Three studies were non-comparative, while five studies were comparative. Four studies compared the pulsed Thulium:YAG and the Holmium:YAG laser technologies and one study compared the outcomes between miniaturized and standard pulsed Thulium:YAG EEP. Mean operative time across studies ranged from 40.8 ± 21.7 to 101.7 ± 18.5 minutes, while the enucleation and morcellation times ranged from 18.3 ± 8.9 to 83.7 ± 17.2 minutes and from 10.2 ± 10.1 to 18 ± 5.1 minutes, respectively. The Grade I-II and III-IV complications rates, according to Clavien-Dindo Classification ranged from 1% to 8.1% and from 0% to 15.6%, respectively. Finally, postoperative urinary incontinence rates ranged from 0% to 18.4%. CONCLUSIONS: Anatomic EEP with the pulsed Thulium:YAG generators seems to be feasible, safe and efficient, being associated with relatively low complications and incontinence rates. Both generators were associated with beneficial postoperative outcomes, regarding improved IPSS, QoL, PVR and Qmax, while Holmium:YAG and pulsed Thulium:YAG lasers were associated with comparable results in a limited number of studies, though. Additional studies on the topic, with larger cohorts and better study design, are essential to draw safer conclusions.