Use of Lasers in Upper Tract Urology: Technology, Applications and Future Directions

Laser energy has revolutionised the treatment of pathology within the upper urinary tract. Lasers were first introduced into urology with early Nd: YAG and CO₂ systems, which were mainly used for coagulation and treatment of superficial urothelial lesions. Over subsequent decades, technological advances led to pulsed holmium: YAG and, more recently, thulium fibre lasers, enabling safe intracorporeal lithotripsy and precise soft‑tissue ablation throughout the urinary tract. They underpin flexible ureteroscopy and percutaneous nephrolithotomy for stone disease, enable organ‑preserving management of upper tract urothelial carcinoma and treat benign strictures. However, each platform has unique physical properties that influence its clinical utility. This chapter reviews laser physics, evolution of technology, and compares Ho: YAG with TFL, emphasising their mechanisms of lithotripsy, modes of operation, instrumentation and safety considerations. Clinical applications in stone fragmentation, tumour ablation and stricture incision are discussed, supported by contemporary evidence. We present a practical algorithm for laser selection and settings in upper tract endourology and highlight future directions, including pulse modulation, dual‑wavelength systems and integration with digital ureteroscopy. Understanding the capabilities and limitations of lasers is essential for urologists to optimise outcomes while minimising complications.