Multi-Center Randomized Clinical Trial Evaluating the Efficiency and Safety of Holmium Laser With Moses Technology Versus SuperPulsed Laser System With Thulium Fiber Laser on Renal Stones
Phase: NA
Conditions: Renal Stone
Sponsor: University of Wisconsin, Madison

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Multi-Center Randomized Clinical Trial Evaluating the 
Efficiency and Safety of Holmium Laser with Moses 
Technology versus SuperPulsed Laser System with Thulium 
Fiber Laser on Renal Stones 
 
 
NCT06070714 
 
May 13, 2025 
 
 
 
 
 
 
 
 
 

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Project Summary 
This is a prospective randomized controlled trial designed to assess the efficacy and safety of 
Lumenis® Pulse™ P120H holmium laser system with the Moses technology (holmium laser with 
pulse modulation) versus the Soltive™ SuperPulsed Laser System with the thulium fiber laser 
(thulium fiber laser), in dusting of renal stones during ureteroscopy with laser lithotripsy. We 
will apply a multi-center approach, which will allow us to test it in a wider array of settings with 
a wide range of population groups.  
 
Study Sites 
University of Wisconsin, Department of Urology 
Ohio State University, Department of Urology  
University of California-Los Angeles, Department of Urology 
Mount Sinai, Department of Urology 
Cleveland Clinic, Glickman Urological Institute  
Background and Significance 
The incidence of urinary tract stone disease is increasing. According to the National 
Health and Nutrition Examination Survey, as of 2012, 10.6% of men and 7.1% of women in the 
United States are affected by renal stone disease.i This has led to an increased demand on 
Urologists for efficient and safe surgical treatment of stone disease. Over the past two decades, 
ureteroscopy with laser lithotripsy has become the treatment of choice for most ureteral and 
renal stones globally.ii The holmium laser is considered the gold standard for laser lithotripsy.iii 
Holmium laser with pulse modulation and the thulium fiber laser are new technologies meant 
to improve the efficiency of laser lithotripsy. Both are FDA approved treatment modalities for 
stone disease. Two in vitro studies have compared holmium laser with pulse modulation versus 
thulium fiber laser and shown that thulium has higher ablative volumes then the holmium laser 
with pulse modulation.iv,v  
We previously conducted a randomized clinical trial to compare the holmium laser with 
pulse modulation and thulium fiber laser. Our results suggested no significant difference 
between the holmium laser with pulse modulation and thulium fiber laser on the procedure 
time and stone free rate.vi However, the post-operative image was a kidney, ureter, and 
bladder (KUB) x-ray and CT is considered the gold standard of evaluating kidney stone 
fragments. Thus, the stone free rate between holmium laser with pulse modulation and 
thulium fiber laser may not be as accurate as if CT were used. It was also a single center study. 
A multicenter trial will allow us to include a larger number of participants, different geographic 

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locations, the possibility of inclusion of a wider range of population groups, and the ability to 
compare results among centers, all of which increase the generalizability of the study.  
In this study, we are going to conduct a prospective, randomized clinical trial to 
determine whether there is a difference in stone free rate, procedural time, intraoperative 
parameters between the holmium laser with pulse modulation and the thulium fiber laser. This 
is significant as this may lead to shorter overall operative times, which may result in decreased 
operative costs and complications, as well as improved stone free rates. vii,viii  Currently, at 
University of Wisconsin, we are using both the holmium laser with pulse modulation and the 
thulium fiber laser during ureteroscopies.  
 At our institution, we perform approximately 200 outpatient ureteroscopies with laser 
lithotripsy annually. Typically, we have evaluated surgical outcomes as part of routine quality 
improvement initiatives or as IRB-approved retrospective reviews. However, in this scenario, a 
randomized trial requiring IRB approval, we have the ability to conduct a higher-level study 
protocol and rigorously compare the time required for acceptable stone fragmentation using 
the two different lasers. A randomized trial, unlike a retrospective review of our surgical 
procedures, will reduce bias sufficiently to allow us to be sure of our results. 
 
Study Objectives 
The primary objective of this study is to compare the stone free rate as determined by 
ultra-low dose limited renal CT at 2 months post operatively between the holmium laser with 
pulse modulation and the thulium fiber laser. Our hypothesis is that the thulium fiber laser will 
have a superior stone free rate compared to the holmium laser with pulse modulation. The 
setting for both lasers will be adjusted as needed by the surgeon during the case.  
Secondary outcomes will include intra-operative parameters and post-operative 
parameters. Our goal is to completely dust the renal stones. This is defined as fragmenting the 
stones until as close to the size of the laser fiber as possible (a 200 micron fiber will be used 
with both groups), to visually estimate the size of the resultant fragments.ixx  
We will use block randomization with a block size of 5. Patients will be randomized into 
groups by a ratio of 1:1. We do not plan to stratify by stone size for randomization because our 
previous results showed no difference when results were stratified by stone size.  
Research Design and Methods 
This study will be a randomized clinical trial comparing ureteroscopy with laser 
lithotripsy with the Lumenis® Pulse™ P120H holmium laser system with the Moses technology 

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(holmium laser with pulse modulation) versus the Soltive™ SuperPulsed Laser System with the 
thulium fiber laser technology (thulium fiber laser). The primary objective is to compare the 
stone free rate as determined by CT scan at two months (6-10 weeks) post operatively. A single 
urologist will evaluate all CT scans for residual stones and will be blinded to which laser was 
used during ureteroscopy.  
The following information will be collected for research purposes as secondary 
outcomes: (1) stone treatment time (time from the start of lasing to the end of lasing; minutes); 
(2) total operative time (minutes); (3) lasing time (minutes, time the laser was in use, not 
including pedal pauses); (4) total energy used (kilojoules, kJ); (5) laser efficiency (mm per 
minute); (6) number of times the laser pedals are pressed (left, right, and total pedal presses); 
(7) laser fiber size; (8) stone analysis; (9) complications, and (10) patients’ quality of life. The 
results from the pre- and post-operative quality of life survey (WISQOL short form) will be 
obtained from the patient’s medical record.  A total of 3 clinic visits (i.e., the pre-operative visit 
and the stone surgery, one post-operative visit after 2 months of the surgery) will be needed 
for this study. All these visits are standard of care. Stone parameters (i.e. size, location, 
Hounsfield units, presence of hydronephrosis, stone volume, and composition), demographic 
information, co-morbidities, and post-operative parameters will be collected from the medical 
record in HealthLink.  
The Thulium laser company is not involved in this research. 
Number of Participants  
Approximately 310 patients will be enrolled (see Data Analysis for sample size 
justification). The goal is to enroll 62 patients per site with a minimum of 20 patients at a single 
site to be included in the study. At UW, the enrollment of this study is 130 patients. This is to 
account for the shorter duration of the study and slower enrollment at other participating sites 
and ensure that the enrollment goal of 310 is reached regardless of study duration or 
enrollment numbers at other participating sites. All urologists at UW have agreed to use the 
laser device dictated by randomization. 
Inclusion Criteria 
1. Patients at least 18 years of age, and less than 89 years old. 
2. Patients with renal stones who require endoscopic laser treatment in the outpatient 
operating room. Patients may have an ureteropelvic junction (UPJ) stone if the 
treatment of the stone is completed in the kidney. 
3. Patients’ stone size in a single renal unit of ≥5 mm and ≤20 mm. Stone size is defined 
as the largest diameter of a single stone on pre-operative CT as assessed by the 

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urologist. Patients with multiple stones will be included as long as their largest stone 
size falls within the above parameters.  
 
Exclusion Criteria 
1. Patients under 18 years of age and over 89 years old.  
2. Pregnant patients 
3. Patients with transplant kidneys or other anatomic variations: horseshoe kidney, 
pelvic kidney, ptotic kidney, urinary diversion or ureteral stricture 
4. Patients with irreversible coagulopathy 
5. Patients with known ureteral stricture disease 
6. Patient who do not have a pre-operative CT  
7. Non-English speaking patients and patients in other vulnerable groups such as 
lacking of decision-making capability, prisoner, or adult unable to consent  
8. Uric acid composition > 50% on pre operative stone analysis. Patients will be 
excluded post operatively if stone analysis from the time of surgery is >50% uric 
acid.  
9. Prior ureteroscopy within 6 weeks of current surgery  
10. Urothelial tumor(s), direct extraction of the stone(s) without needing laser 
lithotripsy, and failure to reach the stone in the upper urinary tract with the 
ureteroscope 
11. Patients with only ureteral stones (UPJ stones may be included as long as treated in 
the kidney) 
12. Patients with renal tubular acidosis or medullary sponge kidney 
 
Recruitment methods 
Patients who are to be scheduled for laser lithotripsy treatment of renal stones as 
outpatients will be approached for study participation. During patients’ pre-operative clinic 
visit, study team members with valid access to patient medical records will perform eligibility 
screening (by reviewing patients’ medical record that is relevant for inclusion/exclusion criteria) 
before recruitment. If patients meet the inclusion criteria, they will be initially approached by a 
study team member who also works in the urology clinic (i.e., the surgeon informs the patient 
that there’s a research study they may be eligible for, and asked if they want to learn more 
about it).   
No other recruitment materials will be used in this study. Holmium laser with pulse 
modulation or thulium fiber laser to treat stones is our routine care. Patients have been 
informed about the laser lithotripsy treatment before they schedule their surgery. We will only 

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recruit patients from the outpatient OR, so this will not include patients who come in 
emergently through the Emergency Department.  
No compensation will be provided to participants.  
Consent Process 
A study team member who is affiliated with the patient’s clinical care (e.g., the surgeon) 
will initially approach the patients who are scheduled for laser lithotripsy treatment of urinary 
stones (i.e., informed that they may be eligible for a research study and asked if they want to 
learn more about it). 
If the patient is interested in the study, a member of the research team will approach 
him/her for enrollment. The consent process will be conducted face to face by a member of the 
study team. Participants will be provided a written consent form in person. No waiting time is 
expected between informing the prospective participant and obtaining the consent. 
Consent will take place in a private exam room during patients’ pre-operative 
clinic visit. If patients are interested and there is not enough time to consent the patient 
in urology clinic, study information will be sent home with the patient and the patient 
will then be consented before their surgery in a private exam room (pre-operative 
room). The pre-operative room provides 1-1 1/2 hours of time. This should be ample 
time to conduct the consent process before surgery anesthesia. 
All information about the study will be provided, and ample time will be made 
available for the participants to consider participation in the study and have any 
questions answered.  
The study team will follow all applicable sections of HRP 090: Informed Consent 
Process for Research when conducting informed consent. To document signed consent, 
the study team will follow all applicable sections of HRP 091: Written Documentation of 
Consent. 
 
Patient Randomization  
Patients will be randomized (ratio 1:1) to be treated with either the holmium laser with 
pulse modulation or the thulium fiber laser. Each site will randomize their own patients. Block 
randomization in block sizes of 5 will be used to assign patients to each laser treatment group. 
If unable to use the specified laser for any reason, the patient will be considered a withdrawal. 
This is a multicenter study. Research procedures will take place at the Ohio State 
University, Wexner Medical Center, Department of Urology; Cleveland Clinic, Glickman 
Urological & Kidney Institute; UCLA Urology; and Mount Sinai Health System, Milton and Carroll 
Petrie Department of Urology. No community advisory board involved. Each site will apply IRB 
approval.  

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Study Procedures 
1. The study team members review patients’ medical record during patients’ pre-
operative clinic visit to see whether patients meet inclusion/exclusion criteria.  
2. If patients meet the inclusion criteria, a study team member who is affiliated with 
the patient’s clinical care (e.g., the surgeon) will initially approach the patients who 
are scheduled for laser lithotripsy treatment of renal stones. (i.e., informed that they 
may be eligible for a research study and asked if they want to learn more about it). 
3. If the patient is interested in the study, a member of the research team will 
approach him/her for enrollment. 
4. Patients will be asked to fill out a WISQOL short form at their pre-operative visit. 
This is standard of care for all stone patients in our clinic.  
5. They will then be randomized to either the holmium laser with pulse modulation or 
the thulium fiber laser group.  
6. Patients will undergo stone surgeries with the laser that they are randomized to. A 
200 micron fiber will be used with both machines to measure the stone(s). The 
patient’s stone(s) will be treated with the goal of dusting the entire stone burden. 
One stone fragment will be collected for stone analysis if the patient does not 
already have a stone analysis on file (this is also standard of care). The faculty 
surgeons will perform all surgeries. We are unable to blind the surgeon to the laser 
used as the laser fibers and laser machines appear and sound different. 
7. Laser time as well as other information (see Study Design for the detailed 
information) is collected. 
8. At 6-10 weeks after surgery, patients will have a follow-up appointment where they 
have a ultra-low dose limited renal CT scan and fill out a WISQOL short form.  Both 
of these procedures are standard of care. Postoperative complications will be 
collected. 
9. Post-operative CT scans will be assessed by a single urologist for residual fragments. 
The urologist will be blinded to which laser was used for ureteroscopy. Parenchymal 
stones will be noted in the operative report and will not be considered residual 
stones.  
Comparison of usual care and study procedures 
 
Compared with our routine care, the only interventions imposed on subjects as a result 
of this study are (1) randomization to laser lithotripsy with either holmium laser with pulse 
modulation or thulium fiber laser, (2) the use of patient & surgery information collected in 
describing our results.  

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All the other activities are part of our routine clinical practice. During surgery, patients’ 
stones will be treated in accordance with our routine clinical practice of dusting the entire 
stone.  
 
Surgeons will use a 200 micron fiber for both the holmium laser with pulse modulation 
and the thulium fiber laser per standard of care, but they will have the discretion to switch to a 
different fiber (ex. 150 micron thulium fiber) if they feel it is necessary during the case. If the 
surgeon changes the fiber during the surgery, the data will be analyzed separately.   
 
A stone fragment will be collected for stone analysis if the patient does not have one on 
file. This is our standard of care suggested by AUA guidelines.xi  
 
Post-operative imaging is standard of care and CT abdomen/pelvis without contrast is 
one of the recommended imaging modalities by AUA guidelines.x  At our institution, we use 
ultra-low dose limited renal CT as our standard of care.xii This is a robust tool of stone 
surveillance, with low radiation (similar to abdominal X-ray, and 92% lower than a standard CT), 
and low cost (less than the charge of a renal ultrasound at our institution). All patients enrolled 
will undergo routine post-operative follow up including clinic appointments and imaging 
evaluation (ultra-low dose limited renal CT).  
 
WISQOL short form will be administered during the pre-operative appointment and at 
the post-operative appointment, which is standard practice in our clinic.  
 
Withdrawal of participants 
Patients can withdraw anytime. Once they decide to withdraw, they will continue their 
standard clinical care with us. We will continue to collect patients’ information from patients’ 
medical records for their routine medical care. Patient information gathered while the patient 
was active in the study will remain in the study record, but no information will be added to the 
record following their withdrawal. 
In rare cases, the study team may withdraw a patient from the study. Such cases include 
the surgeon being unable to find the stone in the kidney, discovery of an unknown ureteral 
structure prior to the surgery, stones are basket not lased, or the surgeon being otherwise 
unable to treat the renal stone. If those happen, patients will be taken out from this study.  
Study Intervention 
 
Holmium laser with pulse modulation and thulium fiber lasers will be used for this study. 
All settings of the holmium laser and thulium fiber lasers are routinely used in ureteroscopies. 
Both are FDA approved lasers for the treatment of urinary calculi through an endoscope. The 
holmium laser with pulse modulation emits two separate laser pulses with a short time interval 
between them. The first pulse divides the water between the laser fiber tip and the stone and 
the second pulse hits the stone unobstructed.xiii The goal is to increase stone ablative volume 
and decrease retropulsion of the stone. The thulium fiber laser has a different wavelength then 
the holmium laser with pulse modulation and thus has slightly different energy properties. It 

9 
 
has also been shown to increase ablative volume and decrease retropulsion without any safety 
concerns.xiv The two lasers have similar specifications; the two fibers are the same size and will 
interact with the instruments (ureteroscopes) similarly. 
Evaluation of the devices on study fall under FDA IDE exemption. Neither the holmium 
laser nor the thulium fiber laser were regulated as drugs before enactment of the Medical 
Device Amendments. Both are approved by the FDA for use in renal stone treatment as they 
are being used in this study.  
Study Timelines 
 
For each patient, the study duration is from consent to the two-month post-operative 
clinic visit. Patients will be on study for approximately 8-10 weeks. 
Risks and Potential Benefits 
 
Treatment with the holmium laser with pulse modulation and thulium fiber laser can be 
associated with the common risks of hematuria, stent pain, passing fragments, UTI, dysuria. The 
rare risks include perforation of the urinary tract, bleeding, and stricture of the ureters. 
However, the surgeon who will perform the surgery will not exceed safe levels. All procedures 
are performed by surgeons who are board-certified. If significant injury or inefficient 
fragmentation of the stone occurs, the surgeon will have the discretion to transition to a 
different laser for patient safety reasons. All patients enrolled will undergo routine post-
operative follow up including clinic appointments and imaging evaluation. Any complications 
will be recorded, reported, and treated appropriately. 
 
There is a risk that patient information could become known to someone not involved in 
this study. Data safety and security considerations to minimize this risk are detailed in Data 
Management and Confidentiality below.   
 
There is no direct benefit to patients as a result of participating in this study. Potentially, 
more efficient laser and laser settings may be identified which may result in faster procedural 
time and lower complication rates.  
Safety Monitoring Plan 
 
All procedures performed by surgeons who are board-certified. If significant injury or 
inefficient fragmentation of the stone occurs, the surgeon will have the discretion to transition 
to a different laser for patient safety reasons (The data will be analyzed as an intention-to-treat 
analysis). All patients enrolled will undergo routine post-operative follow up including clinic 
appointments and imaging evaluation. Any complications will be recorded, reported, and 
treated appropriately. 
Regular inquiries of study flow, pertaining to patient recruitment, randomization, and 
adverse events will be scheduled to occur the first week after study initiation, and subsequently 

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every two weeks. The lead researcher of each site will be responsible for the inquiries.  Any 
adverse events will be monitored as per standard protocol in clinical use. A comparison of 
adverse events between groups (e.g., to determine whether those assigned to the thulium fiber 
laser group are experiencing more frequent or serious adverse effects) will be included. No 
significant adverse events are anticipated for the lasers, as they are routinely used in urology 
practice.  Any adverse events or unanticipated problems will be reported to the PI and IRB and 
treated accordingly. In addition, members of the study team will be performing these 
procedures and will monitor the patient during treatment for any signs of complications. 
 
Date Management and Confidentiality  
 
 
Both department server and REDCap will be used for data storage. All UW electronic 
data will be stored on a HIPAA compliant department server which is maintained on password 
and firewall-protected computers in locked offices of the Department of Urology, located in a 
security-protected building. Data to be analyzed after extraction. All paper records (such as 
WISQOL) will be saved in a locked office/cabinets of IRB approved study staff. Only key 
personnel listed on this study will have access to this information. All data analysis files will be 
devoid of direct patient identifiers, and the key linking identifiers to the study data will be 
stored separately from the study data. Direct identifiers will be destroyed at study closure or at 
the time of publication. De-identified data will be stored for potential future studies that have 
proper approval. REDCap is only used for other sites to transfer their data to UW and store the 
data from other sites.  
 
We will use university-based  OneDrive to temporarily save the enrollment log. At UW, 
the study team member will use their Net ID to access the enrollment log. The enrollment log is 
completely deidentified. Only participant ID (such as 101, 102) and the laser each participant is 
randomized to are saved in the enrollment log. Once we complete data collection, we will 
permanently delete it from the cloud.  
In order to protect patient privacy, all IRB-approved study personnel will be up to date 
on all required institutional HIPAA, human subjects research, and good clinical practice 
trainings. Medical records will only be accessed by study team personnel with authorized 
access, and patients will provide consent for the study team to access their medical records. All 
research procedures will be performed in private rooms where others cannot see or hear the 
procedures being performed, and the study will not collect any information that could pose a 
risk to patients. Patients will be encouraged to ask any questions about the research that are 
necessary to assure their safety and comfort. No patient will be coerced or forced to consent to 
participate in the study or in any study activities they do not want to do. There will be no 
negative consequences if a patient declines to participate in the study, and their typical 
healthcare will remain unchanged from the standard of care. 
 

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Sharing of results 
 
No research information will be shared with patients.  
 
We will only publish aggregate results. No individual results will be shared.  
 
In this study, UW data will not be shared with other institutions. We will only receive 
data collected from other sites. Data will be transferred via REDCap Ortho/Rehabilitation and 
Urology. UW-Madison has created a REDCap project that accounts for all collected data 
variables (see Appendix), which all sites will be able to access in order to input their data but 
will not have the access to download the data. Thus, other sites won’t see each other’s data, 
and only UW can see of all sites. Data stored in REDCap will be coded, and the keys linking the 
codes to patient identifiers will be maintained separately by each study site, such that the 
REDCap project contains no directly identifying information. Study data saved on REDCap will 
be deleted once the study is completed.  
When patients consent to participate in the study, they also consent to have their data 
banked. Patients who do not consent to having their data banked are asked not to participate 
in the study. Data will be stored indefinitely in a secure, password-protected department 
REDCap server and accessible only by IRB-approved study personnel. Stored data will have 
identifiers removed, with no code maintaining the link between the patient and their 
identifiers. Because the data will be anonymized, patients will not be able to request 
withdrawal of their data from the bank, as there will be no way for the study team to link the 
patient to their data. Researchers who want to access this data bank for future urology 
research must obtain approval from the department, and the research must be approved by 
the IRB.  
Economic burden to participants 
This study does not place a financial burden on patients. The study interventions 
are part of our routine clinical practice to treat stones. Treatment and costs will be the 
same as if they are not involved in this study. The cost of the two laser treatments is 
equivalent.   
Resources Available 
Will the research be conducted outside 
School of Medicine and Public Health or 
UW Hospitals and Clinics (e.g. the 
researcher does not have an SMPH 
research feasibility attestation for this 
study)?    
☐ YES (complete 25.1) 
☒ NO (remove text below, but retain this 
section) 
 

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Data Analysis 
The data collected will be analyzed as an intention-to-treat analysis. Statistical analyses 
will include T-test and, if appropriate, Chi-square tests (e.g., for categorical data), and two-way 
MANOVA. Patient demographics and stone characteristics will be summarized as appropriate as 
continuous variables (mean and standard deviation) or categorical variables (frequency, 
percentage). To compare the two groups, continuous variables such as laser time, total OR 
time, WISQOL etc., will be analyzed using T test and MANOVA. Categorical variables such as 
stone free rate will be analyzed using chi-square. We will also stratify the results by the laser 
settings and the study sites using MANOVA or collected as a co-variate using MANCOVA. The 
Thulium laser company will not be involved in data analysis for this study. 
In our last study, the stone-free rate is measured by post-operative image (CT, KUB, or 
US).The stone free rate of renal stones are 64% vs. 52% (thulium vs. Moses). However, only 
8.6% of patients had post-operative CT. Thus, the stone-free difference between Moses and 
thulium may not be accurately measured. A recent randomized trial by Ulvik et al[i]  that 
showed thulium laser had improved stone-free rate (CT in 3 months) of renal stones treatment 
(66% vs. 33%, p = 0.005). However, they used an older low-powered 30W holmium laser. 
Considering the difference between the low-power holmium laser and Moses 2.0 (high power 
and frequency), we estimate the stone-free difference between Moses and thulium as 20%, to 
achieve 80% of power, 186 patients (93 per arm) are need to detect a significant difference 
(p<0.05). We also decide to increase the sample size by 40% (155 patients per arm, 310 in 
total). This will allow for the possibility that the randomization scheme is intra-operatively 
abandoned for some reason (see patient withdrawal section), that the planned procedure was 
unable to be completed for some reason, as determined by the surgeon in charge of the case, 
lost follow up, and/or that the patient – after his/her procedure – wishes to withdraw from the 
study and exclude his/her information from our analysis. 
Appendix 
List of data to be collected across sites and stored in REDCap project 
1. 
Stone-free rate on 2-month post-operative CT 
2. 
Stone treatment time (time from the start of lasing to the end of lasing; minutes) 
3. 
Total operative time (minutes);  
4. 
Lasing time (minutes, time the laser was in use, not including pedal pauses) 
5. 
Total energy used (kilojoules, kJ);  
6. 
Laser efficiency (mm per minute) 
7. 
Number of times the laser pedals are pressed (left, right, and total pedal presses);  
8. 
Laser fiber  
9. 
Stone composition analysis;  
10. 
Complications  

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11. 
Quality of life survey (WISQOL short form) both pre-operatively and post-
operatively. 
 
 
i Scales CD Jr, Smith AC, Hanley JM, Saigal CS; Urologic Diseases in America Project. Prevalence 
of kidney stones in the United States. Eur Urol. 2012 Jul;62(1):160-5. 
ii Geraghty RM, Jones P, Somani BK. Worldwide Trends of Urinary Stone Disease Treatment 
Over the Last Two Decades: A Systematic Review. J Endourol 2017 Jun;31(6):547-556. 
iii Assimos D, Krambeck A, Miller NL, et al: Surgical Management of Stones: American Urological 
Association/Endourological Society Guideline, PART II. J. Urol. 2016. 
iv Andreeva V, Vinarov A, Yaroslavsky I, et al. Preclinical comparison of superpulse thulium fiber 
laser and a holmium:YAG laser for lithotripsy. World J Urol. 2020 Feb;38(2):497-503. 
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phantom retropulsion rate and ablation efficiency using holmium:YAG and super-pulse thulium 
fibre lasers. BJU Int. 2020 Jul;126(1):159-167. 
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ix Patel, Nishant, et al. Accuracy of endoscopic intraoperative assessment of urologic stone 
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x Keller EX, De Coninck V, Doizi S, Daudon M, Traxer O. What is the exact definition of stone 
dust? An in vitro evaluation. World J Urol. 2021;39(1):187-194.  
xi Pearle MS, Goldfarb DS, Assimos DG et al: Medical management of kidney stones: AUA 
Guideline. J Urol 2014; 192: 316. 
xii Planz, Virginia B., Natasza M. Posielski, Meghan G. Lubner, Ke Li, Guang-Hong Chen, Stephen 
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[i] Ulvik O, MS AE, Juliebo-Jones P, et al. Thulium Fibre Laser versus Holmium:YAG for 
Ureteroscopic Lithotripsy: Outcomes from a Prospective Randomised Clinical Trial. Eur Urol. 
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