This commentary refers to the article provided at https://doi.org/10.1007/s00240-024-01541-y.

Dear Editor,

Recent studies in the realm of urolithiasis have illuminated the dynamic landscape of laser lithotripsy, particularly with the advent of the thulium fiber laser (TFL) as a promising alternative to the established holmium: yttrium-aluminum-garnet (Ho: YAG) laser [1,2,3]. The groundbreaking work by Wanderling et al., comparing Ho: YAG and TFL in a meticulously crafted anatomic hydrogel kidney model [1], alongside Wei et al.‘s exploration of thermal consequences with Ho: YAG at varying parameters in vitro [2], and the ex vivo thermal profiling by Hein et al. during endourological procedures [3], collectively contribute to our understanding but also raise intriguing avenues for refinement.

While these studies have meticulously characterized thermal doses and temperature profiles, the need persists for a comprehensive evaluation of the interplay between laser characteristics and biological tissue responses across varied surgical scenarios. For instance, Wanderling’s findings underscore TFL’s tendency for higher thermal loads, yet without definitive trends distinguishing fragmentation from dusting impacts [1]. This gap underscores the necessity for further granular analysis of laser settings, considering not just thermal outcomes, but also their translation to clinical sequelae.

Wei et al. innovatively demonstrated the thermal damage correlation with Ho: YAG power and duration, highlighting the pivotal role of irrigation in thermal mitigation [2]. This echoes Hein’s conclusion on the criticality of irrigation rates in preventing renal damage [3], underscoring the universal principle that safe laser lithotripsy necessitates a nuanced irrigation strategy tailored to laser parameters.

However, future inquiries should delve deeper into the long-term histopathological outcomes and functional implications, beyond acute thermal injuries. Moreover, a comparative ex vivo study encompassing both Ho: YAG and TFL with controlled blood flow simulation would offer a more realistic perspective on clinical realities. Additionally, the exploration of laser-tissue interaction dynamics in a broader range of stone compositions and anatomical contexts is vital to inform laser selection strategies.

Innovation in laser lithotripsy demands a synthesis of physics, engineering, biology, and surgical expertise. The cited studies set a strong foundation, but to advance, we must embrace interdisciplinary collaborations that integrate computational modeling, in vitro/in vivo studies, and clinical trials to unravel the complexities of laser-tissue interactions comprehensively. By doing so, we ensure not only safer, but also more efficacious therapies, aligning with the precision medicine paradigm.

In conclusion, the studies reviewed have significantly advanced our comprehension of thermal management during laser lithotripsy. Their combined insights urge for a multidimensional approach to future research that bridges the gap between bench and bedside, enhancing patient outcomes in urolithiasis management.