<i>In Vitro</i> Comparison of Pulsed-Thulium:YAG, Holmium:YAG, and Thulium Fiber Laser

<b><i>Objective:</i></b> To characterize the pulse characteristics and risk of fiber fracture (ROF) of the pulsed-Thulium:YAG (p-Tm:YAG) laser and to compare its ablation volumes (AVs) against Holmium:Yttrium-Aluminium-Garnet (Ho:YAG) laser and Thulium fiber laser (TFL). <b><i>Materials and Methods:</i></b> p-Tm:YAG (100 W-Thulio, Dornier-Medtech^©, Germany) was characterized using single-use 272 μm core-diameter-fibers. p-Tm:YAG characterization included pulse shape, duration, and peak power (PP) studies. ROF was assessed after 5 minutes of continuous laser activation (CLA) at five decreasing fiber bend radii (1, 0.9, 0.75, 0.6, and 0.45 cm). p-Tm:YAG, Ho:YAG (120 W-Cyber-Ho, Quanta^®, USA), and TFL (60 W-TFLDrive, Coloplast^®, Denmark) AVs were compared using a 20-mm linear CLA at 2 mm/second velocity in contact with 20 mm³ hard stone phantoms (HSP) and soft stone phantoms (SSP) (15:3 and 15:5 water to powder ratio, respectively) fully submerged in saline at 0.5 J-20 Hz or 1 J-10 Hz. After CLA, phantoms underwent three-dimensional (3D) micro-scanning (CT) and subsequent 3D segmentation to estimate the AVs, using 3DSlicer^©. Each experiment was performed in triplicate. <b><i>Results:</i></b> p-Tm:YAG presents a uniform pulse profile in all of the available preset modes. PP ranged from 564 to 2199 W depending on pulse mode. No laser fiber fracture occurred at any bend radius. p-Tm:YAG achieved similar mean AVs to TFL and Ho:YAG for HSP (8.96 ± 3.1 <i>vs</i> 9.78 ± 1.1 <i>vs</i> 8.8 ± 2.8 mm³, <i>p</i> = 0.67) but TFL was associated with higher AVs compared with p-Tm:YAG and Ho:YAG (12.86 ± 1.85 <i>vs</i> 10.12 ± 1.89 <i>vs</i> 7.56 ± 2.21 mm³, <i>p</i> = 0.002) against SSP. AVs for HSP increased with pulse energy for p-Tm:YAG and Ho:YAG and (11.56 ± 1.8 <i>vs</i> 6.36 ± 0.84 mm³ and 11.27 ± 1.98 <i>vs</i> 6.34 ± 0.55 mm³, <i>p</i> = 0.03 and <i>p</i> = 0.02), whereas AVs for SSP were similar across laser settings for all laser sources. AVs with TFL were similar across laser settings for both phantom types. <b><i>Conclusion:</i></b> p-Tm:YAG combines intermediate PP between Ho:YAG and TFL, a uniform pulse profile, no ROF with increasing deflection and effective ablation rates. Further clinical studies are needed to confirm these <i>in vitro</i> results.