Advances in laser pulse modulations.

PURPOSE OF REVIEW: This review summarizes the most recent evidence evaluating the clinical impact of pulse modulation technologies in endourology, with a specific focus on laser lithotripsy and endoscopic prostate enucleation.

RECENT FINDINGS: Pulse modulation alters laser-fluid-target interaction by influencing cavitation bubble dynamics, optical shielding, and momentum transfer. Advanced pulse-shaping strategies, including split-pulse delivery (e.g. Moses Technology, Virtual Basket), extended vapor-channel pulses, controlled cavitation systems, and very low peak power modulation (e.g. Magneto Technology), have demonstrated improved energy coupling, reduced retropulsion, and enhanced procedural performance in preclinical models. In laser lithotripsy, evidence spans in vitro experiments, prospective cohorts, retrospective comparisons, and one randomized controlled trial. While preclinical data consistently support improved fragmentation efficiency and retropulsion control, clinical studies report comparable stone-free rates between pulse-modulated holmium:yttrium-aluminum-garnet (Ho:YAG), conventional Ho:YAG, and thulium fiber lasers, with modest advantages in operative efficiency and energy consumption. In prostate enucleation, available data are mostly limited to nonrandomized studies, suggesting improved hemostasis and procedural efficiency without clear benefits in functional outcomes.

SUMMARY: Pulse modulation improves laser handling and efficiency, but its superiority in hard clinical outcomes remains unproven.