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Surgical Energy Devices in Urology

The linked instrument pages hold detailed device information; the operative hubs hold patient selection and procedural technique.

Electrosurgery: Circuit and Tissue Effect​

Electrosurgery heats tissue using high-frequency current. In monopolar electrosurgery, current travels from the active electrode through the patient to the return circuit. Bipolar instruments localize the circuit between working electrodes, usually without a separate return pad; current still passes through patient tissue. Conventional bipolar coagulation and an advanced vessel-sealing system are not interchangeable.[1][2]

ConceptPractical meaning
CuttingRapid heating and vaporization can divide tissue. A continuous lower-voltage waveform is common, but the mode is generator-specific.
Coagulation/desiccationHeating denatures protein and removes water. Several different waveforms and feedback systems are called “coag.”
FulgurationArcing across a gap in an approved application.
Tissue effectDepends on waveform, voltage, contact area, tissue impedance, compression, duration and repeated activation.
Thermal spreadDepends on the specific device and test conditions.

Monopolar hazards include insulation failure, direct coupling to another instrument, capacitive coupling and return-electrode injury. Bipolar instruments reduce some circuit-related risks but still produce local and residual heat. Coagulation voltage and duty cycle vary by generator and task; no fixed tenfold voltage ratio or universally safe distance in millimeters applies. See Electrosurgical Pencil, Bovie Tips and the robotic Monopolar Curved Scissors.[1][3]

Monopolar Hazards and Bipolar Advantages​

  • Insulation failure: a break in electrode insulation discharges current to unintended tissue.
  • Capacitive coupling: current is induced through intact insulation into adjacent conductors, mainly in laparoscopy.
  • Direct coupling: the active electrode touches another instrument.
  • Return-electrode burns: poor pad contact concentrates current.
  • TUR syndrome: monopolar resection requires hypotonic, nonconductive irrigation (glycine, sorbitol), and absorption causes hyponatremia and volume overload.[1][4][17]

Bipolar resection allows saline irrigation and needs no return pad. In a 12-dog canine model, monopolar TURP raised intraprostatic temperature by 24.2 °C versus 6.8 to 8.1 °C with two bipolar systems, and thermal damage was 0.59 mm versus 0.07 to 0.15 mm. No temperature rise was measured near the neurovascular bundles with any device.[18]

Bipolar Versus Monopolar TURP​

The 2019 Cochrane review of 59 randomized trials and 8,924 participants found little or no clinically important difference in symptom improvement. Bipolar TURP probably reduces classic TUR syndrome and transfusion; certainty was moderate for these outcomes and erectile function, but low for incontinence and repeat TURP.[4]

Bipolar resection permits saline irrigation and substantially reduces the problem of absorbing hypotonic irrigation. Saline absorption can cause volume overload and hyperchloremic metabolic acidosis. Monitor fluid balance and the patient's physiology according to the procedure and anesthetic plan. Reports document this complication but establish neither a universal incidence nor a replacement monitoring protocol.[5]

Patient selection, technique and postoperative care belong in the TURP operative hub.

Laser Platforms​

Laser-tissue interaction is temperature-dependent. Above 60°C, protein denatures and tissue coagulates, producing delayed tissue sloughing and prolonged postoperative dysuria; near the boiling point of water, about 100°C, tissue vaporizes, which is the goal of prostate ablative surgery because tissue is removed from the field immediately; above 150°C, tissue chars (carbonization).[30]

PlatformTypical wavelength and operationMain role in this scopeImportant distinction
Holmium:YAGApproximately 2,100 nm; pulsedLithotripsy and HoLEPSettings, pulse modulation, fibers and thermal effects vary by system.
Thulium fiber laser (TFL)Approximately 1,940 nm; lithotripsy uses pulsesLithotripsy; selected soft-tissue/enucleation platformsNot the same laser as thulium:YAG. The SOLTIVE specification is 1,920–1,960 nm.
Thulium:YAGApproximately 2,010 nm; continuous or pulsed depending on platformProstatic enucleation; EAU 2026 weakly recommends ThuVARP as a TURP alternative, while listing ThuVAP among vaporization techniques under investigation.[9]—
GreenLight532 nm; hemoglobin-targeted photovaporizationPVP for benign prostatic obstruction—
Diode systemsWavelength and absorption varySelected soft-tissue/prostatic applications—
Nd:YAGApproximately 1,064 nm; diffuse, nonselective tissue absorption and deep penetration; continuous or pulsed[30]Rarely used in contemporary urologic practice; historically for a large hemorrhagic prostateDeepest tissue penetration and least predictable coagulation zone of the lasers on this table.

"Penetration depth" for a given laser and chromophore is conventionally the distance over which about 90% of the laser energy is deposited; the remaining energy can still travel farther depending on the chromophore.[30]

Wavelength-related optical absorption is not the same as lateral thermal injury or a safe working distance. Follow the exact laser, fiber, endoscope and eyewear instructions.[6][7][8][16]

Ho:YAG is the most widely used platform across lithotripsy, HoLEP and urethral stricture incision. Its effect is water-absorbed and shallow, and fiber size and settings vary by system. In stone surgery it was the only laser technology and the gold standard until TFL and pulsed Tm:YAG arrived (EAU 2026).[6]

Clinical scenarioReasonable platform
Ureteroscopic lithotripsyHo:YAG or TFL
HoLEPHo:YAG (largest evidence base and training infrastructure)
Thulium enucleation (ThuLEP)Thulium:YAG or TFL
Vaporization in a patient receiving antiplatelet or anticoagulant therapy with a prostate <80 mLGreenLight PVP using 80 W KTP or 120/180 W LBO lasers, with an antithrombotic plan .[9]
Selected DVIU for a primary, single, nonobliterative bulbar stricture <2 cmHo:YAG is an option; EAU 2026 gives a weak recommendation for DVIU here and a strong recommendation to choose hot or cold knife by experience and resources.[35]
One-platform budgetHo:YAG covers lithotripsy, HoLEP and selected short-bulbar DVIU.[36]

Lithotripsy​

The EAU 2026 guideline strongly recommends either Ho:YAG or TFL for (flexible) ureteroscopic lithotripsy, and rates them the most effective systems (evidence summary LE 2a).[6] Comparative findings vary between studies and meta-analyses. EAU cites one meta-analysis that could not show TFL superiority in stone-free rate, though operative time was shorter, and another that found higher stone-free rate, shorter operative time and shorter stay with TFL but a higher sepsis rate. In the 2024 meta-analysis of 11 studies, TFL had a higher stone-free rate for renal stones (OR 3.14, 95% CI 1.69 to 5.86) but not for ureteral stones, and a lower intraoperative complication rate (OR 0.34); operative time (p = 0.051) and major complications did not differ. It also has advantages in retropulsion and fiber size, which come from bench and clinical technique reports rather than from these pooled endpoints.[19] Its pulsed lithotripsy mode should not be described as “continuous-wave dusting.”

Both systems can heat irrigation fluid. EAU 2026 states that laser lithotripsy converts most energy to heat, that intraluminal temperature can pass the cytotoxic threshold (about 43 °C) within seconds when irrigation is inadequate, and that both Ho:YAG and TFL can generate injurious temperatures. Power, activation duration, irrigation and effective outflow influence temperature; raising irrigation pressure to cool the field can introduce a different risk. Intrarenal pressure and infection control require attention alongside fragmentation efficiency. The guideline's intrarenal pressure and temperature sections provide the relevant framework.[6]

Prostate surgery​

Use the HoLEP/enucleation and GreenLight PVP hubs for technique and outcome comparisons. EAU 2026 strongly recommends GreenLight PVP as an alternative to TURP for 30–80 mL prostates; its recommendation in patients receiving antiplatelets or anticoagulants with prostates below 80 mL is weak.[9] Hemostatic capability does not make PVP risk-free or automatically permit continuation of every antithrombotic. In a 13-study meta-analysis of GreenLight PVP and thulium vaporization techniques, pooled symptom, flow, overall postoperative complication and reoperation estimates did not differ significantly; thulium vaporization had a mean 8.56-minute shorter operating time but more postoperative transfusions (OR for PVP versus thulium 0.26, 95% CI 0.10–0.64).[9][20]

Fiber safety update​

SOLTIVE fiber correction

Olympus's May 6, 2025 US device correction addresses damaged SOLTIVE fibers and possible thermal events. It calls for checking the aiming beam for leakage along the fiber or strain relief before use, placing the laser in standby when damage is suspected and replacing a fiber that fails inspection or testing, or one with suspected damage if the aiming-beam test is not conducted. A distal aiming beam does not exclude damage elsewhere. Olympus's September 16, 2026 US removal notice directs facilities to identify affected fiber models and lots and transition to fibers with the new strain relief material. Affected fibers may be used under the IFU and aiming beam precautions until replacements arrive; then stop using affected versions and return unopened, unexpired stock.[33] Use the current local notice and IFU for the exact system and fiber.[10]

Ultrasonic Instruments and Advanced Vessel Sealers​

Ultrasonic devices such as Harmonic ACE act by high-frequency blade vibration that denatures protein through friction. Uses in this field include hilar and perirenal dissection, pelvic lymph node dissection and fine dissection near the neurovascular bundle. An older porcine study evaluated the Harmonic scalpel for laparoscopic partial nephrectomy; a separate porcine comparison below found unreliable vessel sealing above 3 mm.[21][23]

Ultrasonic instruments convert mechanical vibration into tissue effects, including heat; they do not pass electrosurgical current through the patient. Bench work documents very hot active blades and residual heat after activation.[11]

Device exampleModel-specific distinctionDetailed page
Harmonic familySealing capacity depends on the exact product and mode; ACE+7 has a separate Advanced Hemostasis indication up to 7 mm. This does not extend that indication to every Harmonic or historical robotic instrument.Harmonic ACE
LigaSureMany models are indicated for vessels up to 7 mm; jaw shape, generator, rotation and tissue restrictions vary. Rotation is not wrist articulation.LigaSure
da Vinci Vessel Sealer ExtendUp to 7 mm; mechanical cutting component; sterile single use.Robotic Vessel Sealers
da Vinci SynchroSealUp to 5 mm; RF cutting rather than VSE's mechanical blade; sterile single use.Robotic Vessel Sealers
Standard robotic bipolar graspersGrasping/coagulation instruments are not automatically validated vessel sealers with a generic 3–5 mm capacity.Maryland, Fenestrated, Force Bipolar
ThunderbeatCombines ultrasonic frictional heat with bipolar energy in one instrument; a porcine comparison found higher versatility and shorter dissection time than Harmonic ACE, LigaSure V and EnSeal, with similar burst pressure and thermal spread.[32] Olympus's December 2025 removal directs users to stop using and quarantine affected THUNDERBEAT hand instruments because probe tips or tissue pads may break or detach.[34]—

In a porcine comparison of energy devices (in vivo burst pressures and full-thickness peripheral energy spread), the results were:[22]

DeviceMean artery burst pressurePeripheral spread, artery
LigaSure V536 mmHg4.5 mm
Harmonic ACE436 mmHg0.6 mm
Harmonic LCS-C5363 mmHg0.3 mm

The authors concluded that LigaSure sealed vessels up to 7 mm and ACE up to 5 mm. An earlier porcine study found the 5-mm LigaSure sealed arteries to 6 mm and veins to 12 mm, and that the Harmonic scalpel did not reliably seal vessels above 3 mm but had the least collateral injury (0 to 1 mm).[23] These generations of device differ from current models, so use the current label.

Clinical reports in urology are limited. In a 32-patient open urologic series that included 25 radical prostatectomies, LigaSure use was associated with shorter mean operative time (113 vs 135.5 min) and less mean blood loss (529 vs 642 mL) for radical prostatectomy compared with the surgeon's prior technique.[24] In an 80-patient randomized trial at cystectomy, LigaSure and a stapler had similar blood loss (687 vs 708 mL), and device cost was lower with LigaSure ($625 vs $1,490).[25]

Follow vessel-size, tissue-bundle, jaw-loading, activation and contraindication instructions for the actual model.[2][12][13]

Aquablation​

Aquablation removes tissue with an image-guided waterjet. The waterjet is nonthermal, but hemostasis may include cautery or laser, and the complete procedure still carries bleeding, continence and sexual-function risks. EAU 2026 strongly recommends it as an alternative to TURP for 30–80 mL prostates, particularly when ejaculation preservation matters.[9] The 2019 Cochrane review found one randomized trial (184 men, prostates up to 80 mL, 12-month follow-up): symptom improvement was probably similar to TURP (moderate certainty), and ejaculatory dysfunction may be slightly less (very low certainty).[26] In the WATER randomized trial (116 Aquablation and 65 TURP patients with 30–80 mL prostates), 58 and 32 patients, respectively, completed five-year follow-up; mean IPSS improvement at five years was 15.1 versus 13.2 points (p = 0.2764).[37] The prospective single-arm WATER II cohort enrolled 101 men with 80–150 mL glands; 60 completed the five-year visit, and Kaplan–Meier freedom from a secondary BPH procedure was 96.3% at five years.[38]

See Aquablation for selection, functional outcomes and hemostasis.

Morcellation After Enucleation​

Morcellation mechanically fragments and retrieves enucleated adenoma. Systems differ: the Piranha uses an oscillating blade and suction. Published technical experience supports training and careful morcellation; it gives no common grams-per-minute target, and serious injury remains possible.[14][15]

Two designs exist. Oscillating systems such as Piranha move the blade around its axis; reciprocating systems move it linearly.[14][15] A video-based report from 436 GreenLEP cases by three surgeons describes technique and troubleshooting for the oscillating type; ultrasound has been described as an aid to completing morcellation in difficult HoLEP cases.[14][15][27]

Maintain a clear view of the working blade and adequate bladder distension; control bleeding and irrigation and outflow before proceeding. Stop cutting when visualization is lost and re-establish the field. Do not import laparoscopic renal or uterine specimen-containment advice into routine intravesical prostate morcellation as an unvalidated “use an entrapment bag” instruction. Keep the morcellator in the bladder lumen and do not advance it against resistant tissue. Avoid morcellating near the trigone and ureteral orifices. The operative enucleation hub holds the procedural workflow.

Safety Across Modalities​

  • Identify the exact system. Check compatible instruments, fibers, cannulas, generator modes and single-use or reprocessing requirements.

  • Inspect and visualize. Check insulation, tip covers and fiber integrity. Activate only with the intended target and working end visible; avoid unintended metal contact or energizing another instrument.

  • Account for residual heat. Stopping activation does not instantly cool a blade or jaw. A cold mechanical maneuver immediately after activation can still transfer heat.

  • Protect critical structures. Consider cold dissection, pressure, clips or sutures at delicate planes.

  • Prevent fire and plume exposure. Coordinate oxidizer delivery and ignition sources, allow preparation to dry according to its label, holster idle instruments and evacuate smoke at its source. Laser eyewear must match the system's wavelength and required optical density.

  • Plan for implanted electronic devices. Use a device-specific perioperative plan, monitoring and restoration of altered therapies; see the electrosurgical pencil for the AHA-based framework.

  • Laser-specific adverse-event reports: A review of the FDA MAUDE database (1992–2012, clinically related events) and the Rockwell Laser Industries accident database (1964–2005, mostly research-related events) found 433 reports across the two selected databases; 198/433 (46%) involved generator failure or fiber-tip breakage. Eye injuries, ranging from corneal abrasion to permanent vision loss, were reported in 164 events with Nd:YAG, KTP and diode lasers and in none with holmium. Patient harm accounted for 8.3% of reports, including 7 deaths: 4 from air embolism with Nd:YAG and 3 from ureteral perforation with Ho:YAG causing retroperitoneal bleeding. No Tm:YAG adverse events were reported in these databases.[31]

  • Active electrode monitoring (AEM) detects insulation failure and capacitive coupling and shunts stray current. It has been described for laparoscopic monopolar surgery, but adoption is limited.[28]

  • Use the lowest effective power, avoid prolonged activation without tissue contact, and prefer bipolar or cold dissection near the nerve bundle, ureter and bowel.[3][29]

References​

1. Vilos GA, Rajakumar C. Electrosurgical generators and monopolar and bipolar electrosurgery. J Minim Invasive Gynecol. 2013;20:279–287. doi:10.1016/j.jmig.2013.02.013.

2. Intuitive. Da Vinci energy instruments: current product specifications and intended use. Manufacturer overview; SynchroSeal and VSE comparison.

3. Intuitive. Da Vinci X/Xi Instruments and Accessories User Manual, 553873-07 Rev. D. Chapters 6–8: electrosurgical compatibility, monopolar and bipolar instruments. Manual.

4. Alexander CE, Scullion MMF, Omar MI, et al. Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction. Cochrane Database Syst Rev. 2019;CD009629. doi:10.1002/14651858.CD009629.pub4. Review summary and abstract.

5. You AH, Lee JY, Choi JH, et al. Hyperchloremic metabolic acidosis during bipolar transurethral resection of the prostate: a report of two cases. J Int Med Res. 2021. doi:10.1177/03000605211024480.

6. EAU. Urolithiasis guideline, 2026 (limited update, March 2026): section 3.4.6, ureteroscopy (intracorporeal lithotripsy, intrarenal pressure and temperature) and summary 3.4.6.a. Guideline.

7. Olympus. SOLTIVE SuperPulsed Laser System: technical specifications. Manufacturer information.

8. Boston Scientific. GreenLight XPS Laser Therapy System. Manufacturer information.

9. EAU. Management of Non-neurogenic Male LUTS guideline, 2026: laser vaporization and Aquablation. Disease management.

10. Olympus. Urgent Medical Device Correction: SOLTIVE Laser System and Fibers. May 6, 2025; version 1.2. US customer notice.

11. Kim FJ, Sehrt D, da Silva RD, et al. Evaluation of emissivity and temperature profile of laparoscopic ultrasonic devices (blades and passive jaws). Surg Endosc. 2015. doi:10.1007/s00464-014-3787-0.

12. Johnson & Johnson MedTech. HARMONIC ACE+7 Shears with Advanced Hemostasis. Product and indication information.

13. Medtronic. LigaSure Maryland Jaw Sealer/Divider with Nano-coating. Model specifications.

14. Richard Wolf. Piranha Morcellation System. Manufacturer brochure.

15. Rijo E, Misrai V, Aho T, Gomez-Sancha F. Recommendations for safe and efficient morcellation after endoscopic enucleation of the prostate. Urology. 2018;121:197. doi:10.1016/j.urology.2018.06.027.

16. Dornier MedTech. Thulio: pulsed solid-state thulium:YAG laser specifications. Manufacturer information.

17. Wu MP, Ou CS, Chen SL, Yen EY, Rowbotham R. Complications and recommended practices for electrosurgery in laparoscopy. Am J Surg. 2000;179(1):67–73. doi:10.1016/s0002-9610(99)00267-6

18. Ko R, Tan AH, Chew BH, Rowe PE, Razvi H. Comparison of the thermal and histopathological effects of bipolar and monopolar electrosurgical resection of the prostate in a canine model. BJU Int. 2010;105(9):1314–7. doi:10.1111/j.1464-410X.2009.08907.x

19. Uleri A, Farré A, Izquierdo P, et al. Thulium fiber laser versus holmium:yttrium aluminum garnet for lithotripsy: a systematic review and meta-analysis. Eur Urol. 2024;85(6):529–540. doi:10.1016/j.eururo.2024.01.011

20. Zhao L, Yu X, Zhu Z, et al. Comparative efficacy and safety of GreenLight and thulium laser vaporization techniques for benign prostatic hyperplasia: a systematic review and meta-analysis. Lasers Med Sci. 2024;39(1):190. doi:10.1007/s10103-024-04143-7

21. Jackman SV, Cadeddu JA, Chen RN, et al. Utility of the harmonic scalpel for laparoscopic partial nephrectomy. J Endourol. 1998;12(5):441–4. doi:10.1089/end.1998.12.441

22. Hruby GW, Marruffo FC, Durak E, et al. Evaluation of surgical energy devices for vessel sealing and peripheral energy spread in a porcine model. J Urol. 2007;178(6):2689–93. doi:10.1016/j.juro.2007.07.121

23. Landman J, Kerbl K, Rehman J, et al. Evaluation of a vessel sealing system, bipolar electrosurgery, harmonic scalpel, titanium clips, endoscopic gastrointestinal anastomosis vascular staples and sutures for arterial and venous ligation in a porcine model. J Urol. 2003;169(2):697–700. doi:10.1097/00005392-200302000-00067

24. Sengupta S, Webb DR. Use of a computer-controlled bipolar diathermy system in radical prostatectomies and other open urological surgery. ANZ J Surg. 2001;71(9):538–40. doi:10.1046/j.1440-1622.2001.02186.x

25. Thompson IM, Kappa SF, Morgan TM, et al. Blood loss associated with radical cystectomy: a prospective, randomized study comparing Impact LigaSure vs. stapling device. Urol Oncol. 2014;32(1):45.e11–5. doi:10.1016/j.urolonc.2013.06.006

26. Hwang EC, Jung JH, Borofsky M, Kim MH, Dahm P. Aquablation of the prostate for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev. 2019;2:CD013143. doi:10.1002/14651858.CD013143.pub2

27. Tzou DT, Metzler IS, Tsai C, et al. Ultrasound-guided morcellation during difficult holmium laser enucleation of the prostate. Urology. 2020;135:171–172. doi:10.1016/j.urology.2019.09.027

28. Odell RC. Surgical complications specific to monopolar electrosurgical energy: engineering changes that have made electrosurgery safer. J Minim Invasive Gynecol. 2013;20(3):288–98. doi:10.1016/j.jmig.2013.01.015

29. Voyles CR, Tucker RD. Education and engineering solutions for potential problems with laparoscopic monopolar electrosurgery. Am J Surg. 1992;164(1):57–62. doi:10.1016/s0002-9610(05)80648-8

30. Te AE. The next generation in laser treatments and the role of the GreenLight High-Performance System laser. Rev Urol. 2006;8(Suppl 3):S24-30. PMID:17173099

31. Althunayan AM, Elkoushy MA, Elhilali MM, Andonian S. Adverse events resulting from lasers used in urology. J Endourol. 2014;28(2):256-260. doi:10.1089/end.2013.0451

32. Milsom J, Trencheva K, Monette S, et al. Evaluation of the safety, efficacy, and versatility of a new surgical energy device (THUNDERBEAT) in comparison with Harmonic ACE, LigaSure V, and EnSeal devices in a porcine model. J Laparoendosc Adv Surg Tech A. 2012;22(4):378-386. doi:10.1089/lap.2011.0420

33. Olympus Corporation of the Americas. "Urgent: Medical Device Removal—SOLTIVE SuperPulsed Laser Fiber." September 16, 2026. Customer notice.

34. Olympus Corporation of the Americas. "Urgent: Medical Device Product Removal—THUNDERBEAT Hand Instruments." December 22, 2025. Customer notice.

35. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Males." 2026. Guideline.

36. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral stricture disease guideline amendment (2023)." J Urol. 2023;210(1):64–71. doi:10.1097/JU.0000000000003482.

37. Gilling PJ, Barber N, Bidair M, et al. "Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH." Can J Urol. 2022;29(1):10960–10968. PMID:35150215.

38. Bhojani N, Bidair M, Kramolowsky E, et al. "Aquablation therapy in large prostates (80-150 mL) for lower urinary tract symptoms due to benign prostatic hyperplasia: final WATER II 5-year clinical trial results." J Urol. 2023;210(1):143–153. doi:10.1097/JU.0000000000003483.