Efficacy and safety of transurethral thulium laser cauterization in male patients with urethral hemangioma: a single-center retrospective case series

Introduction

Hemangiomas are benign vascular lesions typically found in the skin and liver, but rarely in the urinary system, particularly the urethra. Urethral hemangioma presents with non-specific symptoms, mainly intermittent gross hematuria, which makes early diagnosis difficult (1). Several treatment options exist for urethral hemangioma. For asymptomatic or incidentally discovered small lesions, observation with periodic surveillance may be appropriate. Due to the sensitive nature of urethral vascular channels, endoscopic treatment is challenging, and these lesions tend to recur unless completely eradicated (2). Initial management involved complete resection followed by urethral reconstruction (3,4). With advances in surgical techniques, less invasive protocols have emerged, including transurethral holmium laser coagulation (5,6), thulium laser excision (7), transurethral resection, and electrocauterization (8). Conventional surgical methods (e.g., open surgery, transurethral electrocoagulation, and resection) have notable disadvantages (2). Laser technologies, such as holmium and potassium titanyl phosphate (KTP) lasers, have achieved good therapeutic effects for urethral hemangioma (2,7,9). However, each has distinct physical properties that influence tissue interaction and clinical outcomes. Thulium laser has recently been applied in endourology (10). Thulium laser (wavelength 2 µm) offers several theoretical advantages (11-13). Its continuous-wave mode provides stable, uniform energy delivery, avoiding the explosive vaporization seen with pulsed lasers. Furthermore, the thulium laser has a shallow penetration depth of only 0.5–1 mm, producing a superficial coagulation zone that minimizes collateral thermal injury. In addition, its excellent hemostatic capability effectively seals small vessels (≤1 mm), ensuring a clear surgical field during endoscopic procedures.

However, there are scarcely any reports on transurethral thulium laser cauterization (TTLC) therapy for urethral hemangioma, and only a few cases have been reported. Therefore, in this retrospective study of 15 patients, we assessed the efficacy, perioperative safety, and mid-term outcomes of thulium laser treatment for male urethral hemangioma. To our knowledge, this study represents the initial evaluation and clinical value assessment of TTLC in patients with urethral hemangioma. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0367/rc).

Methods

This research involved a retrospective consecutive case series of treated patients at Cangzhou People’s Hospital. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments (14). The study was approved by the ethics committee of Cangzhou People’s Hospital. All participants agreed to take part in the project after being informed.

Patients

This research involved a retrospective consecutive case series. Using electronic medical records, we identified patients diagnosed with urethral hemangioma at Cangzhou People’s Hospital between November 2018 and December 2025. Inclusion criteria were as follows: (I) admission date between November 2018 and December 2025; (II) diagnosis of urethral hemangioma confirmed by urethrocystoscopy; (III) age ≥18 years; (IV) male; (V) underwent TTLC. TTLC was the preferred endoscopic approach at our center during this period due to the availability of the thulium laser system and the senior surgeon’s preference for its hemostatic properties and shallow tissue penetration in vascular lesions. We acknowledge that this introduces potential selection bias. No patients with urethral hemangioma were treated by other surgical modalities (e.g., electrocautery, holmium laser, or open surgery) at our institution during the same period. The diagnosis of urethral hemangioma was established based on characteristic urethrocystoscopic findings (well-circumscribed, compressible, reddish-bluish submucosal lesions), and no preoperative biopsy was performed due to the risk of procedure-related hemorrhage. Histopathological confirmation was therefore not available. Exclusion criteria were strictly applied and included: (I) age <18 years; (II) female; (III) underwent other surgery to treat urethral hemangioma; (IV) incomplete medical records.

Surgical method

Following anesthesia, the patient was positioned in a head-elevated foot-plantar lithotomy stance. The procedure began at the external urethral meatus with continuous irrigation to maintain a clear surgical field. Special attention was paid to the region around the seminal vesicles and the membranous urethra. A thulium fiber laser and an 800 µm laser fiber were used for TTLC. The laser wavelength was tuned to 2 µm, with laser resection energy and coagulation power set to approximately 40 W and 30 W at the sample plane, respectively. Throughout the resection, clear visibility was maintained, and the resection depth was limited to the mucosal layer, ensuring that the muscular layer remained intact.

Observation indicators

The outcome measures were perioperative safety and effectiveness, including intraoperative blood loss, tumor residual, transfer to the intensive care unit (ICU) during the perioperative period, resolution of symptoms at discharge, re-insertion of an indwelling urethral catheter, intraoperative complications, postoperative complications, and long-term complications. All patients were scheduled to undergo routine urethrocystoscopy at 6 months, 12 months, and annually thereafter, regardless of symptom status. Telephone contact was used only as a supplementary measure for patients who did not attend scheduled visits (often because they remained asymptomatic). Symptom resolution: complete absence of presenting symptoms at discharge and all subsequent visits. Recurrence: endoscopic evidence of a new vascular lesion in the urethra during scheduled cystourethroscopy, and/or return of attributable symptoms. Late complications: any adverse event >30 days postoperatively, including stricture (endoscopic narrowing), incontinence, ejaculatory pain, or retrograde ejaculation.

Statistical analysis

All statistical analyses were performed using SPSS version 25.0. Continuous data were presented as mean ± standard deviation (SD) or median (interquartile range, IQR), depending on the normality of the variables as assessed by the Shapiro-Wilk test. Categorical variables were presented as number (n) and percentage (%).

Results

Demographic and baseline data

Table 1 presents the baseline clinical characteristics of the patients with urethral hemangioma who underwent TTLC. A total of 15 patients with urethral hemangioma were enrolled based on predefined inclusion and exclusion criteria. Fifteen patients represent all consecutive patients diagnosed with urethral hemangioma at our institution during the study period who met the inclusion criteria and underwent TTLC. The majority presented with hematuria (n=12, 80%), with an average age of 67.7 years. Eleven of the 15 patients had no predisposing conditions, one had indwelling urinary catheter, and three were sexually active. No patient had cutaneous hemangioma, Klippel-Trenaunay-Weber syndrome, or a family history of hemangioma. Four patients (26.7%) had a prior history of urethral surgery, among whom all had previously undergone transurethral resection of the prostate, and one patient (6.7%) had a previous history of tumour. None of the patients had recent use of anticoagulants or hormones. Thirteen patients (86.7%) had first-episode disease, while 2 (13.3%) experienced recurrence. Preoperative imaging abnormalities were observed in only two patients (13.3%): 1 (6.7%) presented strong echo tubular echogenic structures in the prostate on urinary system color Doppler ultrasound (Figure 1), and 1 (6.7%) presented a well-circumscribed, mixed hyperintensity and hypointense signal within the bulbar urethra corpus spongiosum on fat-suppressed prostate magnetic resonance imaging (MRI)-plain scan, measuring approximately 28 mm × 15 mm × 5 mm (Figure 2).

Figure 1 Urinary system color Doppler ultrasound presented strong echo tubular echogenic structures in the prostate.

Figure 2 Magnetic resonance imaging-plain scan presented a well-circumscribed, mixed signal of hyperintensity with hypointense areas within the bulbar urethra corpus spongiosum fat-suppression in the prostate, approximately 28 mm × 15 mm × 5 mm.

Operative outcomes and perioperative complications

Table 2 presents the efficacy, safety, and perioperative complications of the urethral hemangiomas treated with TTLC. Most patients [American Society of Anesthesiologists (ASA) classification ≤II, n=10, 66.6%] had a low surgical risk. All patients successfully completed the procedure and the haemangioma was completely excised without intraoperative complications (such as cardiovascular accident, creation of a false tract, rectal/bladder injury, or obturator nerve reflex). During surgery, we found that the urethral hemangioma was located in the prostatic urethra. The lesion range in 13 patients (86.6%) was one-half of the circumferential diameter, and two patients (13.3%) presented with local lesions. No patients were transferred to the ICU during the perioperative period. The median intraoperative blood loss volume was 10.0 (10.0, 10.0) mL. The median preoperative hemoglobin level was 145.0 (139.7, 149.4) g/L, decreasing to 140.0 (108.0, 145.9) g/L postoperatively. During the laser procedure, no specimens were retrieved because the lesions were vaporized rather than resected. No patients developed ejaculation pain, retrograde ejaculation, severe hematuria, urinary retention, urethral stricture, incontinence, or septicemia during hospitalization. In all patients, the catheter was removed one week after surgery, and they were discharged from the hospital. All patients were symptom-free at discharge, and none required an indwelling urethral catheter.

Follow-up

The average follow-up time was 33.6±24.0 months (median 39.0 months; range 2.0–72.0 months), during which no postoperative recurrence was observed (Table 3). Additionally, no complications such as ejaculation pain, retrograde ejaculation, urinary retention, urethral stricture, and incontinence occurred during the follow-up.

Discussion

In this retrospective study of 15 patients, thulium laser cauterization proved to be an effective and safe treatment for male urethral hemangioma, with no intraoperative or postoperative complications, complete symptom resolution, absence of residual tumor, and no recurrence during a mean follow-up of nearly three years. These findings suggest that thulium laser therapy is a promising minimally invasive treatment for urethral hemangioma in male patients; however, given the retrospective, single-arm design, our results should be viewed as hypothesis-generating rather than definitive proof of efficacy.

Although urethral hemangioma is histologically benign, its management remains challenging due to the complex anatomy of the male urethra, its rich vascular supply, and the potential for significant morbidity associated with traditional surgical approaches. Conventional treatments include transurethral resection, electrocoagulation, cryotherapy, sclerotherapy, and even open surgery. However, these modalities are often limited by intraoperative bleeding, incomplete resection, thermal damage to adjacent structures, and high rates of postoperative complications such as urethral stricture and incontinence (15-17). In recent years, laser technology has revolutionized the field of endourology by enabling precise tissue ablation with simultaneous hemostasis. Among various lasers, the thulium laser (wavelength 2 µm) has garnered particular interest due to its unique physical properties: it operates in a continuous-wave mode, is highly absorbed by water, and produces a superficial coagulation zone of only 0.5–1 mm, thereby minimizing collateral thermal injury (18,19). These characteristics make the thulium laser theoretically ideal for treating vascular lesions in delicate locations such as the urethra.

To contextualize our findings, we reviewed the available literature on laser treatment for urethral hemangioma. Several laser modalities have been reported with variable outcomes. Holmium:YAG laser coagulation has been described in multiple case reports. Pal et al. (5) reported successful treatment of a 14-year-old male with recurrent penile urethral hemangioma using holmium laser settings of 12 Hz and 1.2 J, with no recurrence at follow-up. Another case of prostatic urethral hemangioma treated with holmium laser achieved total lesion disappearance without complications (20). However, a pediatric case of urethral varices treated with holmium laser reportedly failed, requiring subsequent electrofulguration (21). Nd:YAG laser photocoagulation has also been employed successfully in multiple urethral hemangioma cases, with one series reporting effective treatment of three male patients with small-to-medium sized lesions in the penile and posterior urethra (2,6). Notably, in that series, two of three patients (66.7%) experienced recurrence of hematuria within one month of the first treatment session and required a second laser coagulation session, though no third intervention was needed during 10–39 months of follow-up. KTP/532 laser has been used successfully for extensive urethral hemangiomas, with one reported case achieving durable remission for over two years after a single endoscopic session, and has been advocated as a first-line treatment for extensive lesions (9). Argon laser has also been reported as an effective outpatient treatment option with minimal urethral trauma (22). Thulium fiber laser has been described in a case of a 7-mm navicular fossa lesion using a 60 W system, with successful removal (7).

Table 2 reveals that the majority of patients had ASA classification II (53.3%) and III (33.3%), indicating a predominance of middle-aged to elderly individuals with comorbid conditions. This distribution is consistent with the natural history of urethral hemangioma, which often remains asymptomatic until adulthood, when hemodynamic changes or minor trauma trigger bleeding. In such a population, a surgical technique that minimizes physiological stress and preserves functional outcomes is particularly desirable. The median intraoperative blood loss was only 10 (10, 10) mL, underscoring the exceptional hemostatic capability of the thulium laser. This is attributable to its continuous-wave emission, which generates a uniform and stable coagulation zone, effectively sealing small arteries (≤1 mm) and veins without the explosive vaporization seen with pulsed lasers like holmium:YAG (13). Furthermore, the absence of bleeding ensures a clear surgical field, thereby reducing the risk of inadvertent injury to the urethral sphincter or neurovascular bundles. The efficacy endpoints are equally compelling. All 15 patients experienced complete resolution of presenting symptoms by the time of discharge, and no residual tumour was identified on endoscopic examination. The median preoperative hemoglobin was 145.0 (139.7, 149.4) g/L, while the median postoperative hemoglobin level (available for twelve patients) was 140.0 (108.0, 145.9) g/L. No patient required urethral catheter reinsertion or transfer to the ICU, further attesting to the benign postoperative course.

Perhaps the most striking finding is the complete absence of any perioperative complications. Among the 15 patients, there were zero instances of intraoperative cardiovascular accidents, false passage creation, perforation, rectal injury, bladder injury, obturator nerve reflex, or transurethral resection syndrome. Postoperatively, no patient experienced ejaculatory pain, retrograde ejaculation, severe hematuria, dysuria, urinary retention, septicemia, urethral stricture, urinary tract infection, or incontinence. This safety profile is exceptional, even when compared to established endoscopic procedures for benign prostatic hyperplasia or bladder tumours. The zero rate of urethral stricture is particularly noteworthy, as stricture formation is a common sequela of any urethral instrumentation, especially when thermal energy is applied. The thulium laser’s shallow penetration depth (0.5 mm) and precise tissue interaction likely preserve the underlying healthy mucosa and the basement membrane, facilitating rapid re-epithelialization and minimizing scar formation (23). Moreover, the absence of sexual dysfunction (retrograde ejaculation, ejaculatory pain) suggests that the laser energy does not spread to the nearby ejaculatory ducts or cavernous nerves, thereby preserving antegrade ejaculation and erectile function. These functional outcomes are crucial for quality of life in male patients and represent a significant advantage over more aggressive modalities such as transurethral resection or open surgery. The mid-term follow-up data reinforce the durability of thulium laser treatment. After a mean follow-up of 33.6±24.0 months (median 39.0 months; range 2.0–72.0 months), no recurrences were observed. The median value, together with the range, confirms that the majority of patients were followed for a substantial period, although a few had shorter follow-up intervals, which we acknowledge as a limitation. Furthermore, none of the patients developed any of the assessed complications during the follow-up period. This recurrence-free survival, coupled with the absence of delayed adverse events, indicates that thulium laser cauterization achieves not only immediate disease control but also sustained remission. While 33.6 months is a respectable follow-up duration for a rare benign condition, longer observation is warranted to exclude very late recurrences or strictures that may manifest years later. While our results are encouraging and consistent with the favorable outcomes reported for other modalities, they do not demonstrate superiority over existing approaches. The apparent differences in catheterization duration and complication rates should be interpreted with caution given the small sample size, lack of a control group, and variability in follow-up protocols across studies.

Compared with these previous reports, our series of 15 patients represents, to our knowledge, the largest cohort of male urethral hemangioma treated with thulium laser cauterization to date. Our outcomes—zero intraoperative complications, zero perioperative morbidity, complete symptom resolution in all patients, and zero recurrence during a mean follow-up of 33.6 months—compare favorably with previously published series. The 66.7% early recurrence rate reported with Nd:YAG/thermal coagulation stands in contrast to our 0% recurrence rate, which may reflect the superior hemostatic and ablative precision of the thulium laser’s continuous-wave mode and shallow penetration depth (0.5–1 mm), enabling more complete eradication of vascular lesions while preserving the underlying mucosal integrity (6). While KTP laser has shown efficacy for extensive lesions, and holmium laser remains a viable option, the thulium laser’s unique combination of continuous-wave emission, high water absorption, and minimal collateral thermal damage may offer distinct advantages for treating vascular lesions in the anatomically sensitive male urethra (5,9).

Despite these encouraging results, several limitations must be acknowledged. Firstly, this was a single-center, retrospective study with a small sample size (n=15). Although urethral hemangioma is rare, the absence of a control group precludes direct comparison with other treatment modalities, and the findings should therefore be interpreted with caution. Secondly, selection bias may have influenced the outcomes, as all procedures were performed by experienced endourologists in a tertiary referral center; thus, the results may not be generalizable to less specialized settings. Thirdly, follow-up data were available for a mean of 33.6 months, but the wide range (SD: 24.0 months) indicates considerable variability, and longer-term surveillance is needed to confirm the absence of late recurrences or complications such as urethral stricture, which can sometimes emerge years after surgery. Fourthly, the study did not stratify outcomes by hemangioma characteristics (e.g., size, location, or histologic subtype—capillary vs. cavernous), which could influence treatment difficulty and prognosis. Finally, this study did not include histopathological confirmation of the hemangioma subtype, as biopsies were not performed for safety reasons. Consequently, we were unable to stratify outcomes by capillary versus cavernous subtypes. We encourage future studies to prospectively collect detailed lesion parameters (size, depth, vascular pattern, and histology when available) to better define which hemangioma subtypes derive the greatest benefit from thulium laser cauterization.

Future research should aim to address these limitations through multi-institutional collaborations to enroll subjects for larger cohorts and establish a prospective registry for urethral hemangioma. Ideally, a randomized controlled trial comparing thulium laser therapy with observation (for asymptomatic small lesions) or with sclerotherapy would provide the highest level of evidence, though such a trial is likely to be challenging given the low incidence of the disease. Comparative studies involving other laser modalities (e.g., holmium:YAG, green-light laser) are also warranted to determine the optimal wavelength and delivery mode.

Conclusions

In conclusion, this study suggests that thulium laser cauterization appears to be a safe and technically feasible treatment option in this small series, with encouraging short- to mid-term outcomes. While the results are promising, larger prospective comparative studies are needed to further validate the efficacy and safety of this technique and to better define its optimal role in clinical management.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0367/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0367/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0367/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0367/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of Cangzhou People’s Hospital. All participants agreed to take part in the project after being informed.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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