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it mean? This endoscope can rotate 270 degrees. It looks very simple today, because all the endoscopes, when you manipulate, are making this 270-degree deflection, on both sides. You know, it looks very easy, but at that time, it was not like this. It was 120 or maybe 180 degrees. So, when it came, it was in 2004-2005, it was a big, big evolution of endoscopy because it allowed going everywhere, into the kidney. So simple but a huge evolution! The second one was digital. Can you imagine we had this view with fiber optic, which was not excellent, you know? From one day to another, we switched to digital technology. And then it was, wow! The vision was exceptional. You know, what you can see again every day, now, it was a big step, because it gives us a lot of benefits to see so nice! And then we had single-use. Single-use was something completely crazy that came in 2016! It would be impossible, in 2000, for somebody to imagine that we will use single- use digital scopes to go into the kidney. Nobody could imagine that! So, it was a huge evolution! Number four was the introduction of thulium fiber. You need to realize that for more than 30 years, we have been using Holium: YAG, and all the people were very happy with it. And then this new energy came. And why do we like actually, thulium fiber? It's because of the quality of the dust that we can produce. So maybe people will say: "Okay, well, it doesn't make any difference to have the dust a little bit smaller or not". No, it makes a huge difference, because due to this improvement now, we can imagine the next one: suction! So, you see five big steps. Suction is coming. It's not ready, actually, but it will come. Do you know what is fantastic in Endourology? That's the engineering! The engineers can realize what you imagine. They are fantastic people and they will solve the problem regarding suction. So, it means that in two years, I think they will come with new endoscopes, small enough to respect the anatomy, able to laser, and at the same time to aspirate the dust. And that's
why thulium fiber is interesting, because this is the best energy to produce tiny dust. So, that's what I think the evolution and probably we will have even much more in the future, like the 3D picture, robotics and a lot of artificial intelligence evolution, I'm sure that you will enjoy all the new technology and improvement coming.
T.S.: Thinner scopes, access sheaths and scopes with suction and more efficient laser devices are constantly released. In your opinion, how far are we from treating all stones (even staghorn ones) with flexible ureteroscopy?
Professor Olivier Traxer: I think we're not very far, to be honest. The question is if we always have access to the stone retrogradely. In this case, we will be able to treat even huge ones. I'm convinced about that. So that would be possible when we get this kind of instrument. And again, this technology doesn't exist today, but it will come. There's no limit, no limit for technology. So, we need to be ambitious. I'm sure it will come! The only problem is if you have no retrograde access. So, what does it mean? Just a very simple example: if we have an ileal conduit. Sometimes we cannot access retrogradely an ileal conduit. In this situation, of course, you will need to do perc, because there is no way to access the collecting system. So, if you cannot have a retrograde access to the kidney, yes, we'll still use some percutaneous surgery, of course. But I believe that if the ureteral access is possible retrogradely, we will probably be able to do it.
F.N.: In your opinion, will advancements in smaller flexible ureteroscopes reduce the need for ureteral access sheaths?
Professor Olivier Traxer: Absolutely! And it's not only the miniaturization! Again, if you imagine a system that can aspirate at the same time, what is the benefit of a ureteral access sheath? It facilitates access when you go in and out multiple times. It also minimizes the intrarenal pressure, because you facilitate the irrigation, and these are more or less the only benefits of the ureteral access sheaths. So now imagine that you have a system that is small enough to pass just one time into the kidney, so you have no need to go multiple times in and out, and the system is able, because of the suction, to control completely the pressure, because the pressure will be constant and it will aspirate all the dust. This means that there will be no need for a ureteral access sheath.
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