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And we have also smaller and smaller endoscopes! The last one is 6.3 Fr. We have also some competitos coming, with 6.5 and 6.9 Fr and probably we can also go even a little bit smaller. Do we need it? I don't know. Okay, I think that if we have something around 6 Fr, it's supposed to be easy to introduced in all the the ureters. But of course, miniaturization is something that we need absolutely and it will probably reduce the use of urethral access sheaths, baskets and other equipment.
T.S.: There are many laser devices for treating stone disease. In the beginning, it was the Holmium: YAG laser. Then the Thulium Fiber Laser (TFL) arrived in the market, the development
of which was to a grade degree a result of your research. Recently, the pulsed Thulium: YAG generators were also released. In your opinion which is the "perfect" laser and which are the "perfect" laser settings for treating stones?
Professor Olivier Traxer: And you know, even before Ηolmium we had also the Candela laser, we had the Nd: YAG (Neodymium: YAG) laser, and other technologies. I think that, if today we have different technologies, that means that none of them is perfect. If one laser was superior to the rest of the lasers, we would use only this one. If we can use different lasers, it means that we have some benefits and disadvantages with each one of them. It's very complicated to recommend the colleagues that they need only one laser, with which they can do everything. No! You can do everything with one laser, but probably not in the best way. So, for me, if I'm looking for dusting, full dusting technique, Thulium fiber is the best, because of the quality of the dust. If you are looking for more fragmentation, for example when you do PCNL with laser technology, probably Holmium is the best, because Holmium can produce nice fragmentation. You don't need to have small dust when you do PCNL. You can accept to have more tiny fragments. So, Holmium is probably superior. Then, you have also to consider if you are treating prostates. If you are treating prostates, you must know that the three types, Thulium fiber, Tm: YAG or the Ho: YAG, are all okay. They do more or less the same in terms of results. Just the technique is a bit different. Some people prefer Holmium, some people prefer the Thulium fiber or Tm: YAG, it depends. In the end, I don't think it makes a big difference for the patient, but you have different energies. So, if you are doing some stone treatment and also prostates, you need to adjust according to
the energy that you prefer for the prostate. Again, it is very difficult to tell you which laser is the best. In an ideal world, if you have all of them, that's perfect. Then, you can select for each patient the laser you think is the best. It's not always easy, because it's expensive. It's not easy to have many different lasers. But again, there is no perfect laser.
T.S.: Currently endoscopic management of UTUC can be considered for low-risk UTUCs. Do you believe that the recommendations will ever be generalized for even high-risk UTUCs, especially in single-kidney patients and patients with chronic kidney disease?
Tεύχος 34 | Mάρτιος - Απρίλιος 2025
Professor Olivier Traxer: This conservative treatment of UTUCs is a fantastic topic. To be honest, that's one of my preferred topics because it's challenging. It's oncology, so we like it. Since we are skilled with stones, we know the equipment perfectly, we know the lasers, and we know all the tips and tricks for treating stones, and you can do easily the conservative treatment of UTUCs. You need to know some specific tips and tricks, but it's not very complicated to learn when you treat a lot of kidney stones. I do a lot regularly. Almost every week I have cases to treat. I must say that this technique is excellent, but we need to respect very carefully the indications and the main criteria. The main criteria are, as you said, whether it is an aggressive tumor or not. What does that mean? It means the grade. If it's low grade, we have excellent data and excellent follow-up with this kind of patient. When it's high grade, it's much more complicated. Sometimes we have no solutions. We still have to do it, even if it's not recommended to treat high-grade tumors with conservative treatment.
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