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Sometimes, because it's bilateral because the patient has a lot of comorbidities, he has renal insufficiency or solitary kidney, we have to do it. We indeed have acceptable results. But if we look at the patients who are not moving in a good way after conservative treatment, most of the time it's this kind of patient with high-grade tumors. So probably, that means that the equipment is not enough. These are retrograde approaches. We need probably to do something in addition, maybe with specific drugs, maybe some local agents. But for today, my recommendation is to do this kind of treatment for the low-grade tumors and to respect the guidelines and the indications. Maybe in the future, we will be able to expand this indication to high-grade patients.
F.N.: What future developments do you expect in the field of urolithiasis management?
Professor Olivier Traxer: Regarding medical management, I must tell you that we are a bit blocked. Of course, we are all dreaming of some medical treatment to dissolve the stones and to manage stone disease. It looks like a dream, and it is still a dream. We know that there is no project in the pharmaceutical companies to treat stones. It's a very complex process. It's not just to take a pill and then the stone dissolves because the stones are very diverse. I'm not sure if the pharmaceutical companies are interested in doing more research in this field. So, in terms of medical management, it is a bit complicated. We know more or less what we need to recommend in terms of fluid intake and terms of diet. More than 80% of stones occur because of the diet. Many people think it's because of the metabolism, some problem with the parathyroid hormone or vitamin D. Yes, it exists, but it's a very small part. Most of the stones occur because of the diet and the fluids from every day. We have probably to put a lot of effort into re-educating the people regarding diet and fluid intake. This is probably the best we can do for the patients. But in terms of medical management, it is a bit limited. I will just tell you something regarding patients with cystinuria. Cystinuria is a genetic disease. Maybe we will find a solution in the future to help this
kind of people, using some gene transfer. There is a project to instill the missing genes into the kidney to incorporate and change the production of cysteine in the urine. This is a very interesting project for this very particular population of patients. But in general, if we are talking about calcium oxalate stones, I am not sure that we will be able to change the medical management shortly. Regardingsurgicalmanagement,asIsaidbefore, we can imagine many developments, probably robotics. Robotics will play a major role. It's a bit complicated today to develop some robotic instruments because it's not exactly like the robot that replaced the laparoscopic instruments. It's not the same concept. We would like to have something very similar for Endourology, but we have a lot of constraints when it comes to the development of an easy system that is really efficient. You need to realize that your hands are fantastic instruments. For Endourology, the manipulation is so delicate. You have to make some small movements, very delicate and not so easy to reproduce with the robotic equipment. But it will come. Additionally, we will probably improve the quality of vision. We will probably have some tools to help you during the treatment, maybe to recognize the type of stone and to have more ideas regarding the technique you will use. There is also a system coming very soon that can recognize automatically the stones from the mucosa, meaning that when the system is on the mucosa, the laser will stop automatically and will restart when you are on the stone. Some systems actually will activate the laser if you are at a good distance from the stone, meaning that if you are too far and you activate the laser, nothing will happen until you are at a good distance. Some systems will calculate the speed with which you are moving. When you are moving on the surface of the stone, if you are moving slowly or maybe fast, the laser emission will adapt, because we know that if you stay in the same place, after some shots the next one is not efficient. They will be able to calculate according to the distance and the speed and the frequency will change. We have also a lot of new settings coming. In the pulsed laser, the pulses are always the same. But technically speaking, it's possible to change each pulse and to produce a pulse differently. That is what we call pulse modulation. We have an excellent project to see if changing this modulation and the pulse will make the effect different. All of these improvements will come and they will be tools to help you. The only problem will be that it will be so complex, that we will have less and less control ourselves. We will have to trust the system. It's like when you drive a car. Many years ago it was very simple to understand what happened. Now,
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