olivier traxer steeve doizi€¦ · rirs : endoscopes & laser bern-2015 olivier.traxer@aphp.fr...
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RIRS :
Endoscopes &
LASER BERN-2015
olivier.traxer@aphp.fr
steeve.doizi@aphp.fr
Olivier TRAXER
Steeve DOIZI
DISCLOSURE
2015 Consultant for
COLOPLAST
ROCAMED
OLYMPUS
BOSTON Sc /AMS
Ureteral Length :
30 cms
Intra-mural Part : 13-
14 mm
Ureter-Bladder Angle
: 90 to 135°
Ureteral Diameter :
10 Fr
ANATOMY
ANATOMY
The Ureter is not straight
Flexible URS
FIBER OPTIC DIGITAL
URF-
V2 Olympus
Less than 9 Fr
F-URS & UAS : OVALE / ROUND
French or Ch depends of the circumference not of the diameter !!!
URF-V2 &
FlexXC : 8,5 Fr
UAS : The BEST SIZE ?
12/14 F better than 10/12 F ???
10/12 12/14
As small as possible : 10/12 Fr !
URETERAL ACCESS
F-URS : NEW GENERATION
Fibre Optic Digital
So what do we need now ?
A small Digital F-URS !!! < 9 Fr
URF V2 Flex-XC
FURS MANIPULATION
Pendular Mode Fixed Mode
ORIENTATION
Digital-URS is not a pendular system :
« I-Phone technology ! »
DIGITAL CAMERA OR FIXED CAMERA ?!
Bubbles always indicate Anterior calices, at
12h00 !!!
12h00 !
Mendez-Torres et al. Urol Clinic N Am 2004
LASER INCISION
FURS: Optical System
Optical
System
0°
LASER FIBER – Angle of View
THM : When you see the Fiber,
You are safe for your scope !
Deflection
Up / Down
ENDOSCOPES
New vs old generation : are more rigid
« The semi-Flexible URS » !
FURS : the new generation
FURS & TIP Flexibility !
Fiber Optic are superior to Digital
!
40 ml/min
Working Channel
3,6 Ch
FURS : Irrigation
Olympu
sURF-
P5
Wolf
Viper
ACMI
DUR-D K Storz
FlexXC
Olympu
s URF-V
Wolf
Cobra
K Storz
FlexX2
9.00 pm 9.00 pm 2 pm 12 & 2 9.00 pm 3.00 pm 6 pm
FURS: Working Channel
FLEXIBLE URS / SINGLE USE
POLYSCOPE - Polydiagnos
• ED: 8.5Fr / 1 Working Ch: 3.6 Fr
• New ED : 6 Fr !?
FLEXIBLE URS / SINGLE USE
SemiFlex by Maxiflex
• FDA for 15 uses ED: 8.5Fr / Working Ch: 3.6 Fr
SINGLE USE F-URS
2011 FLEXOR VIEW – COOK Medical
- Size 15 Fr !!!
- Manipulation ?
- Deflection: Down 180° !
- Optic : Fibers !
- WC : 9 Fr !!!
- Instruments ?
- Irrigation ?
- Cost ?
- Clinical Evaluation ?
SINGLE USE F-URS
2015 LithoVue Boston Scientific
FURS & NBI Technology
FLEXIBLE URS
SPIEs Storz Professional Image Enhancement System
FIBER OPTIC OR DIGITAL ?
Fiber Optic Digital
+
15 to 30 Watts........... 120 W
Holmium-YAG Laser
15 to 30 Watts
Laser means Light ! Infra Red 2100 nm
Holmium-YAG Laser
Holmium-YAG Laser
3 s
eco
nd
s at
5 H
z
Villa et al EndoUrol
2015
Holmium-YAG Laser
Energy
PULSED LASER (Power = Energy x Frequency)
Time
Watt = Joule x Hertz
Holmium-YAG Laser
PULSED LASER
Holmium-YAG Laser
Power = Energy x Frequency
Watt = Joule x Hertz
BUT…….. !!!
Holmium-YAG Laser
Holmium-YAG Laser
Energy
PULSE DURATION (μsec) : SHORT or LONG
Time
Holmium-YAG Laser
Energy
PULSE DURATION (μsec) : SHORT or LONG
Time
Holmium-YAG Laser
3 PARAMETERS : ??? combinations
- Energy
- Frequency
- Pulse Duration
?
?
?
Holmium-YAG Laser
3 PARAMETERS… #1
Pulse Duration
(μsec) Energy (Joule)
Frequency
(Hertz)
Holmium-YAG Laser
Pulse Duration
(μsec) Energy (Joule)
3 PARAMETERS… #2
Frequency
(Hertz)
Holmium-YAG Laser
Pulse Duration
(μsec) Energy (Joule)
Frequency
(Hertz)
3 PARAMETERS… #3
Holmium-YAG Laser
Kronenberg & Traxer BJU 2014
Holmium-YAG Laser
Kronenberg & Traxer BJU 2014
!!!!
Holmium-YAG Laser
< 273 μ
15 ml/min
THM: “ Pour la même Efficacité, Plus de Flexibilité,
Plus d’Irrigation et Moins de Rétropulsion !
Holmium-YAG Laser
STRIPPED UNSTRIPPED
Holmium-YAG Laser
STRIPPED UNSTRIPPED
Holmium-YAG Laser
Kronenberg & Traxer JUrol 2014
!!!!
Holmium-YAG Laser
LIMITEE si
-Basse Energie
-Calcul Tendre
-Durée
d’Impulsion
Longue
AUGMENTEE si
-Haute Energie
-Calcul Dur
-Durée d’Impulsion
Courte
Holmium-YAG Laser
Cut the Fiber’s Tip MORE Often if :
- High Energy
- Short Pulse Duration
- Hard Stone
Take HM: Cut 1 cm every 8-10 000 J !
Holmium-YAG Laser
Fragments Low Frequency : 4-5 Hz &
High Energy : 1-2 J
Short Pulse : 200
Power : 4-10 W
High Frequency: 15-20Hz
Low Energy : 0,3-0,5 J
Long Pulse : 800
Power : 4,5-10 W
DUST-Vaporizat°
Kronenberg & Traxer
WJUrol 2013
FRAGMENTATION
Kidney stone
from the
surface to the
center
SOMANI, AL-QAHTANI, GIL DE MEDINA, TRAXER. Urology 2013
Ureteral stone
from the
Center to the
Surface
FRAGMENTATION
THM : Don’t Touch & Move all the time !!!
DUSTING : The trick !
FRAGMENTATION
SPD & Energy 1 to 1,5 J & Frequency : 10 to 15!!!
POP CORN Technique : « The jumping stone » !
FRAGMENTATION
Who knows the exact definition of
Fragments and/or Dust ?!
< 2mm ?
FRAGMENTATION
1 cm in 40 min
SOMANI, AL-QAHTANI, GIL DE MEDINA, TRAXER. Urology 2013
Skills Vision Irrigat° Laser Composition Size/Volume
FRAGMENTATION
64!
8! 1 cm to 5 mm :
2 cm to 5 mm :
FRAGMENTATION
FRAGMENTATION
CaOx MonoHydrate
CaOx DiHydrate
Uric Acid
Cystine
Struvite
FRAGMENTATION
Calcium Oxalate MonoHydrate surface
section
SPD
1,5 J
5Hz
Hypercalciuria (250 to 300mg/d)!
Calcium Oxalate DiHydrate
Small octahedral crystals
LPD
0,3 J
20Hz
Extraction/Fragmentation
< 2.2Fr
Pasqui & Traxer Eur Urol 2003
STONE ABLATION
LOWER POLE STONE
Schuster, 2002, Kourambas 2000, EAU Guidelines 2015
LOWER POLE STONE
Courtesy M. Pearle
LOWER POLE STONE
Results
Mean F
ragm
en
tation V
olu
me
(mm
3)
p =
0.72
THM
- Relocalization if possible
- Single use laser fiber
- Small < 270 microns
- Low Energy < 1J
- Fragmentation and
relocalization
LOWER POLE STONE
Results
Mean F
ragm
en
tation V
olu
me
(mm
3)
p =
0.72
NO ! YES !
LASER Fiber Tip : Normal vs BallTip
LOWER POLE STONE
40 Hz x 0.2 J 40 Hz x 0.4 J 40 Hz x 0.6 J 40 Hz x 0.8 J
New fiber
After 1
minute
After 2
minutes
After 3
minutes
After 4
minutes
OUI !
LOWER POLE STONE
DRAINAGE
STONE BLOCKED WITH BASKET
Laser Fiber < 273 μ and Basket < 2 Fr
LASER & INSTRUMENTS
Laser Fiber < 273 μ and Basket < 2 Fr
LASER & INSTRUMENTS
UNCRUSTED JJ
LASER & INSTRUMENTS
Leakage test
LASER & ENDOSCOPES
• Laser Ablation : 10 Watts
- 10 Hz
- 1 J
- Long Pulse Duration
UTUC
THM : Don’t
Touch it !!!
THANK YOU
FOR YOUR
ATTENTION
olivier.traxer@aphp.fr
steeve.doizi@aphp.fr
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