Olivier Traxer
@OTRAXER
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Prof of Urology Chairman Tenon Hospital Sorbonne University &Director GRC #20 Lithiase Urinaire (UrolithiasisClinicalResearchGroup)SorbonneU. AAGUS & AAEU Member
Joined July 2017
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BWALE-24: Beautiful view of ureter after Tm-Fiber lithotripsy of cystine stone. Full of small white bubbles (the typical one after laser treatment of Cystine stone. See BWALE-16 & T&TV12): like thousands of PEARLS!
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BWALE-12: For Excellent dusting with Laser: Low Energy & Long Pulse Duration. Fix Frequency Low or High if you want to go Slow(for more precision) or Fast. Keep minimal Distance between Stone Surface and Fiber’s Tip & Respect the same Speed when you are moving at Stone surface
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BWALE-7: LECURS. Lithotripsy Endoscopically Controlled by URS. Perfect control of each SW efficacy. Constant irrigation for optimal SW transmission. Possible basketing &Laser at the same time. No risk for Flexible-URS if using Single-Use URS. ESWL is not dead, we still need it!!!
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T&TV32: “F&B”. When stone fragment is around the corner, difficult to catch with basket. Remember: Irrigation is excellent to move stone from one point to another1. Using Syringe /Manual pump: move stone by flushing: Assistant must be ready to catch it when passing through basket
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BWALE-20: Another beautiful intra-renal view. All the calyces on the same line, like a perfect alignment of planets.
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BN105:Today with HighPowerLaser(HoYAG 100-150W&TFL60W)we face more&more UreteralLesion(Stenosis!) Our responsibility as KOL-Experts&LaserCompany is to RECOMMEND“SAFE SETTINGS” forPatient¬“OptimalOnes”for max.EFFICIENCY.Please pay attention toURETER.Use LowPower&LowFrequency🙏
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T&TV61: Incision of infundibulum. If you cannot reach the stone (especially in the lower pole), while you are in maximum deflection: the infundibulum must then be incised. With a Thulium-Fiber laser: 1J-10Hz-ShortPulse (HPP-500W). Benefits: precision and bloodless
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BN107: To all of you who love EndoUrology & Urinary Stones.Don't delay &ask COLOPLAST for this superb book.Magnificent photos of the most beautiful stones from my personal collection and amazing comments from the 60 most renowned KOLs in the world in endoUrology. LIMITED EDITION!
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T&TV3: When placing a stiff guidewire into the ureter: if Ureteral Orifice opens like a «Tent», you have a good chance to place UAS(especially small-10/12Fr). But If ureteral orifice stays small &narrow : no need to try, think about Sheathless Technique or pre-stent the patient
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T&TV63: Duplicate System. When you are searching for the ureteral orifice of the upper pole (usually below the one for the lower pyelocaliceal system), don’t forget that sometime you will not find it into the bladder but in the urethra… look carefully!
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BWALE-29: Fornix Rupture. This natural jonction between kidney parenchyma and collecting system is so fragile… Can not resist with High Pressure. It cracks so easily and then bleeds. Need definitively a good system to record Intra-Renal Pressure…. Coming soon, stay tuned.
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BN26: Yesterday First Case with ThuliumFiber in Paris,France&probably 1of the first in Europe.Just what we expected! 15mm stone COM (1700 mm3) Completely dust:24 min! 100mJ-240Hz (150 mic.fiber) &35.000J : 20J/mm3 & 1,18mm3/sec! Vs:Ho-YAG : 2Times faster &smaller Dust!So Exciting
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BN86: for the very first time, a company is producing a Single Use Digital Flexible URS not only with American or European deflection but possibility to select 3 or 9 o’clock position for the Working Channel. According to tweet T&T71 (29/05/2018). “UROFINO” fURS From SEEGEN
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BN106: regarding BN105.Some more comment to be very clear: LASER safety for Ureter is: LOW Power AND Low Frequency TOGETHER! It’s not because you are using LowEnergy that you can use HighFrequency. Into the URETER you MUST go Slow(=Low Frequency!!!) whatever the Energy you use!
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T&TV54: En Bloc Resection of Bladder Tumor with TmFiber. Excellent & Precise incision to find the good plan. Less bleeding, excellent coagulation. Settings: 1J-10Hz-High PeakPower(short pulse).Just use Ch22 cystoscope &laser fiber 200-550 microns stabilized with ureteral catheter
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T&TV5: When FlexibleURS is placed into the kidney, vision is initially not clear (urine,blood,debris). Don’t aspirate otherwise bleeding starts (because negative pressure).Just increase gently &slowly irrigation with manual pump/seringue. In 2 min view is perfect. Take your time!
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BN22: Great news today. “The new Thulium-Fiber Laser is finally CE approved!!!”
A new era opens for the treatment of urinary stones & endourology in general. Thank you to Olympus!
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BWALE-19: Impressive KUB with bilateral Nephrocalcinosis. Into the collecting system, not so much visible. If treatment needed, just treat the visible part, don’t go too deep into the parenchyma. RIRS better than PCNL.
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T&TV29: Bladder stone & Tm-Fiber. No retropulsion, beautiful fine fragmentation. The only limitation is limited frequency if too much energy selected. Here 0,5 J (HPP) : max Frequency 120 Hz...
But still fast and efficient.
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BN74: After so many years giving together AUA & EAU-ESU course.What a privilege to be associated to the «RIRS Pioneers» Drs BAGLEY & GRASSO to edit this amazing book! Dr Hubosky another top-expert in RIRS managed all the details to finalize this project. Have a look, it’s a Must!
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RX6: when performing RIRS, never forget ANATOMY. Ureter is long, tortuous and definitively not straight and small in diameter. Respect Anatomy of your patient and Adapt your instruments to each of them, not the opposite «dixit Prof. Roberto Scarpa»
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BWALE-21: When the stone is almost arrived in the bladder...
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BWALE-33: The transparent tip of a Laser Fiber is very fragile. It can break. Use Nitinol basket to remove it. But remember that we dont need transparent tip. So CUT it with regular scissors. Laser efficiency remains the same,tip visibility is excellent(blue) &no risk of breakage
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To celebrate 10.000 followers. Let me offer you this video“Because We All Love Endourology” &to announce the creation of a new platform “BWALE Channel” very soon in 2022: to demonstrate T&T,Surgical technique,Semi-Live,Product Evaluation &Many more. Happy Holidays to all of you🙏
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T&TV34: How to realign a tortuous ureter? 1-: First, always select a STIFF Hydrophilic guide-wire & 2-: Push the wire and KEEP PUSHING until the stiffness of the wire will realign the ureter. THM: STIFF Hydrophilic 0,035/0,038 GW & keep Pushing!
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T&TV13: Laser settings &stone. Remember 2THM: 1).Power(W)is not the issue: for same power you can dust or fragment: The good combination of Pulse duration,Energy &Frequency is ESSENTIAL! 2).Frequency is just to go faster. Energy &Pulse Duration/Shape are the important parameters!
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BN77: Very Honored, Proud&Happy to become the new CHAIRMAN Urology Dpt Sorbonne University-Tenon Hospital. Leading a magic team: Prs O.Cussenot & é; Drs S.Doizi-S.Benbouzid-C.Cioffu-F.Gomez-G.Raynal-I.Cussenot-V.Frydman-D.Grinholtz-A.Uzan-M.Felber-&G.Marra
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BN43: First use of the NEW SingleUse (SU)digital Flexi-URS 7,5Fr (Pusen). Today this is the smallest SU Digital F-URS. A bit bigger than regular 7Fr JJ. It opens the door for the future to treat stone in emergency & not place a JJ. Not yet recommended but must be investigated
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BN10: new section coming soon: « BWALE » Because We All Love EndoUrology. Small videoclips to illustrate beautiful findings in EndoUrology. Enjoy
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T&TV42: JJ irritate urothelium. Not only into the bladder. The intra-renal pigtail is also responsible of irritation of renal papillae & mucosa with hematuria, pain, inflammation... The best we can do is: “to remove the JJ ASAP...”. Don’t leave it thinking “we have time”...
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RX2: KUB (scout film) with JJ in place is informative for ureteral access with UAS. If JJ demonstrates a nice curve at the level of iliac vessels, the passage with UAS Should be easier compared to the «S-curve». «S-curve» is regularly seen when ureter are fixed over iliac vessels
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T&TV39: The new 7,5Fr Single Use Digital F-URS from Pusen. Excellent quality of View allowing perfect cystoscopy & Excellent Manipulation/Small size allowing direct ureteral access (no wire/no UAS «The no-touch Technique») It’s time to reevaluate our technique of ureteral access
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T&TV2: UAS and ureteral lesion! Remember the very simple THMessage: “if you decide to use UAS for RIRS: (should never be systematic) -First: As small as possible (10/12Fr is the best compromise) according to FURS size and -2nd: never Force (smooth and delicate insertion force)
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BWALE-18: Nice intra-renal endoscopic view. Renal papillae : always different and specific for each patient like fingerprint!
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T&TV15: What is the exact definition of dust? The “Tenon’s Definition” is: Particules less than 250 microns! Why?: Because it floats with pressure 40cm of H2O (pressure to irrigate during RIRS) & can be aspirate via 3,6Ch Working Channel with no blocage. What’s yours?
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T&TV21: Difficult Ureteral Access. The best combination to manage tortuous ureter, difficult intra-mural part, re-implanted ureter,... is: Angle tip hydrophilic guide wire together with angle tip ureteral catheter.
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T&TV14: Conservative Ttt UTUC &Ho:YAG. Good setting: LONG PulseDuration-Medium Energy(1J)-Medium Frequency(10Hz). If you touch it bleeds:”Take distance”, activate Laser&Move to UTUC.When it starts to become white,stop moving &Keep this distance. If you prefer Contact Mode use0,4J
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BWALE-6: Multiple stones in Calyceal Diverticulum. Due to urinary stasis. Easy to predict when looking at the preop-CT. If the stone is round on the CT it means « one single one ». If the stone is flat it means « accumulation of small multiple one »
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BN18: Every evening at 8.00pm, french people at the windows, making noise & applause to support Doctors/Nurses and staff fighting against Covid-19. Thank you for the support, so great! 🙏🙏🙏
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T&T36: when placing a STIFF wire for ureteral access. If ureteral orifice stay round and narrow around guide wire, no need to try UAS placement: place JJ or consider sheathless technique. But if UO opens like a « tente » great chance for UAS placement
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BWALE-5: Narrow Band Imaging in the upper tract. Irritation of Urothelium by stone or JJ looks like urothelial tumor. With NBI no “Frog egg’s Effect” (no vascular structure visible in the Mucosa), so more in favor of benign lesions (irritation)
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BN40: Stone Classification. If you love kidney stones, have a look at this publication. The Amazing Classification of Dr Michel DAUDON. Fully illustrated. A MUST!
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BN29: very impressing carbonisation effect of Tm-Fiber laser with Cystine stone. Second case now. Not so visible with other stone composition. 150 micron fiber: 100mJ-240W-MediumPP. Need to be evaluated and explained.
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BWALE-9: UTUC & RIRS. NBI technology is a nice tool, easy to use to optimize the detection of small UTUC and to define much better their limits. It takes just 2 seconds to switch from white light to NBI: just press the button!
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T&TV12: Cystine is rare (approx 1% stone formers). Medical management is essential so patient must be diagnosed ASAP. Easy to recognize cystine if laser treatment: it smells Sulfure & bubbles are becoming OPAQUE & WHITE:”the bull’s-eye bubbles”. Just confirm with IR-Spectroscopy
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BN135: When dreams become true. RIRS-Laser with simultaneous suction & pressure control for optimal results: IMMEDIATE STONE FREE, even for volume well above 4000 mm3 (STONE >2 cm). The future is now. Seeing is believing!
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T&TV8: FlexibleURS with fiber optic(FO) are STILL the best to manage patient with challenging anatomy: Lower Pole,Horseshoe kidney, Narrow Ureter: smaller size& better maneuverability. Digital FURS are the best if you are looking for better quality of view (diagnosticURS-UTUC)
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BN25: Finally... After Russia, India, USA, Middle East, Tm-Fiber Laser is coming to Europe and France. We are all very interested to use this new technology in our practice for the benefit of our patients
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BWALE-38: CT&Endoscopy of DENT’s Disease(X-linked recessive nephrolithiasis with renal failure). Renal tubular disorder due to proximal tubule dysfunction, including Low-molecular-weight Proteinuria-Hypercalciuria-Nephrolithiasis-Nephrocalcinosis-Progressive Renal failure
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BWALE-2: the « Mercedes Papillae ». The anatomy of renal papillae are really diverse. Single, double, multiple with very small or large connections. In this example, 3 papillae with large connection.
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T&T18:«Position of laser fiber’s tip».Tip should not be too close/too far regarding position: consider midline of the screen(Radius-red arrow)&Place Tip of fiber at the middle(1/4 of diameter).The external view shows tip largely outside if using this reco
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BWALE-22: Randall’s plaque(RP): subepithelial calcification of renal papilla(left Video),acting as anchor for CaOxstone (middle). CaOx stone detached from papilla together with RP(V3 right). THM: treat Stone but Always respect RP, dont laser it! & RP is Not MedullarySpongeKidney!
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WCE Paris2018. FANTASTIC Meeting because of all of you! We were in total: 2111 !!! Great success. Thank you so so much! Be sure that PARIS loves you. Good luck for WCE2019 29oct-2nov! ABU DHABI-UAE. We will be there!
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BN76: Fantastic system to record IntraRenalPressure during RIRS. A pressure-sensor placed in the renal pelvis, totally INDEPENDANT of FURS. Can be used with any kind of FURS &able to stay in the RenalPelvis even if FURS moves from kidney to Ureter &vice versa. More example coming
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T&TV19: Irrigation is essential in EndoUrol. Increasing Irrigation can increase IntraRenal Pressure &generates complications. Best equipment to adjust irrigation are«Manual systems»(pump, seringue) These systems are also very useful to dislocate stone/fragments with short flushes
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BN35: Great new system: «HYPNO-VR»Virtual reality for hypnosis during ESWL. No anesthesia,No pain killer.Just great relaxation. Patient selects his preferred Environment:Watching nice video&Listening relaxing voice.Under evaluation: initial results: less pain & much more confort
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BN126: Today, first use in Human HUGEMED 6,3Fr SingleUse F-URS. 3,6Fr WC. Excellent Torque &Beautiful Endoscopic vision. Easy to engage ureter in «No touch Technique »: A great step for RIRS. Will facilitate children/infant RIRS & will allow ureteral stone treatment in emergency
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BN49: Just thinking about design of JJ. Since the first introduction more than 40 years ago, JJ are still the same: a tube with holes & 2 “pigtail/J type”. Do we really need holes? Since encrustations always start at these point. JJ TumorStent has no holes but drains perfectly...
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BN30: Cystine stone: same patient. Comparison of TmFiber laser (100mJ-240Hz-Medium PP) & Holmium-YAG laser (1J-15Hz-MediumPP). No retropulsion Very small dust & excellent visibility with TmFiber. But strange carbonisation effect.
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T&TV16:«Glue Clot’s Tech.» useful to remove small fragments. RECOS: Use 5-10ml autologous blood(B).Remove Contrast(C) before injecting(C&B don’t mix together),Inject SLOWLY directly on fragts (to keep B in situ),Wait 10min (clotting),Use Nitinol Basket & don’t close it completely
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T&T98: In case of ureteral irritation (oedema+++ at ureteral orifice UO).If JJ is in place,don’t remove it. You may have difficulties to see again UO. Place FIRST a GuideWire alongside the JJ &then remove JJ. Much Easier &Safer. Hydrophilic wire are great in this situation
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T&T83: Ureteral Stenosis PROXIMAL URETER (from UPJ to Iliac Vessel): make the incision at 7.00 o’clock for the RIGHT Ureter and 5.00 for the LEFT one: similar to UPJ Obstruction! Be sure you are well-oriented (bubbles indicate 12.00). And use: LongPulseDuration-1J-10Hz
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T&T68: Never forget that stone volume is more important than largest diameter. When you treat a real 2 cm stone, you treat in terms of volume 8 times more than a 1 cm stone!!! So 8 times more for operating time...
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T&TV6: If stone blocked into a basket(B): before cutting B or dismantling the handle TRY to pass in the working channel a small laser fiber(270 microns) just beside the B. Open completely the B & laser the stone just by moving slowly URS handle(torque mvt)Always possible if B<2Fr
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Quizz-3 Answer:
Dr Enrique Pérez Castro (Spain Madrid): first therapeutic RIRS 1979. Dr Peter Alken (Germany Mannheim) PCNL-Alken dilators. Dr Christian G. Chaussy (Germany Munich) inventor of ESWL. RESPECT!
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T&T38: REUSABLE Laser Fiber:don’t forget to respect the «20 cm DIAMETER» to store them.Exactly like for Light Cable!!! If not,you fragilise the fiber(micro-fissures)with high risk of breakage during the next use(perforation of working channel).So Do It to preserve flexible URS!
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BN87: FLEX-XC1: the new Single Use digital flexible URS from Karl Storz is coming soon. A MUST: Excellent torque, amazing quality of view & very robust. To be used together with the reusable ones FLEX-X2S & FLEX-XC. So now it’s your choice for your patient!
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T&TV11: Irrigation is crucial in EndoUrology using exclusively Saline(no sterile water). Low intrarenal pressure is essential (less 40cmH2O) Forced irrigation generates HyperPressure with intrarenal reflux &urinoma by Fornix rupture. THM: take your time & Never Force irrigation
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BWALE-31: Stones are so beautiful. It’s such a pity we have to destroy them. But not sure that our patients care about their beauty…
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BN121: New Frontiers in stone management : “The Magneto” by Quanta. When Holmium:YAG laser is back with new possibilities due to NEW Pulse-Modulation : LOWER PEAK POWER & Extra LONG PULSE. Similar to ThuliumFiberLaser: for optimal dusting & less retropulsion. To be continued…
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T&TV36: LowerPoleStone & Relocalization-LPS&R. We don’t recommend ANYMORE to systematically relocate LPS. Laser IN SITU is regularly OK with excellent FURS(reusable/single use) &smaller laser fiber 200micron(Ho:YAG), 150(TmFiber). If you prefer LPS&R: be sure Stone is not too big
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