Combination of holmium and thulium laser ablation in upper tract urothelial carcinoma
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LETTER TO THE EDITOR
Combination of holmium and thulium laser ablation in upper tract urothelial carcinoma Alberto Breda1 · Angelo Territo1 · Francesco Sanguedolce1
© Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editor Thanks to the latest technological and technical advances in endourology, the management of upper tract urothelial cancer (UTUC) has changed over the last years, with expanding indications for a conservative approach. The endourological management has been described by means of flexible ureteroscopes and of holmium:YAG fibre lasers [1]. A systematic review showed that oncologic outcomes at 5 and 10 years of follow-up were similar by comparing cohorts of low-risk UTUC patients undertaking either nephroureterectomy or endourological ablation [2]. Accordingly, since 2018 the European Association of Urology Guidelines on UTUC have recommended the elective conservative management of UTUC in selected patients with low-risk lesions, i.e., those 2 cm in size, solitary, lowgrade, non-muscle-infiltrative and without upper urinary tract dilatation at CT scan [3]. More recently, the use of thulium laser (TL) has been described in the context of UTUC [4–6]: as far as it concerns the technical features, TL consists of a diode-pumped laser that provides a continuous wave and a lower tissue penetration, which allow for a more precise vaporization, excellent coagulation, and a lower risk of injury to normal tissue, making it the ideal laser to deal with soft tissue disease In 2011, Defidio et al., in a series of 59 cases of UTUC, demonstrated that the thulium laser ablation was non-inferior to holmium:YAG laser ablation in terms of oncological outcomes [4]. More recently, Musi et al. [5] reported the outcomes of the largest published cohort of UTUC patients * Alberto Breda [email protected] Angelo Territo [email protected] Francesco Sanguedolce [email protected] 1
Department of Urology, Fundaciò Puigvert, Autonoma University of Barcelona, Barcelona, Spain
(n = 42) undertaking thulium laser vaporization: the authors showed oncological outcomes comparable to those available in literature, with a recurrence-free survival of 81% at a median of 44 months of follow-up, and a very low rate of complications. Drawbacks of TL is related to necrotic tissue adhering to the fiber tip, a drawback that may require multiple entries through the access sheath. On the other hand, owing to its pulsed nature, the energy released by the holmium laser (at the setting for tissue ablation) provides a more efficient cutting effect than electrocoagulation, but increases the risk of bleeding and impairs endoscopic vision. Given the high volume of upper and lower urinary tract diseases to be managed conservatively, in our institution both holmium-YAG (Lumenis 120 W and Cook 30 W) and thulium-YAG (Revolix 120 W) lasers are available. A dedicated team performing endourological treatments of UTUC was established in 2017, in order to standardize techniques and optimize the use of technology; though no data are ye
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