Surgeon: Arthur Smith

Moderators: Evangelos Liatsikos, Ben Chew and Necole Streeper


Arthur D. Smith, M.D. graduated from the University of Witwatersrand in Johannesburg, South Africa. He completed a residency in General Surgery followed by a residency in Urology. In 1977 he immigrated to the United States and worked in the Department of Urology at the University of Minnesota. While working there he and Ralph Clayman developed the concept of Endourology.

In 1982 he accepted the position of Chairman of Urology at the Long Island Medical Centre. Shortly thereafter he founded the Endourology Society in 1983 and was the President for the first 25 years. He is often referred to as the "father of Endourology". Together with Dr. Ralph Clayman he started the Journal of Endourology and they continue to be the present editors.

Dr. Smith has published nearly 500 papers and chapters, produced over 100 medical movies and lectured and operated at many institutions around the world. This has resulted in many awards including an honorary doctorate from the University of Athens, honorary membership of the British Urology Society, Peruvian, Dutch, South African, the United Arab Emirates and other societies. His textbook "Smith's textbook of Endourology" is recognized internationally as the major text on the subject. He is the founding President of Videourology and this organization has had annual meetings which he has arranged for over 25 years.

Clinically he has been recognized in Best Doctors in New York and Best Doctors in the United States for many years.

Recently Dr. Smith gave up the administrative position of Chairman of the Department of Urology at Long Island Jewish Medical Center but remains in active clinical practice at the Arthur Smith Institute of Urology

 

Dr. Evangelos Liatsikos is the new elected Chairman of the European School of Urology (ESU). He is a Professor of Urology and the Director of Urology Department at the University Hospital of Patras in Greece. He is a Guest Professor at the University of Leipzig in Germany and Adjunct Professor at the Medical University of Vienna, Austria. He was Chairman of the European Section of Uro-Technology (ESUT) from 2016 to 2020. He is distinguished in literature for his research in Laparoscopy and Endourology, with his work accounting for more than 290 international publications. Dr. Liatsikos has also been invited as a speaker and live surgeon in a series of the most prestigious urological congresses worldwide. For his scientific contribution, Professor Liatsikos was nominated for the “Arthur Smith Endourology Lectureship” award in 2009 by the World Association of Endourology. He received the award of “Academic Endourology Fellowship Program Director” on November 2016 during the World Congress of Urology.

 

Ben H. Chew, MD, MSc, FRCSC is a urologist and the Director of Clinical Research at the Stone Centre at Vancouver General Hospital and an Associate Professor of Urology at the University of British Columbia in Vancouver, Canada.  He is also the Chair of Research for the Endourological Society (www.endourology.org ).  His main interests lie in the treatment and research of the pathophysiology of kidney stone disease. His research focus includes metabolic stone disease as well as biomaterials used in the urinary tract for ureteral stents.  He has worked on various stent designs, stent coatings and drug-eluting ureteral stents to try and improve the quality of life for patients with kidney stone disease. He continues work on a degradable ureteral stent and has completed the first-in-human trials. Current studies include attempting to understand second messenger systems that are activated within the kidney and ureter once a ureteral stent has been placed. These could be exploited as future therapeutic targets for new drug eluting ureteral stents or designs to reduce symptoms. He is a consultant to a robotics company in the race to develop the first robotic assisted ureteroscopy.

 

Necole Streeper MD, is an Assistant Professor of Surgery in the Division of Urology at the Penn State Milton S. Hershey Medical Center. She completed medical school at the University of Iowa Carver College of Medicine followed by a residency in Urology at University of Texas Health Science Center at San Antonio. She also completed a fellowship in Endourology and Minimally Invasive Surgery at the University of Wisconsin. Dr. Streeper specializes in surgically treating complex kidney stone disease. In addition, she is the director of a multidisciplinary kidney stone prevention clinic that focuses on the prevention of kidney stones through both medical and dietary therapy.

Her clinical research is dedicated to improving the prevention, treatment and detection of kidney stones. Specifically, she has received grant support to develop a wrist worn inertial sensor to improve fluid consumption for the prevention of kidney stones. In addition she is also interested in identifying management strategies to improve the quality of life in patients with kidney stones. Dr. Streeper has authored several research publications and book chapters in the field of kidney stone disease.

 

Webinar Transcript

Dr. Jared Winoker:

I want to be the first to welcome everyone here today. If you're returning, we appreciate you coming back. We're going to be continuing with the Endourology Society's master class in endourology. Today we're in for a treat. For those who have seen such a similar lecture in the past, we're going to be discussing nightmares in endourology with an all-star panel led, of course, by Dr. Smith.

Dr. Jared Winoker:

As a reminder, like all of our webinars, the webinar today is going to be recorded. This is an overview of today's CME program, so feel free to refer back to this for more information. But I think it's best to jump right in. I'm going to go ahead and turn over control and the lead to Dr. Smith.

Dr. Arthur Smith:

So I've got a great panel with me today. [Dr. Ben Chew 00:00:50] from the University of British Columbia. He's also chair or research for the Endourology Society. We've got [Dr. Evangelos Liatsikos 00:01:00] who's from the University of Patras, and who's also chairman of the European Group of Urology. And [Dr. Necole Streeper 00:01:10], who's from Penn State Health Surgical, who's a very experienced endourologist.

Dr. Arthur Smith:

Necole, here's a person who presents to you, she's a 61-year-old female who had an ultrasound, was diagnosed with a right-sided staghorn stone and the stone was in the renal pelvis. She's also had two previous episodes of stone passage in the past and an episode of pyelonephritis, and she has recurrent right-sided flank pain. So the referring physician sent it to you with this ultrasound and it shows a big stone that's present ... apparently a big stone that's present in the kidney here, and he sent it to you for a percutaneous stone extraction.

Dr. Arthur Smith:

So here was the QB and here was the intravenous urogram, and I want to know, Necole, would you operate on this patient at this stage?

Dr. Necole Streeper:

I typically will get a CT scan to get some better information before I proceed with a PCNL. So I'd want a CT first.

Dr. Arthur Smith:

So here's the CT and you see that on the CT this patient is [inaudible 00:02:32] that's got a calcified aneurysm, and the rule is always never ever operate on a patient with stones without doing a CT beforehand to confirm the presence of the stone. Ultrasounds can give you false diagnosis.

Dr. Arthur Smith:

Okay, so let's go over some of the operative problems. Here's a patient who had some hemorrhage from medially directed puncture. Ben, what would you do? Here's the problem.

Dr. Ben Chew:

Yeah, I would just pull that needle back and, I mean, it's not a huge needle, but certainly you need to pull that out of there. And then the question is whether you would continue to go on or not. I might try to puncture again to the system but-

Dr. Arthur Smith:

So you would pull this back.

Dr. Ben Chew:

You got to pull that back.

Dr. Arthur Smith:

And then it stopped bleeding and we were back into the track, I pushed it in too far the first time. So I overstepped the mark. Yeah, it's not a big deal and so we went on.

Dr. Arthur Smith:

Okay. So here, Dr. Evangelos Liatsikos, is another patient, and I did a perc on this patient, and I would botch the guide wire, and certainly you see the guide wire is going, "Woo." What are you going to do?

Dr. Evangelos Liatsikos:

Call the cardiologist probably. Just pull back the wire. The wire is out in the vena system, it went up into the vena cava, so the only thing you have to do is pull your wire back and try to direct it down the ureter. Do not dilate over this wire.

Dr. Arthur Smith:

So I did this. This patient, I did dilate her with a wire and I suddenly found myself in the renal vein. Ben, you've had a similar experience. Tell me-

Dr. Ben Chew:

Yeah. I was doing an upper tract TCC and we basically resected right into the renal vein. It's very scary, a lot of blood comes out quickly and you see a smooth surface there. So we put a big tamponade balloon in there, just in the renal pelvis, to tamponade all the bleeding.

Dr. Arthur Smith:

It's interesting that what happens is that when you look at it, and if your flow is good, it almost looks like the renal pelvis. It's quite an amazing thing. Then when you slow down the blood, then you see the significant bleeding. And I agree with you, the treatment of choice is to put a balloon catheter in and then it's a matter of deciding when to remove that balloon catheter that controls the bleeding. And I think that over the course of several days you slowly deflate the balloon and you see what happens.

Dr. Arthur Smith:

So here's another case from Ralf Clayman, it's a 65-year-old woman with a functionally solitary left kidney and bilateral pyelonephritis, who now presents with a recurrent UTI. The urine culture is sterile, the CT shows a lower pole intratubular stone that's not nine by seven by nine millimeters, and a second stone that's much bigger. The right kidney is atopic and you can see here that the renal scan shows that the right kidney is only six percent function.

Dr. Arthur Smith:

So here you can see the stone. And what he did is he uses a 14 French urethral access sheath was placed. They do a supracostal cross puncture and he dilated it to 24 French, and the stones were identified, and rigid and flexible nephroscopy was used to remove the stones.

Dr. Arthur Smith:

During basketing of the stone fragments in the lower pole, blown out calyx, the patient suddenly developed severe hypertension, which responded poorly to pressers. Necole, what they did here was they put in the 10 French loop nephrostomy tube was placed and the case was terminated. So the differential diagnosis was sepsis, hemorrhage, pleural effusion or abdominal compartment syndrome.

Dr. Arthur Smith:

When you had this patient on the table, Dr. Necole Streeper, what would you have done?

Dr. Necole Streeper:

I would be concerned that there was a plural effusion, and whenever it was supracostal puncture I would have done fluoroscopy when I was intra op to take a look at the pleura, make sure there wasn't a hydrothorax or a pneumothorax.

Dr. Arthur Smith:

Well, that's exactly. You can relapse a hemorrhage quite easily because you know what's going on in the operating room, how much blood you're losing. So pleural effusion.

Dr. Arthur Smith:

This was the patient's X-ray test, and what should have been done was exactly what Dr. Necole Streeper said, they should've done fluoroscopy at the time, but they didn't and they subsequently did this and then they put in the recovery room.

Dr. Arthur Smith:

So how can you avoid it? Try and puncture with the patient in full exhalation, or preferably use an intracostal punch where possible.

Dr. Arthur Smith:

Another case of Dr. Clayman's, who's a 61-year-old woman with chronic [inaudible 00:08:11] pain. The urine culture showed proteus. The CT scan was a right lower pole branched calculus of that size. So, again, they used the access sheath, and then they did a percutaneous access under ureteroscopic control while the upper pole posterior calyx was dilated with a balloon dilator to 30 French. And what happened during the dilation, the 30 French sheath advanced beyond the balloon with a perforation noted in the renal pelvis.

Dr. Arthur Smith:

They then proceeded to do the stone removal and everything was going well for a while, and initially it was uneventful because it had an access sheath in and a nephrostomy sheath. But after 45 minutes, there was a precipitous drop in blood pressure. And again, we have the differential diagnosis there. Dr. Evangelos Liatsikos, what's your thought here?

Dr. Evangelos Liatsikos:

The logic thought here is that the water goes more out into the retroperitoneal space than it goes out through the sheath or the access sheath. So you have an abdominal compartment syndrome probably here, creating all these problems.

Dr. Arthur Smith:

Procedure was terminated. They put in a pigtail stent, and a nephrostomy tube as well, and they gave the patient Lasix and Mannitol to mobilize fluid, and then they pinned the patient's [inaudible 00:09:54] wide with abdominal pressure rose to 42 millimeters of mercury and was a tense abdomen, and the patient was hypertensive so what did they do? They did abdominal ultrasound and they found a large pocket of fluid in the left lower quadrant. And under ultrasound guidance, they put a nephrostomy tube ... a needle in, and then a nephrostomy tube, and they drained the fluid and the patient recovered.

Dr. Arthur Smith:

The point that I want to make, and that you should all be aware of, whenever there's urinary extravasation or you've got a big hole in the renal pelvis, you must stop the procedure and put in a nephrostomy tube and come back another day. Do not proceed with a big hole in the renal pelvis, which was done here, even though there was a big sheath in place and an intraureteral sheath as well.

Dr. Arthur Smith:

So in the case of a significant renal pelvis perforation, especially in a patient with prior [inaudible 00:11:04] place the nephrostomy tube and come back in two to three weeks, when the fenestration has healed and the nephrostomy tract is mature.

Dr. Arthur Smith:

So now let's talk about some bowel injuries. This is the first case. A 54-year-old female presented with a staghorn calculus. Dr. Ben Chew, this patient, there was an injury noted to the perineum. What would you do in this situation?

Dr. Ben Chew:

I think I would get general surgery to be involved too, just to be on standby. But I think this could be managed because it is all retroperitoneal. I think you can manage it conservatively at first. And I think, also, resist the urge too to let general surgery completely take over, as sometimes they just see one thing and they might just jump to the gun. But you could try and manage it conservatively, first of all, say drain the kidney either with a stent and nephrostomy tube and do a nasogastric tube, but then if the patient changes at all or gets an acute abdomen, then of course you need to go to open surgery. But I wouldn't automatically do a knee-jerk reaction to that.

Dr. Arthur Smith:

Good. It doesn't happen often, but when it happens, you can treat it conservatively if the patient is doing well.

Dr. Arthur Smith:

Next patient, 82-year-old man with newly diagnosed metastatic cancer, was incidentally noted on CT to have bilateral pelvic stones. And here's the pictures of the stones. And they underwent bilateral simultaneous [percs 00:12:41] on the right side while the lower calyx, above the 12th rib, and on the left side, below the 12th rib. Unremarkable on post-operative day one, no problem. On routine imaging and antegrade nephrostogram, they found that the nephrostomy tube was traversing the small bowel.

Dr. Arthur Smith:

So Dr. Evangelos Liatsikos, what do you want to do with that?

Dr. Evangelos Liatsikos:

What do I want to do or what do I ...

Dr. Arthur Smith:

What do you have to do with that?

Dr. Evangelos Liatsikos:

What do I have to do. Well, when it's small bowel, it's clear that it's trans ... it's inside the abdomen, so there's no chance you can deal with it in a conservative way. So you need to correct, and once you need to correct you always need to keep in mind that there is two holes, one going on and one going out the bowel, because in your panic sometimes you go in, you operate, you see the hole and you suture it, then you never remember that logically the tube goes in and out from the bowel. So this is not something that you can treat conservatively

Dr. Arthur Smith:

Good. They went ahead and they did a diagnosis laparoscopy and then they were able to remove seven centimeters of small bowel and the whole thing, skin-to-skin, proceeded to end 55 minutes with the general surgeons and the patient did well.

Dr. Arthur Smith:

Next patient. 82-year-old patient with a staghorn in a horseshoe kidney. And here you can see, because of the staghorn ... sorry. And a perc was performed, and this is the perc that was done for the stone. Necole, do you see anything wrong with this perc?

Dr. Necole Streeper:

Yeah. It looks like they're coming into like an interpolar calyx rather than coming into the upper pole, which would be preferred for a horseshoe kidney.

Dr. Arthur Smith:

The reason that you want to do that is with a horseshoe kidney the bowel is often lying more or less over the middle of the kidney. So as far as possible, a horseshoe kidney almost always approaches to the upper pole calyx.

Dr. Arthur Smith:

So this is the post-operative nephrostogram. It looked perfect, but 24 hours later, the patient ... we wanted to see if the patient was stone free and then they found that the perc tract was traversing the descending colon.

Dr. Arthur Smith:

So here you can see the pictures of it going through the colon and the question is now what are you going to do, Necole?

Dr. Necole Streeper:

So you need to separate the two systems. So I would pull back the nephrostomy tube and that can act like a colostomy tube, and then you need to either put a stent in or a new nephrostomy tube to drain the collecting system so that you have two separate systems.

Dr. Arthur Smith:

So here you see, you're pulling back and here an attempt was made to insert double pigtail catheter. Here's a [inaudible 00:16:13] was put into the colon and now another tube is going down to insert a double pigtail stent. And this is the end result, is the double pigtail stent and the colostomy.

Dr. Arthur Smith:

So whenever you have a patient with a distended colon or prior renal surgery, who had gastric bypass, or extremities in body habitus or [inaudible 00:16:51] or scoliosis, you must consider these people may be necessary to do a CT guided or an ultrasound guided access.

Dr. Arthur Smith:

The reason I say the alternative is an ultrasound guided access is because with ultrasound you can often see the bowel more clearly with air in it and you can avoid it more easily with ultrasound guided than you can with fluoroscopic guidance alone.

Dr. Arthur Smith:

So here's another patient who had a right upper pole, underwent ... sorry. Left percutaneous stent extraction. Initial access was above the 12th rib. The post op chest X-ray was negative. They did well initially. The Foley catheter and the urine was light pink. Next morning the patient was short of breath, and we did a CT scan on the patient and the CT scan shows that the nephrostomy tube is going straight through the spleen. And over here is a test, you can see the patient's also got a pneumothorax.

Dr. Arthur Smith:

So, Ben, how are you going to deal with this?

Dr. Ben Chew:

I have gone through the spleen as well too. I have a great picture of it. I do consult the general surgeons and, again, that thing is they actually said, "We're going to take him to the OR right away." I said, "Oh, okay. Why is that?" He said, "Well, we actually don't care about the spleen, we think that's going to be fine probably, but we're really more concerned about the hole you made in the diaphragm. We want to go and repair the diaphragm."

Dr. Ben Chew:

So I don't think they know that we do these supracostal punctures all the time. So, again, I prevented them from doing that and we just watched the patient conservatively, leaving the tube in for a few weeks, letting the tract mature. And then we didn't keep the patient in the hospital the whole time, brought them back and then removed the tube in interventional radiology with a sheath up just in case that the spleen did bleed, they could go ahead and embolize that.

Dr. Ben Chew:

We didn't have a pneumothorax at that time, but I think for this patient, if it's a significant one, I guess you would need to consider whether or not you need a chest tube.

Dr. Arthur Smith:

Great. So we did exactly what you said. We put in an intracostal tube because of the pneumothorax and we watched the patient. And then the question came for us, "Which tube should you remove first when you have a pneumothorax and you've also got a leak, a tube that's going into the kidney?" Which would you have removed first if you're in this situation? We removed the nephrostomy tube first. And then the chest tube later because we were scared that when we removed the nephrostomy tube there may have been some extra leakage into the chest.

Dr. Arthur Smith:

So this conservative management of abdominal and thoracic complications in a patient, whenever you're worried about anything, always do a CT quickly and see what's going on.

Dr. Arthur Smith:

So the next case is a patient with a history of appendiceal cancer. Carotid artery stenosis. Pelvic floor iliac stents, triple aneurysm. So a lot of problems. Uneventful right percutaneous nephrostomy was performed and they went to the [PACU 00:20:52], hemoglobin was 11.5 and now here's what you see, this is the post-operative course, and you see here that the tube has gone straight through the liver.

Dr. Arthur Smith:

The percutaneous nephrostomy tube was removed slowly at the clinic on the 14th day post operatively, so that patient was discharged with a tube in place because the patient was hemodynamically stable and one can do that in these sort of patients.

Dr. Arthur Smith:

Another patient in a similar situation. This is a 53-year-old person with a three centimeter renal pelvic stone, who was on Warfarin, she's morbidly obese, had gastric bypass and was medically cleared, and the Warfarin was held for surgery but they wanted to put her back on it. And post operatively, here was the approach, here's the stone. Post operatively, you see here that the nephrostomy tube went through the liver and is quite a big ... here you can see a significant perihepatic hematoma and perinephric hematoma.

Dr. Arthur Smith:

So what would you do in this particular patient? Dr. Evangelos Liatsikos, it's your turn.

Dr. Evangelos Liatsikos:

Well, this is ... Warfarin is an enemy of ours in all these cases. Still, if the patient is stable and still you could have a chance of waiting and keeping the tube in place, and follow the patient and see if the hematoma increases or if it's stable, I wouldn't do anything. If it increases, then you need to explore and correct, but it won't be any better if you open. I mean, it will still bleed, once you open it's not going to be an easy case.

Dr. Evangelos Liatsikos:

The best thing here would be to go conservative, and when you pull back this tube, make sure that you put a wire through the tube and you straighten the tube because otherwise it will still bleed once, even after 14 days.

Dr. Arthur Smith:

In this sort of patient, you would be inclined to take it like Dr. Ben Chew was suggesting, remove the nephrostomy tube in the interventional radiology department?

Dr. Evangelos Liatsikos:

Yeah.

Dr. Arthur Smith:

So that's what they did and so they consulted interventional radiology and they decided to install the hemostatic agent after withdrawal of the nephrostomy tube, without embolization of the kidney, of the kidney and of the liver.

Dr. Arthur Smith:

So here's the complete catheter going in and here's the edge of the renal capsule. And they injected ... sorry. They injected ... what's it called? I'm blocking for a moment.

Dr. Ben Chew:

Gelfoam?

Dr. Arthur Smith:

Gelfoam. Thank you. Injected Gelfoam and that stopped the bleeding and the patient did very well. So the next patient is a patient who had a nephrostomy tube in place prior to procedure from an outside institution. The upper pole access was placed by interventional radiology and that tells us that, by and large, urologists should do their own percs. During the access, attempts ... the gall bladder was inadvertently punctured and pulled with contrast. 20 mil of bowel was aspirated from the gall bladder, the needle was removed, and then they did upper pole access.

Dr. Arthur Smith:

And here, you can see the situation. Here's the [inaudible 00:25:25] in the kidney, and the gall bladder has still got contrast in it. Necole, what would you do with this case?

Dr. Necole Streeper:

Yeah, I think in this case I would consult general surgery. I think it would be difficult to do conservative management of this. So I think the patient's probably going to need to have a cholecystectomy.

Dr. Arthur Smith:

This case was written up by [Steven Acarda 00:25:55], as well as another one. He had two cases with perforation of the gall bladder, and he recommends that these people have immediate laparoscopic or robotic cholecystectomy because a biliary peritonitis is not a good situation. So, so much for that.

Dr. Arthur Smith:

Another patient was a 32-year-old with renal colic, was seen in the emergency room. Referred to the urologist one month later with recurrent episodes of renal colic. A KUB and an intravenous pyelogram showed that the stone had not moved and the urologist, at that time, decided on definitive treatment.

Dr. Arthur Smith:

So, here, you see the stone and here's the intravenous urogram with the stone in place over here. And this is a case from the days prior to ureteroscopy, but it could happen as easily with ureteroscopy. So in this patient, the patient performed blind stone basketing, but it could've been done under vision as well. If you have a big stone that is bigger than the ureter.

Dr. Arthur Smith:

And here are the stages you can see. Here's the stone basket going up. There's the stone basket pulling down on the stone. And here you can see significant extravasation. And here you can see the lower end of the ureter, all crinkled up in the bladder.

Dr. Arthur Smith:

So this is the situation. So, Necole, what would you do with this patient?

Dr. Necole Streeper:

Yeah, I think that this deserves an open exploration and that's quite a length to make up, so I think that you certainly could try to do a Boari flap to reconstruct, but that's pretty far to go. So I'm thinking this patient may end up needing an autotransplant. You could consider doing the ilioureter, but I think in this case I'd probably see what I could do first with doing the Boari flap, and if you couldn't, then think about doing an autotransplant.

Dr. Arthur Smith:

So what ... at the immediate phrase there, as you went in, the same time as you go in, you would explore and then you'd done one of these three, either order transplant or an ileal interposition at that point in time?

Dr. Necole Streeper:

Yeah. I think so. I mean, it would depend what your resources are, I think. But if you had capability of fixing it immediately then I think that would be the thing to do.

Dr. Arthur Smith:

So order transplant if you've got the transplant surgeon available to help you with an order transplant, the treatment of choice for you? All right.

Dr. Evangelos Liatsikos:

Can I make a comment on this? Can I make a comment on this?

Dr. Arthur Smith:

Yeah.

Dr. Evangelos Liatsikos:

You need to consult the patient. I'm not sure that in the consent form we write that you can have such a damage that you will do an [inaudible 00:29:30] or a media loop interposition. Also, for legal aspects, if you haven't consulted your patient that you might have a complication like this and you might have to do something drastic like this, probably it's wiser to put it first in the tube and then wake up the patient, inform the environment, the relatives, and then proceed to another operation.

Dr. Arthur Smith:

Right. So how easy do you think it would be to do ... Let me go back here. Dr. Evangelos Liatsikos, look at this patient. Look at this collecting system there. How easy do you think it would've been to do a perc here?

Dr. Evangelos Liatsikos:

I do percs, in this case now, it has to be done by a very experienced team. The only way to do a perc here is to inject intravenous contrasts. And, yes, it would be [inaudible 00:30:23]

Dr. Arthur Smith:

There's a big hole like-

Dr. Evangelos Liatsikos:

It would not fill that hole, but you would be to see even that point there and put a wire, and put a nephrostomy, because otherwise you can't put up a double-J stent, you have to be very lucky to put a wire up and find that case-

Dr. Arthur Smith:

It won't work?

Dr. Evangelos Liatsikos:

It won't work.

Dr. Arthur Smith:

[inaudible 00:30:44]. The ureter is curled up in the bladder.

Dr. Evangelos Liatsikos:

There are some people that have taken the ureter going up the ureteroscope again, and putting it in position because they are so scared. No, no. We have reports like this. They're so scared, at least they want to put it in the right position, even it will scar and it will stenos, but I would still have an experienced interventional radiologist position [inaudible 00:31:08]

Dr. Ben Chew:

Dr. Evangelos Liatsikos, there was another case reported too where someone actually-

Dr. Arthur Smith:

Okay, Dr. Ben Chew, what are you going to do?

Dr. Ben Chew:

There was one case report too, Dr. Evangelos Liatsikos, where they took the ureter and actually sewed everything back up together. But, I mean, when you pull it all the way back into the bladder, it just should be completely devascularized, right? Like that [inaudible 00:31:29]

Dr. Evangelos Liatsikos:

Yeah. There's no chance that this will work. There's no chance

Dr. Ben Chew:

Yeah. Yeah. I think with the consent issues, I think that Dr. Evangelos Liatsikos brings up ... I mean, when we have seen this, you just have to stop and put a nephrostomy tube in, although that's very difficult. Essentially, it ends up being a drain around the left kidney because the urine's just leaking everywhere. So essentially it's just a drain there. And then talking to the patient and trying to do it relatively soon, see if you can prep the bowel as well if you're going to do an ileal interposition.

Dr. Ben Chew:

I think that would be one of the things. The other thing you can do sometimes too is call a relative, explain the whole situation, and then get consent from a relative if you're going to go ahead right away. I think that's reasonable. Certainly, I don't tell my patients they might get a laparotomy at the time of urteroscopy. But just looking at some of the comments, Dr. Arthur Smith, Dr. Mahesh Desai says he would do a nephrostomy tube first and then an ileal interposition at a later time.

Dr. Ben Chew:

And then the other thing, another question that someone else had that I want you to comment on, was they were saying, "Should you just not put a Dornie basket above the pelvic brim?" I'm not sure if they're meaning blind basketing or with a scope? I'm not sure what that comment refers to but they just-

Dr. Arthur Smith:

Well, in the old days, you never used a Dornie stand basket in anything above the lower third of the ureter. So, that is correct. But, in any case, nobody does blind basketing anymore, thank God. Those days are over. Any other comments, Dr. Ben Chew, that people have raised?

Dr. Ben Chew:

Just one other comment about re-putting it back in and sewing it back up right away, and maybe that's impossible because the ureter's lost its blood supply.

Dr. Arthur Smith:

I've shown this slide in other meetings as well, and the consensus has been you go out and you speak to the relatives, and if there's a transplant surgeon available to help, the ideal thing thus probably would be to do an autotransplant there and then, otherwise you'd have to try and get a nephrostomy tube, and if you can't get it in percutaneous then you would have to explore the patient, drain the urine, and I would then put in a nephrostomy tube open, myself, and leave it to settle. And then think about being ileal interpositioned at a later stage.

Dr. Evangelos Liatsikos:

We must also consider that not many centers have the possibility to do an autotransplantation.

Dr. Arthur Smith:

Well, that's right. If you can't do that then obviously the easiest thing and the best thing would be to do a percutaneous nephrostomy and then leave and try and put in a drain as well, next to the kidney, you can do that percutaneous as well for drainage of the perinephric area.

Dr. Ben Chew:

Dr. Arthur Smith, there's a really good question from the audience here. How would you manage a post [inaudible 00:34:51], essentially a fistula, from a thin atrophic kidney parenchyma?

Dr. Arthur Smith:

Good. That's a good question to ask. That really is not such a big problem because all you have to do is to put in a double pigtail stent and ensure that there's good drainage of the bladder, preferably Foley catheter as well, until the fistula dries up. And then, once it's dry, you take out the Foley catheter, and if it remains dry, then you can remove the double pigtail stent.

Dr. Ben Chew:

One other question for you. When you do have thin parenchyma, that does seem to be the best angle of attack to get to the stone, do you shy away from that area, from putting a puncture there? Or is it okay to puncture through a thinned calyx?

Dr. Arthur Smith:

I try not to puncture through a thin calyx if at all possible. I try to exit through another exit because-

Dr. Ben Chew:

Somewhere else. Kind of like Steve McArtur's case, where he had that one, because it was a thin parenchyma, but the stone was in the lower pole, you would access from the upper pole as well too.

Dr. Arthur Smith:

Yes. Absolutely. That would be-

Dr. Ben Chew:

Evangelos and Necole, would you guys do that as well too?

Dr. Necole Streeper:

Yeah.

Dr. Evangelos Liatsikos:

Yeah, I would clearly not go through the thin parenchyma. Yes.

Dr. Necole Streeper:

Yeah, I agree.

Dr. Ben Chew:

A couple other questions from the audience. One of them is how do you actually tell the patient and his relatives that there's a ureteral avulsion?

Dr. Evangelos Liatsikos:

Start crying [inaudible 00:36:29]

Dr. Ben Chew:

Then they feel sorry for you?

Dr. Arthur Smith:

Well, you have to tell them, you just tell the truth. What else can you do? You can say the stent was stuck and we tried to remove it, but the ureter was very frail and it ruptured, and we have to do something to repair it.

Dr. Evangelos Liatsikos:

The question is, do we inform the patients beforehand that this is a possible complication? Very, very minimal in chances that this will happen, but does anyone inform their patients that they might have a ureteral avulsion? We don't, but I'm asking the rest of you.

Dr. Necole Streeper:

I typically tell people there's potential for injury, and in most cases, it'll be minor, that may just require the stent to stay longer, but a rare occasion where it needs an open surgery. That's kind of my typical spiel I give them. I've never had to do it, but ...

Dr. Arthur Smith:

Dr. Ben Chew, have you got any comment?

Dr. Ben Chew:

It's a tough one. I agree with Evangelos and Necole. I tell them briefly as well too that sometimes we make a hole in the ureter, it's not a big deal because the stent will take care of it. Rarely it will make a huge hole which will require further surgery. And I kind of leave it at that. And then we try to put it back together and then sometimes, if we can't put it back together, then we actually have to take your kidney out or do other things.

Dr. Ben Chew:

That's what I tell them, but it kind of varies. Some patients, you can just tell they don't want to hear a lot of bad stuff because they're already very anxious, and you want to just tell them some general things. And then when you get the real inquisitive lawyer types who you sort of get the feelings of, "I need to tell this person everything," then I tell them every little thing that can happen. Particularly if I don't want to operate on them, I tell them that as well too. "I told you this might happen."

Dr. Ben Chew:

Can I give you a couple other questions, Dr. Arthur Smith and the panel, from the audience here?

Dr. Arthur Smith:

Sure.

Dr. Ben Chew:

One of the other things about the avulsion is that could you put in a nephrostomy tube and close the upper ureter? Is that an option?

Dr. Arthur Smith:

Well, if you're doing it as an open case then obviously you have to tie off the lower part, more or less, at the site of the avulsion. So if you still got a good upper set of the ureter and you can tie it off, that's the ideal thing. You would have a nephrostomy tube and you've got the tied off ureter, then all the extravasation will settle down, and then you can go in electively at a later stage, and at that point in time, you can try and do [inaudible 00:39:18] to get to that stump.

Dr. Arthur Smith:

That would be the ideal situation. But if you're doing it percutaneous, it becomes very difficult to put a plug into that ureter from percutaneous approach. All right.

Dr. Ben Chew:

Is there any difference in rates of bleeding between bullseye puncture and triangulation techniques for access? I don't think there is any published differences on there, is there?

Dr. Arthur Smith:

There is no difference. No. I don't think there is a difference, no.

Dr. Evangelos Liatsikos:

Of triangulation techniques, there are so many different types triangulation techniques, that's why there is no publication. Everyone, any kind of change in the CR organization, people call it triangulation. So there's no clear idea of what triangulation is.

Dr. Arthur Smith:

I think that [inaudible 00:40:24], if you're going below the 12th rib and you're angulating the needle up towards the upper pole calyx. That's what they're referring to.

Dr. Evangelos Liatsikos:

This logically has more bleeding than going directly to the calyx.

Dr. Arthur Smith:

It can be if there's torque on the kidney. When you dilate the tract and there's more torque on the kidney then there's bleeding. If there's more torque on the kidney, whenever you're manipulating a stone, the more torque you put on your nephrostomy tract with the access sheath, the more chance you have of bleeding. It's not the puncture site.

Dr. Ben Chew:

I've looked at my own data and the times that we have the most blood loss is actually mid pole punctures. I think it's because the mid pole is really only good for getting out stones at the midpoint because if you need to go up or down, I think you're just torqueing on the kidney quite a bit and cracking, because to go up, you've got to crank, to go down, you've got to torque.

Dr. Ben Chew:

So that's what we've found in our personal series. So the majority of our punctures are lower pole. And certainly upper pole had more respiratory problems when we look at our own data.

Dr. Ben Chew:

One other question for the panel from the audience, is there any possibility or room for laparoscopic percutaneous nephrolithotomy in these situations? For instance, like the one in the horseshoe kidney, that one that we saw there, would you guys ever consider or have you guys ever done any laparoscopic assisted percutaneous procedures?

Dr. Evangelos Liatsikos:

Only in ectopic kidneys. Ectopic that are not reachable with a needle. You can't have a window towards the kidney, then you can go in and do a laparoscopic, let's say a clearance of the kidney, and then you can either do a [inaudible 00:42:02] assisted laparoscopy or go in laparoscopically, if it's only a stone in the pelvis, you cut the pelvis, take the stone out, and suture again.

Dr. Arthur Smith:

People have gone in laparoscopically and tried to bivalve the kidney and take out stones, I really don't see a place for it in today's world. [inaudible 00:42:24] for the pelvic kidney, as Dr. Evangelos Liatsikos mentioned. Any other questions, Dr. Ben Chew? Otherwise I'll share [inaudible 00:42:36] cases.

Dr. Ben Chew:

Yeah, there's another question here from the audience about how to deal with bilateral ureters that are retied during hysterectomy post-operative day one versus day three. Is there any difference?

Dr. Evangelos Liatsikos:

Most of those ureters are not tied. They are actually pulled, so the suture or some kind of damage has angulated the ureters and they make a very acute angulation and, most of the times, if you go antegrade down, your wire passes down the ureter and you can easily dilate that suture and those sutures are absorbable sutures, and most of the times they open. So I go antegrades for them. Always.

Dr. Ben Chew:

And I think someone has been reading some of your work here. Another question, Dr. Liatsikos, is it still mandatory to puncture through the calyx?

Dr. Evangelos Liatsikos:

Yeah, this is a provoking question. You said before that you had problems with bleeding going through the papilla of the middle calyx, we'll never have that because we don't have torqueing through the parenchyma or middle calyx, we go to the pelvis through parenchyma and we can torque wherever we want. So I'm clearly not going to [inaudible 00:43:52] the papilla, and you know that.

Dr. Arthur Smith:

Well, you don't go through the pelvis. You go through the infundibulum.

Dr. Evangelos Liatsikos:

No, no. I don't go through the infundibulum. This is a discussion we've been having all the time. I go through the parenchyma to the pelvis.

Dr. Arthur Smith:

So you-

Dr. Evangelos Liatsikos:

It depends on the anatomy of the kidney. It depends, if the infundibulum is very large and big, then I go through the infundibulum. It all depends. So the kidney is not always the same, it's not always a book picture. It changes, it has different anatomies. It has to do many times also with what kind of dilation meter. You have a very small calyx or a small pelvis, and you go in with a 30 French dilator, it bleeds like crazy. You go in with a smaller dilator, it doesn't bleed. It's a multifactorial concept, I think.

Dr. Arthur Smith:

Okay. So let me show you another case. We've got a little bit of time. Here's a 62-year-old person who failed ureteroscopy, is referred after stent placement, inability to access the stone ureteroscopically. The patient had advanced spinal fusion 10 years ago, no history of stones in the past.

Dr. Arthur Smith:

Here's the patient, you can see where they had the spinal fusion. They went in ureteroscopically and this is what they saw Ben.

Dr. Ben Chew:

It looks like a clip or something. I'm not sure what it is.

Dr. Arthur Smith:

Well, that's where the clip was.

Dr. Ben Chew:

That's right next to the ... oh boy.

Dr. Arthur Smith:

That's the clip.

Dr. Ben Chew:

Oh, okay. So it's a piece of the hardware.

Dr. Arthur Smith:

The hardwares are loaded into the ureter.

Dr. Ben Chew:

Oh my gosh.

Dr. Arthur Smith:

Now what do you want to do?

Dr. Evangelos Liatsikos:

Dismembered pyeloplasty.

Dr. Ben Chew:

I'd use the hardware.

Dr. Arthur Smith:

Here's the urine case. Here's the urine. So they could get a catheter past here. They were able to put in a double pigtail. So this is what the image looked like close up, and they put a catheter in. So what would you do now?

Dr. Ben Chew:

I think you would have to ... well, I can keep the stent in but I think I'd have to talk to the patient about doing a ureterolysis, almost like a retroperitoneal fibrosis situation. And I think we need to also tell too that what's going to happen to that ureter at that area, too, of the injury, does that need to be resected and re-anastomosed as well too? And then try and get it laterally and then wrap it in some momentum.

Dr. Arthur Smith:

That's what they did. They moved the ureter, they repaired it, and this is what it looked like after the repair. So here's another problem case of Mahesh Desai’s, the patient had a nephrocutaneous fistula associated with an upper pole infundibular stenosis. So here's the patient and here's the upper pole infundibular stenosis, and here you can see it. Over here, the hydrocalyx on this side, and what should you do with it? Well, what would you do, Dr. Evangelos Liatsikos?

Dr. Evangelos Liatsikos:

Well, there's clearly something obstructing the upper calyx there. So clearly I would go separate on that and clear the stone, but the problem is what happens after? So I would clear the stone with [inaudible 00:47:41]

Dr. Arthur Smith:

So if you clear the stone, now you've got this infundibular stenosis, what would you do there?

Dr. Evangelos Liatsikos:

Well, you have to check your CT scan. Is there a vessel over that stenosis there? Is there something obstructing it? If there's no vessel, you could dilate it and you could put a [inaudible 00:47:56] re-entry tube down it. I don't know, some people could also [inaudible 00:48:01]

Dr. Arthur Smith:

But you can't dilate it. You couldn't get any wire down it.

Dr. Evangelos Liatsikos:

Then you need to go both ways, retrograde and antegrade, and find your way with a ureteroscope and find your way, and see it from the percutaneous tract, and then incise your way down. I've never seen this. I didn't know it was done, but that sounds logic to me.

Dr. Arthur Smith:

It's a [inaudible 00:48:24] of the upper pole calyces, as noted, and here's this area with infundibular stenosis. You see the area of infundibular stenosis over here. And what he did, this is what Mahesh did, he then had the ureteroscopy and then he went in, looked with a flexible scope, just like you said, looked down, saw the light, and then advanced the guide wire through there, and then dilated up the tract. There you can see two scopes seeing each other and then they have to kiss.

Dr. Arthur Smith:

So there you have it. And then he dilated up and put it in the appropriate tube. So he dilated it up and he lifted a nephroureteral stent for some time.

Dr. Arthur Smith:

By and large, these ... here you can see the subsequent films, post-operative CT scan, you see there still is some hydrocalycosis, but there is function in this kidney present.

Dr. Arthur Smith:

Over the course of time, this upper pole segment doesn't usually do all that well, and I often wonder if the treatment of choice for this sort of patient is, "Well, you can do this like this if the patient becomes symptomatic. Then I think the next stage is to do an upper pole partial nephrectomy. Would you consider that, Dr. Evangelos Liatsikos?

Dr. Evangelos Liatsikos:

I would, not in this case. There are other cases that are far worse and are symptomatic, as you say. So if the case here is not symptomatic, question is what happens if there is a continuous recurrent of stones and it's not symptomatic? So you clear the stone, and then after a year it comes back with another stone, and another stone, and another stone. So probably I would consider it, yes, but I would really need to see a nice reconstruction of this kidney, see what kind of arterial supply it has, and if I would consent ... it depends also from the age of the patient.

Dr. Evangelos Liatsikos:

So if this is a 75-year-old, I would not do a partial nephrectomy. I mean, he has a normal kidney on the right, I would do a nephrectomy, if needed. If I would reach the point of doing something, I would probably do a nephrectomy in that case then.

Dr. Evangelos Liatsikos:

So I would balance the morbidity with the gain and loss, and then decide.

Dr. Arthur Smith:

Okay. Here's a patient who had temperature of 101 after the perc, 18 hours after following removal of the nephrostomy tube. The patient had an X-ray test in abdomen. So here's the X-ray test and there's the CT of the abdomen, and you see there's a big fluid collection over here with a perirenal urinoma. And an intravenous urogram was done and you can see here there's extravasation of contrast still from the upper pole calyx. So, Ben, what are you going to do with this patient?

Dr. Ben Chew:

It looks like it's just ... I don't know if that's draining into the chest or not, but certainly think that if-

Dr. Arthur Smith:

No. It's subdiaphragmatic.

Dr. Ben Chew:

It is. Okay. So I think this patient needs drainage really. I think the patient needs a stent, and I think the important part for that too is not just the stent, but also a Foley catheter, particularly if it's a male, particularly if they have any signs of BPH, because then all that ... if they do just have a stent, all that urine that comes in from the other kidney, when they void, will just go back up into that area.

Dr. Ben Chew:

So whenever I do, do maximum drainage, I always try to put a Foley in. Oh, and I see you put a perc drain in too, which I think is also a good idea. Yeah, I didn't think of that.

Dr. Arthur Smith:

Now, the patient's got a stent in and the percutaneous ... and the drainage of the urinoma, and everything was great. And then the retroperitoneal was drained and the patient developed a fever, and the double pigtail stent was occluded. And the retrograde pyelogram showed here that it's just extravasation. So as soon as you inject contrast, it goes straight up through this hole in the upper pole calyx.

Dr. Arthur Smith:

So you're now going to block the double pigtail stent and you've got a collapsed system, so what are you going to do now?

Dr. Ben Chew:

I would make sure there was a Foley in there. That's my first question, is there [inaudible 00:53:24]

Dr. Arthur Smith:

You had the Foley before.

Dr. Ben Chew:

So it's still a Foley.

Dr. Arthur Smith:

What are you going to do? The system's collapsed.

Dr. Ben Chew:

I would wait. I'm not sure what else I would do. Try to inject something in there, but how do you find exactly where to inject? In scoliosis area.

Dr. Arthur Smith:

What about a retrograde perc there? You can put up a ureteroscope and put it into whichever calyx you want to put it into, or you can use the technique of retrograde access perc that's been described in the past. Where you can advance the [inaudible 00:54:05] and you can do a retrograde puncture, and then put in a nephrostomy tube, which is what I did in this case and the patient settled.

Dr. Evangelos Liatsikos:

[inaudible 00:54:17]

Dr. Arthur Smith:

There's a lot I want to comment on-

Dr. Evangelos Liatsikos:

Can I have a comment on this previous case?

Dr. Arthur Smith:

Yes, of course.

Dr. Evangelos Liatsikos:

I am a big fan, when I have leaks of the kidney like this, I'm a big fan of nephrostomies, and not of double-J stents for two reasons. One is if you need to keep these drainers for quite a lot of time, it's very tough to leave the patient with a Foley catheter and send him home with a Foley catheter on. And second, I always like to have the shortest route to the problem. I mean, the first is the shortest track to the problem. You can control it, you can inject. Plus, it evacuates much more efficiently than a double-J stent, and it doesn't occlude. And if it does occlude, you see it immediately. Urine doesn't come out so you unblock it. You do something.

Dr. Evangelos Liatsikos:

I'm not a fan of double-J stents and Foley catheters in such difficult situations.

Dr. Arthur Smith:

[inaudible 00:55:08]. I just want to comment here. Delayed hemorrhage, if you have that, one or two days more hemorrhage post operatively or a secondary bleed, the treatment choice is probably to do angiography and [inaudible 00:55:29] of embolization as was done in this case. So if you look at our cases, we looked at 4,700 cases, and they embolization rate was 1.3%. 50% had pseudoaneurysm, 30% had [IB fistulas 00:55:47] and 20% were just bleeding and we couldn't ...

Dr. Arthur Smith:

The other choice that you can have occasionally is you can think about you're doing preoperatively, you can put in a Fogarty catheter in a patient, say, who's got tremendous bleeding tendencies, you can put in a Fogarty catheter over here, blow up the balloon, and then do a percutaneous puncture under complete control. But the only absolute technique to prevent hemorrhage after percutaneous renal surgery is not to operate.

Dr. Arthur Smith:

I thank you all very much for your participation. I thank my panelists for all the help that they've given us, and I look forward to seeing you guys all participating in the next endourology congress that will be held next year in Germany.

Dr. Jared Winoker:

I just want to jump in and say we appreciate all of our panelists. Really a lively discussion, just looking at all the chat responses. So, that was fantastic. Just as a reminder for anyone watching, that the session today, like all of our sessions, has been recorded, so if there's anything you missed or you want to share it with a colleague, it will be made available on our website at Endourology.org. It'll be posted on the homepage, but you can also visit the Education tab and then Master Class in order to do that and all old webinars. And at the same time, you'll be able to register for any upcoming webinars that you see listed there.

Dr. Jared Winoker:

As you can see in front of you, next week we roll on, we got back to robotics, looking at the robotic adrenalectomy with a star-studded cast of surgeons who will be discussing that, so I certainly encourage you to go ahead and register for that now.

Dr. Jared Winoker:

Certainly, everyone will be curious about continuing medical education, you'll be receiving a survey from Michelle [Paley 00:57:39] at the end of this month and each month that we're running these webinars. Just go ahead and indicate which webinars you actually attended during that month and your CME certificate will be emailed to you. It is important that you do fill out the evaluation questionnaire that comes for each seminar as this is actually important for you securing that CME credit.

Dr. Jared Winoker:

Certainly, we encourage anyone who's not already a member to join the Endourology Society. Plenty of benefits, including but not limited to full text online access to all of our journals and publications. Again, visit the website for more information.

Dr. Jared Winoker:

And, of course, as Dr. Smith mentioned, we hope to see everyone in Hamburg, Germany next September for the World Congress of Endourology and Uro Technology. I hope everyone has a good day. Take care.