Faculty: Nadya York, Alex Meller

Moderator:  Bodo Knudsen


Dr. Nadya York

Dr Nadya York is an endourologist working in Auckland, New Zealand. Following urology residency in New Zealand, Dr York completed a 2 year Endourology Society accredited fellowship with Dr. James Lingeman at Indiana University, Indianapolis, Indiana, USA. Dr York’s interests are surgical management of stone disease, metabolic stone workup and management of BPH including HoLEP. 

 

Dr. Alex Meller

Dr. Alex Meller is an endourologist working in São Paulo, Brazil. He completed your residency in São Paulo at Federal University of São Paulo and after some period dedicated to private practice,  returned to the University to develop academic activity. Nowadays he is the Vice Chief of Endourology & Stone Disease Division at Federal University of Sao Paulo (Brazil) since 2016. He became staff in 2014 assuming the responsability to organize residents and academic activities, continuing medical education courses and surgical activities in Endourology group. He was coordinator of Endourology & Stone Section of Brazilian Society of Urology between 2016/17 and organize hands on courses and lectures all over the country. Dr. Meller is well know in Brazil as a promoter of education and training in endourology technique.

 

Dr.  Bodo E. Knudsen

Bodo Knudsen, MD, FRCSC is the Director of the Comprehensive Kidney Stone Program at the Ohio State University Wexner Center and holds the rank of Associate Professor with Tenure. He holds the Henry A. Wise II Endowed Chair in Urology and is currently the Vice Chair of Clinical Affairs within the Department of Urology. Dr. Knudsen completed his medical school at the University of Manitoba in 1997 and his residency in 2002. He then completed fellowship in Endourology under the supervision Drs. John Denstedt and Stephen Pautler at the University of Western Ontario in London, Ontario, Canada. Dr. Knudsen joined the Ohio State University in 2005 and has been on faculty since then. His clinical practice is primarily focused on stone disease. Dr. Knudsen is a member of the R.O.C.K. Society and the EDGE Research Consortium. Dr. Knudsen has published extensively in the field of Endourology but also strives to achieve appropriate work/life balance and has been proactive in physicians achieving overall well-being.

 

Webinar Transcript

Dr. Bodo Knudsen:

Welcome, everyone to this masterclass in Endourology today. We have a great set of talks coming up, talking about Fluoroscopy and PCNL access. This is truly an international day because we have one speaker, Dr. Nadya York, joining us from New Zealand. And then Dr. Alex Meller joining us from Brazil. I'm in Columbus, Ohio at The Ohio State University Medical Center. The Endourology Society and Society of Urologic Robotic Surgeons wish to thank Cook Medical for their generous grant and supporting this activity. It's with these types of grants that we're able to deliver this type of content to you.

Dr. Bodo Knudsen:

This is a CME accredited talk, so you will receive a survey from Michele Paoli and you will indicate on there which seminars you attended. This will get you a CME certificate. Please fill out the evaluation questionnaire at the end of the seminar as this is really helpful feedback to the Endo-society to help plan for future events. During the talks today, there is going to be a Q&A function to ask questions. And I'll be monitoring that as the moderator today. So please use that if you have questions as things go on. All the future webinars are listed on the endourology.org website. So visit that to see the schedule of events. We really encourage everyone who is not already a member of the Endo-society to join. The more members we have, the more we're able to develop and bring content like this to the membership. And it also really helps to understand sort of the demographics of having people around the world and what kind of content to deliver. So please join, it's really valuable and it will help the Endo society bring more great things to you.

Dr. Bodo Knudsen:

So let's talk a little bit about percutaneous access. So as we know there are many different ways to doing a PCNL, one can have a Radiologist or Urologist do the access. It can be done antegrade or even retrograde. There are different techniques for fluoro or ultrasound guidance. For fluoro, bull’s eye, triangulation, endo-guided have all been used. It can be done freehand or with a needle guide. And of course, it can be done prone or supine. So there are many different combinations. Today we're going to focus mainly on fluoroscopy and talk about triangulation and some differences with that technique. But we'll also touch on some of the other things and how they apply. One thing though, that I think is very important is that Urologists try and learn the skill themselves. Jim Watterson in a landmark study at the University of Ottawa showed that when a Urologist got access versus a Radiologist that the complications were significantly less when a Urologist did it, and the stone-free rates are better. It also gives you maximum flexibility and versatility in the OR.

Dr. Bodo Knudsen:

Just this morning, I had a case where a patient came in from an institution who had an F tube in and we took him to the OR for a PCNL only to discover that their neph-tube had fallen out, a very common scenario. So we were able to easily get access in the patient and still get him taken care of today. So this is a really important skill. And I'm really excited to have our speakers today talk about it for us. So Dr. Nadya York is going to start with a 20-minute talk on how she does it. And then Dr. Alex Meller is going to follow up with how he does it. And then we're going to have some time for discussion at the end. So welcome, Dr. York and it will be interesting to hear how you are doing things now.

Dr. Nadya York:

Yeah, hello everyone, all the way from Denham, New Zealand. It's very early morning. I'm just waiting for my slides to come up. It's never too early to talk about stones of course. And so I will be talking to you about triangulation, right. Okay. So, yes, so here I am down under New Zealand. And however, I have done… This is just a standard picture of New Zealand. I've done my fellowship in America, however, with Dr. Lingeman in Indiana and he taught me how to do percutaneous access myself and I usually do triangulation. Everything I talk about is listed in the Hinman's chapter and also an article that I'll show you at the end. And one of the journals describing how to perform triangulation.

Dr. Nadya York:

So officially, as you know, there are two types of access, bull’s eye or eye of the needle. In triangulation, the upside of the eye of the needle is that it's easier to learn. But there are some downsides, for one, you risk having your hands in the fluoroscopy field and there are some ways to get around it but it's inherent in the technique. You also have a very acute angle of access, which means it's more difficult to pass away into the collection system and the torque, which can increase the risk of bleeding. And of course, if there is a rib or organ in the way, you simply cannot do bull’s eye because it's in the way of the calyx that you want to access.

Dr. Nadya York:

So this is a video published by one of the organizations showing bull’s eye, and you can see the surgeon's hands in the field and it's just not acceptable to have this much radiation close to your hands. So, the other way to go about this, of course, is triangulation. This is what I was saying about the acute angle of access with a bull's eye. By definition, you have almost a 90-degree angle to get into the main collection system. While with triangulation you can have a more gradual path that makes it easier for you to pass wires. So the upsides of triangulation is that it keeps your hands out of the field. It's a straight shot to the renal pelvis, as I've explained. And it also allows your flexibility to access any calyx you want from any point in the skin. The ultimate flexibility. The downside, of course, it's difficult to learn because you must center in two planes.

Dr. Nadya York:

Now, this is the kind of thing that puts people off triangulation, you'll be pleased to know I don't even know what this slide is talking about. You do not need to understand this to be able to do a triangulation. I like to keep it more simple. So three steps to it. The first one is choosing the calyx of access. This is not unique to triangulation. The second one is tilting your C-arm away to protect your hands. And then the third part is doing the actual triangulation which is in two planes as I've mentioned, the AP plane and the oblique plane. So select an access calyx, which is not unique triangulation. It depends on the stone location and stone burden. Obviously, there are ribs or other organs in the way that will influence the path you take.

Dr. Nadya York:

Generally lower pole is preferred. But ultimately you want to maximize stone removal with a rigid nephroscope because it's going to give you the fastest stone clearance possible. And the rule that Dr. Lingeman taught me is that rigid is better than flexible, so as much as you can, try to do it with a rigid nephroscope. For example, for a local stone like this, local access would be suitable. And a very general place to start where you place your clamp is about two fingers below the 12 strip and medial to the 12 strip. That's where I put my clamp and then I take a clearer shot and see where the calyx actually is and then I move my clamp accordingly. But that's a very general area.

Dr. Nadya York:

If you have an upper bowel stone, you have three choices you can do infracostal puncture aiming from below, but it does not give you access to the rest of the kidney. You can do intercostal puncture, or you can do super costal. This is one of the advantages of doing prone PCNL, if you do this very medial puncture that you can see goes medially to laterally, It gives you very nice access to the entire collective system, makes it easy to pass wire down the ureter, and gives you a really good clearance. So here it is live, this is the upper bowel calyx. See how medial it is, so you can only do this in prone. And you're aiming literally into the main collection system. So you're almost at the paraspinal muscle. This is a patient of mine that did a bilateral simultaneous PCNL and on the left side, the bilateral nephroscope was able to clear all of the stones with one upper pole access mostly with rigid and a little bit of flexible nephroscope. And afterward, he looked like this.

Dr. Nadya York:

So upper pole access is for prone position in the medial at the edge of the paraspinal muscles either below the [inaudible 00:09:34] or above if necessary. The next part is selecting your access calyx. So the next part sorry, we had talked about selecting access calyx. The next part is tilting your C-arm away to protect your hands. So I'll show you a video of this. This is simply to avoid having your hands in the view. So, if you're doing a low pole access you tilt the C-arm away towards the head of the patient. These videos are from Dr. Lingeman.

Dr. Nadya York:

And if you're doing an upper pole access, then you tilt the C-arm towards the patient's feet. And that's purely to keep your hands protected. And then you do the triangulation. This is what you've come here for. And you do it in two planes: AP plane and oblique plane. You want to localize calyx of puncture into planes. For the AP plane, this is really important to understand, the AP is in relationship to the needle only, it's not related to the patient, it's not related to the table, it's not related to the level of the theater floor, it's purely in relationship to the needle.

Dr. Nadya York:

So and then oblique is 15 to 20 degrees from that AP point. So you can swing the oblique view either way, either towards you or away from you depend on how literal you are already. So AP plane, and then the other important point about triangulation, the AP plane, which as I said, is in line with a needle where it punctures the skin. In that plane, you need to adjust left and right. So you can see the needle and this is the fluoroscopy views going in line with it. And in that plane you're just left to right, so I'll show you a video. Here you can see needle being adjusted to lateral, to medial, and just right by aiming for that lower pole calyx.

Dr. Nadya York:

And here is a video. You can see the surgeon's hands moving left and right. So it's very important when you're in that AP plane which is perpendicular to the skin at the point that the needle is entering the skin that you move your hands only left and right and not in any other direction. And then the oblique plane is 15 to 20 degrees of that, it does have to be 30, just 15 to 20, and in that plane you're just up and down. Okay, so your hands are moving up and down like this. And again in that plane, you're only moving up and down. So again, this is our calyx of entry too high to low and just right.

Dr. Nadya York:

And again the video. So you can see their hands are moving up and down to aim for that lower pole calyx. Okay, so AP left and right, oblique up and down. That's all you need to remember about triangulation. You can see the C-arm going into the position. Now it's really important to have your own fluoroscopy pedal, I think to try and do that with a radiographer controlling the C-arm would be too difficult because you're moving a lot and you're moving quickly and also the patient's breath is suspended. So please arrange to have your own fluoroscopy control. In my hospital I had to do a course to... before I'm allowed to do that. Again, you must only move in the two planes. So this is your AP plane movement, this is your oblique. You do not want to be drifting between the two and it's the most common mistake and that's why people struggle. Okay, so you want to pretend it's like a train track and you're only moving in two planes and you don't want to have any drifting.

Dr. Nadya York:

Tips and tricks to make it easier for you. So firstly, stabilize yourself. So have the table up really high and forearm resting on the patient, and remember railway tracks no drifting, that's the most common mistake. Otherwise, you end up chasing the targets like this. You want to have precise calyceal punctures so you must aim for the same part of the same calyx in two views, especially if it's quite a large related calyx, If you're aiming for different parts, it's not going to line up properly. And what you can do is press… live Fluoro is you spin the C-arm between the AP and the oblique and then you can see that you are in the same part of the calyx to check. And you only adjust in one plane at the time. Like I said, this is also very important. So if you're an AP, you're just left to right. If you're an oblique you go up and down only.And then every time you adjust it, you must then check the position in the other plane and if you need to move it in the other plane, you then need to check back in the first plane that it's still okay. So that's again really important, a really common mistake. You cannot adjust once you got into the kidney because you then truly have the situation but the kidney most of us use we need to pull the needle back and then go in.

Dr. Nadya York:

Each time you adjust position you need to check another view. I know I'm repeating myself but this is really important for success. Usually what I do is advance the centimeter under the skin, line it up in both views, then go halfway down, line up in both views and then go directly into the kidney. And the movements you should be quite quick so that you don't… so the kidney doesn't move as much. And I usually ask the anesthetist to suspend respiration and aspiration to pull lungs away, and also to stop the movement because why would you want to have a moving target when you can have a still target. It's for a short time until the wire is in the calyx.

Dr. Nadya York:

And then usually I have a urinary catheter from below with diluted contrast and sometimes methylene blue, and so I use extension tubing to expurgate, to check I'm in the kidney, and then I pass the wire. And if you do feel the stone you can go directly to the wire and try to get the wire as far into the collecting system as possible. So this is the important slide. This is what you need to remember, AP again perpendicular to the skin at the point that the needle is going in, it's… And you move only left and right and oblique you move up and down and it's 15 to 20 degrees.

Dr. Nadya York:

Now, this is a slightly older version of my slides, but I'll just skip through to show you the things I use. 18-gauge diamond-tipped needle, extension tubing [inaudible 00:15:21] catheter which I take to patient's side and then once the patient is prone, I make a small hole in the drape and clean it and have extension tubing so its easy to control myself. Zip wire that I angle the tip, bend the tip and then flush it and then use it that allows it… [inaudible 00:15:37] resistance and frictionless allows you to get into the collecting system easily. I use a cobra, what's called a cobra angiography catheter to negotiate my wire as far into the collecting system as I can, ideally down the ureter obviously, as soon as possible. If I can't get it down the ureter straightaway, then as soon as I can. Once I'm in the kidney, the first approach is to get a wire down the ureter that allows for much more secure access. That should also be your first priority.

Dr. Nadya York:

This is a video of a Cobra, again from Dr. Lingeman. You can see the cobra catheter moving and feeding the wire down the ureter. So this is what you want to see. This is when I can relax. I would implore you to try and do that as much as you can, don't pass it below the VUJ or UVJ to reduce edema. So just so [inaudible 00:16:26] It does not need to be in the bladder.

Dr. Nadya York:

The other really useful device, unfortunately only Boston make it at the moment, but this is a really handy 8/10 dilator. So use a long 8-dilator to spread it over the wire, over a super-stiff wire. And then I put the 10 in and take the eight out and that allows you to add a second wire very easily. So then you have two wires down the ureter, you are very secure, you will not lose access. It's a really handy device. And this part once you put the 8 down, you don't need to use fluoroscopy to put it in. And then you can do the PCNL itself.

Dr. Nadya York:

Okay, now the other two things to quickly mention. One is, as you may know, at least in a quarter of the cases, the preoperative urine in the bladder does not match with the culture that grows from the stone as you know, sepsis Is a significant risk with PCNL. So I always do a stone culture, it's very easy to do. You just get a sterile grasp in the piece. As soon as you see a bit of stone, grab a sterile grasp that you haven't used, put it, grab a piece of the stone, put it in a sterile pot, crush it with the forceps, and then add a little bit of saline and send it to the lab. It allows you to know what stone culture bacteria are... and if the patient is septic in one or two days later you know exactly what to treat them with. Minimal effort really good routine. Make sure you warn the labs that you're doing it so they don't throw away stone culture by mistake like mine once did.

Dr. Nadya York:

And then at the end of the procedure, I always do what I call…what Dr. Lingeman used to call mappings, This is fluoroscopy but the same idea. If you do fluoroscopy this looks stone-free, right. But when you actually look with your eyes, there's actually a lot of stone and if you're going into the effort of doing PCNL on a patient and putting them through an operation, the least you can do is make sure that they really are stone free. So use a pressure irrigation bag, wide Amplatz sheath, and a flexible stethoscope which is easier to use fiber optics, so you can switch easily between the rigid nephroscope and the flexible. And I go around the collecting system with a little bit of dilute contrast injected and check that I have been everywhere and that there is no calyceal stones. And in the end, I put a 10 French nephrostomy.

Dr. Nadya York:

And if I am planning to come back, another really useful tip is to put a five French uretic catheter down the ureter… halfway down the ureter, the patients do not notice it but it allows you very secure access and when you come back you simply throw a wire down that five French, you use the 8/10 dilator that I've shown you to add a second why and then you're in kidney in seconds with secure access down the ureter. And I do sit till the next day. And the methylene blue nephrostogram. I'm just mindful of time… that allows you to[inaudible 00:19:08] without taking them to fluoroscopy. Everything I've talked about is in this chapter 131 in Hinman's and also this article here. There are two videos that I have put on YouTube with techniques on PCNL. If you want to check it out, just Google my name using NadyaYoko one word until you find it. Thank you very much.

Dr. Bodo Knudsen:

Thank you. While we're bringing up Dr. Meller's slides, there was one question that came in during your talk. And I'll just read, it said what if the spine is in a horizontal position and you want to triangulate. What would be the movement of your hand?

Dr. Nadya York:

If the spine is horizontal, see I do it prone. So its… I don't quite understand what you mean.

Dr. Bodo Knudsen:

I guess maybe they are thinking the way the C-arm image is positioned, either the spine across the top of the screen versus being up and down.

Dr. Nadya York:

I see Well, if it's just a fluoroscopy image, then you just ask the radiographer to rotate it. So it's vertical. That's easy to do. Yeah.

Dr. Bodo Knudsen:

That's kind of what I was thinking. I think the easiest is if you're not in the plane you want to be you can rotate your C-arm image rather than just leave it like that. With the spine across the top as well because your hands move in the same plane. I think we can move forward with Dr. Meller's talk.

Dr. Alex Meller:

Hello, everyone. First I'd like to thank Dr.[inaudible 00:20:39] all in neurological society. To be part of this masterclass edition, it's a pleasure to be here and my talk will be about how I do fluoroscopy access during the work. So let's start. This is my disclosures. And first we talk a little bit about the position prone versus supine. In the past three years, I'm moving for supine position. So I was training in prone. And now I have experienced the Disney World which is supine. In this table, I put my opinion about the two positions. When you talk about technical difficulty, it depends on your surgeon experience, if you were training on prone, probably will be better in prone to puncture. When I have a complex case I prefer to do in prone. If I have a more simple case I'm trying to move to supine which I think it's an easier position to have in the OR.

Dr. Alex Meller:

When you talk about irrigation pressure in supine, you have a lower irrigation pressure. But on the other hand navigation would be worse because you don't have the [inaudible 00:21:51]. So for the beginners sometimes its difficult to navigate. The fragment drainage is bearing supine is almost automatically and you can have vacuum cleaner effect in both positions, in even ECIRS. Remembering that ECIRS make prone positions more complex, you must have sometimes a specific table for that. So it's easier to do in supine. This is our regular distribution now all our equipments you can see here the video, you can see... Let me put that presentation here. You can see here the video, you can see CR, the ultra sound equipment, and [inaudible 00:22:33].

Dr. Alex Meller:

First, we're going to choose the right calyx the target one, I always asked to the residents to show us the images in three different fields, actual coronal and sagittal. To pre-plan which tract we're going to do. and one other trick is to put the CT images in one window where you have lower brightness, and you can see specific the stone size. And it's important to have those images readily available in the OR when you have some doubts during the puncture. These slides are only for remembering the anatomy, you can see the kidney the ratio with the other organs in the vascularization especially the arteries in the kidney, when you see the posterior phase of the kidney is less [inaudible 00:23:28] And it's the preferable way to go is posterior.

Dr. Alex Meller:

And when you do the posterior puncture, the alignment with the axis is better, so it's easier to put the guidewire inside the return to move forward to return. It's different when you do an interior puncture, we probably will have difficulty to pass the guidewire for the return. So, we prefer always to posterior.

Dr. Alex Meller:

When you see those images from Sampaio's work, a well-known Brazilian that studied the anatomy of vessels in the kidney. You can see the posterior plane of the kidney is less, you have less arteries in the papilar especially in the tip is the place where you have less chance of puncturing a vessel. So this is an established concept always try to do the posterior and papilar tip access. But in recent years, Dr. Evangelos discussed this established concept in a paper recently published, where he did some punctures in pelvis in compared to another group where they do a regular puncture. And the more important thing which he had was the time saving which was only nine minutes. I don't know if it's too much important and he couldn't find any difference in bleeding or transfusion. But he did evaluate the transfer rate and he did it in small groups. So I think we need more evidence and more papers to discuss or to challenge these established concepts.

Dr. Alex Meller:

In how to choose the calyx when you are starting the case, and you only have the [inaudible 00:25:14]. Our colleague from Harvard, Dr. Brian Eisner published a long time ago a simple trick to find it. If you have a lower pole to calyx like this one, in 93% of the cases, the latter one will be the posterior one. And if you have a three calyx lower pole like this, the one in the middle will be 70% the posterior calyx. So you can use this trick, this orientation to find your right calyx.

Dr. Alex Meller:

Then, when you are choosing the calyx, try to puncture the calyx with stones. Try to establish a straight path to the highest volume, try to posterior access. If possible, choose the dilated calyx and choose a lower pole calyx as I had said. Okay, let's start the puncture. First, we draw the landmarks to know where's the rib is, the belt bone. And I will discuss the two biplanar techniques that Dr. York already said. We are discussing biplanar technique in prone, the bull's eye and the triangulation.

Dr. Alex Meller:

And let's start with Bullseye technique. The bull's eye technique has a problem, your hand could keep receiving a lot of radiation. But I will try to describe it step by step. First, you're going to establish your skin puncture site with the C-arm in zero degrees. You put the C-arm zero degree, find your target calyx and mark your first landmark here. Second, you rotate the C-arm 30 degrees toward the surgeon and establish your second point which will be the point where you put the needle into the puncture. To establish your depth of puncture, you move the rotated C-arm again to the other side away from surgeon to 15 to 20 degrees. And you can see the depth of the puncture you are doing. So hold your needle, when you're in this position, probably you're gonna see a dot which is the bull's eye, and advance your needle into the depth you imagine you are right. And then tilt your C-arm a little bit and see if you are in the right place.

Dr. Alex Meller:

And now we are going to discuss the other technique. I was trained in this techniques, so I will describe this technique showing one case that we did last month. So let's see some videos in a step by step function. First, we always use the ultrasound to find a safety window. So we use the ultrasound not to puncture exactly, but to find a place where you can do a puncture without accident, without any organ in the way. So we draw a safety window to establish our skin puncture. Pay attention to have a laser guide C-arm here. I will discuss a little bit about it after how to minimize radiation.

Dr. Alex Meller:

This is the first image you have without contrast. You can see the stone in the ethereal catheter. Put your C-arm in zero degree and try to put your needle aligned with the infundibula axis in the point your needle will be in the target calyx that you chose previously. So you're going to move your CPR needle a few centimeters away, respecting the safety window in which you do the triangulation. You try to find your right angle here and start your puncture inside the safety window. This is a video during the puncture. So there are important tricks here. When you are advancing your needle, try to move it aligned with different infundibular axis. Don't move around, don't do a lot of movements. So try to establish a direct path to your target calyx. It's common when you have residents starting their learning curves that they move the needle a lot and this could angle your tract, it could angle your wire. So it will be difficult to do the dilation after.

Dr. Alex Meller:

Now there is another video. The next step would be to rotate your C-arm, tilt to the head of the patient to establish if your angle was right and to find your correct depth. As you can see here, the needle is at the right aspect of the third calyx. if you see this probably you are... sorry. You are too deep too interior in the patient in prone. So you must adjust the needle more superficially. If you have the needle in the left aspect of the target calyx, probably you are too posterior or too superficial.

Dr. Alex Meller:

And remember, if you are doing a lower prone puncture as I did in this case, you're going to tilt the C-arm to the head. But if you are doing an upper pole puncture, you're going to tilt the C-arm to the foot and the parameters here are the opposite of what I said.

Dr. Alex Meller:

This next video, we'll adjust our angle, our depth. Its important now that you only move your needle in one plane, which you will be in this case anterior-posterior plane. Don't move the needle again to lateral and medial plane, and then try to establish the same line that you did in the first puncture. Now you see, I prefer to do it in with the C-arm in zero degree, I just adjust the needle superficially, and I think I have the correct function. Next step would be to check it with the C-arm 30 degrees. You can see here that you are in the right target calyx. And you must see urine coming out from your needle. One tip here is to inject some saline in the urethral catheter to have more pressure. And you can see easier if you are in the right place. As Dr. York said, collect some urine sample for the cultures after.

Dr. Alex Meller:

And now let's move on to the dilation part. First, we're going to pass the guidewire. There are some important tricks here. As you see in the videos, I'm moving back and forth the guidewire inside the needle. Usually, I hold the needle out of the tip in this place. And I move the needle with the guidewire to find the especially the correct path to put the guidewire inside the ureter. Our goal is always put the guidewire inside the ureter and pay attention. If you are moving back and forth the guidewire, you could damage the guidewire inside the tip of the needle So don't pull in, don't push too forcefully. Be smooth when you are moving the guidewire inside the needed to not damage it. After the guide wire is. The next move will be to dilate. The first dilation I use a 10 French dilator which are thin and you don't have to worry about it damaging the pelvic system inside, just put it to the first dilation.

Dr. Alex Meller:

After that, we're going to pass the guidewire protector. In this step you can move when you can advance the...charge with all those lights. In this moment, you can pass the guidewire protection into the ureter. It’s very thin, it won’t damage the infundibular and not the calyx.

Dr. Alex Meller:

And let's discuss about it a little bit about the one shot versus serial dilation. We all know that the unbox kit come with a lot of dilators in sequential mode, but quite long ago. The papers show that one shot could be a good choice. In this paper from CROES office, they try to find what factors are more important to have meaning and you can see that operative time, the stone load, and the shift size are the most important factors for bleeding. If you do a sequential dilation, probably you take more time and you can blead more. And in the same paper they found that the dilation method doesn't matter about bleeding. So my option, my choice is always do one shot or at least double shot dilation. As I'm going to show in the next slides.

Dr. Alex Meller:

In what my preference is about which dilators i use, balloon or fascial. I always talk to the residents if you have a patient with no scars, no previous surgery in your puncture was aligned, was a correct puncture, a straight puncture, you can use the balloon, which is faster. If you are planning to do multiple punctures, or if you are starting your learning curve, it's more easy to use the fascial dilators. Now you want to dilate with the third French dilator, it's a one-shot. The two tricks here are always rotate your wrist to do a smooth dilation, and take care not to advance to much in the kidney, because the tip of the dilator could damage the infundibular and it will produce bleeding during your dilation, during your surgery. So we stay at the tip of the papilla when you are passing through the first dilator.

Dr. Alex Meller:

And now, the last step, we are going to put them Amplatz sheath. The two tricks here are with your non-dominant hand, hold firmly your dilator, your 30 French dilator to avoid it goes inside the kidney and damage the infundibular here. And leave the emperor shifts exactly at the tip of the dilator, not to advance too much and to damage the system inside.

Dr. Alex Meller:

And now we are in you can see that was a successful puncture, the stone is there, no much bleeding, and you can start the case and start to fragment the case. And finally, we're going to discuss two or three points about how to minimize radiation. This paper published from Dr. Baldwin and his group gives some tips about how to minimize radiation. In the left image, In the picture here you see a laser guide CR where they mark where is the bladder, where is the kidney. So you can move between these two positions without activating the paddle. The majority of equipments of radiation are presetting in continuous fluoroscopy mode, and we don't need this to refine image. So you can use the posted one with one pulse per second, two pulse per second could work. So ask your technician to change these parameters before you start the surgery. So the tips are use a laser-guided C-arm to move your C-arm without activated pedal. The foot pedal as Dr. York said, it's important to be with the primary surgeon because he will really activate only when is necessary.

Dr. Alex Meller:

Pulsed fluoroscopic versus continuous is better. And this is another tip that is not in the paper. But I use this way of doing. When you did the puncture, the puncture is correct. During the dilation process, you can use a low dose protocol in your equipment, you can adjust it to half a dose, to quarter a dose and the the only thing is the image will have some delay. So you activate the peddle, you have to wait a little bit to move your dilator because the image is not exactly real time. But you can do it without any problem. If you have a designated Fluoroscopy Technician will be better because he's used it with the back procedure. And if you are experienced, you can use some tactile maneuvers, especially when you are advancing guide wires, dilators, etc, to minimize your radiation.

Dr. Alex Meller:

Again, I will thank you in your society for this kind invitation. And I'm here for the question and answer part.

Dr. Bodo Knudsen:

Great. Thank you, Dr. Meller. That was great. There were a few questions that came in. So while we're pulling up the discussion slides, maybe we can go through them. And both of you certainly can answer them. One of the questions that came in is what if you're dealing with a hypermobile kidney? When you're doing your puncture? Are there any tricks? You do to help with that?

Dr. Nadya York:

I can answer that. Yeah, so yes some kidneys are more mobile often in patients who have a large BMI. The key is to move quickly. So I line up with the skin and then you move really quickly and you almost overpass the needle and then you can come back because the worst thing you can do is slowly move and then the kidney is moving away and you're chasing it halfway across the patient. So the quick movement is really key for everything. For passing the needle and then for passing the dilators.

Dr. Alex Meller:

Yeah, I use the same trick. I think after you puncture the kidney start to fix more and you can dilate it with no problem. The thing is the first puncture, I did a really quick move to puncture Yeah.

Dr. Nadya York:

And then get the wire down the ureter as quickly as you can. As much into the kidney as you can and then down the ureter as quickly as you can.

Dr. Bodo Knudsen:

Some very thin females, I've had some kidneys had been extremely mobile. I had one some years back that we really struggled with. So we ultimately dealt with it by doing a retrograde puncture. So we ended up bringing the needle out from the kidney itself. And that's solved the issue. So it's not a technique that's used a lot anymore. I think Cook still makes the kit, the Lawson kit for retrograde punctures, but it's a good trick to have in your back pocket if you have a really difficult case.

Dr. Alex Meller:

In this situation I tried once when I was in supine, I asked for my assistant to just push the abdominal part and try to start some force there to stable the kidney. Yeah, never published, but I think could work too. Yeah, if you quite a thin patient.

Dr. Nadya York:

And also the upper pole, of course, upper pole access is going to move less. So if you can do upper pole then it's going to be easier. [inaudible 00:41:18].

Dr. Bodo Knudsen:

This one is made for Dr. Miller. Question, why not use an alkane dilator first when doing a single puncture with I guess a one-step dilation with a 30 French dilator. So why not use an alkane dilator first?

Dr. Alex Meller:

Oh, good question in our university we have an alkane dilator because it's cheaper. But here in Brazil, we don't have alkane dilators in all hospitals, I did this case in private hospital in [inaudible 00:41:52], they don't just don't have it. I'm just a little bit worried about Alkine because it's so hard and if you don't hold firmly, the long needle you could damage the system inside. So when I train new residents with the Alkine, I always tell them to hold firmly because the movement could damage the kidney inside the system but you know you can use if you have it in your service. It's cheaper. It's reusable so I like it but take care with the movement.

Dr. Nadya York:

Just one tip. Dr Meller, when you use multiple puncture with balloon I just thought that you can use balloon with multiple punctures. I just use a 12 delay to boost and then you reform the balloon by putting the plastic sheath that comes in back over so you can reuse it you just need to put a 12 inch in first. Dr Meller by the time the metal dilators came out you knew it was going to be a bad case.

Dr. Alex Meller:

You know, I try several times to put the balloon inside the sheath, its not an easy tasks. [crosstalk 00:42:59]

Dr. Bodo Knudsen:

Any tricks to approaching a stone in an anterior calyx.

Dr. Alex Meller:

Do you have any comment?

Dr. Nadya York:

Look, this whole anterior posterior calyx I feel like I'm not following the line. I just, I just kind of go for the stone. So I just find the stone and I puncture onto the stone. So this anterior posterior thing I'm kind of disregards. May be able I will run into trouble with it. But I just aim for the stone and access the stone directly. So I don't really pay too much attention to what's anterior and what's posterior.

Dr. Alex Meller:

Yeah, in my experience the interior puncture is quite challenging. Sometimes you can put the guide wire, you use guide wire during dilation. So we tried to puncture posterior and try to go to the anterior calyx where you have this stone. If you have the flexible ureteroscopy, you got you could put the flexible inside the kidney move the stone if it's possible, but it's challenging to puncture anterior calyx. I have bad stories on that, bad cases.

Dr. Bodo Knudsen:

One thing I'd add and I do most of my percutaneous supine, and with supine, your track tends to be more lateral, so puncturing into an anterior calyx supine, I think sometimes it's easier, just because of the line of the access. But always carefully look at your preoperative CT, because sometimes you can function into the poster calyx and then still easily move into the anterior one to get the stone depending on the angle, especially if the systems a little bit dilated. And with smaller nephroscopes they're very maneuverable. So often, you can still turn that corner, but you have to... every kidneys is a little bit different. So you really have to study your anatomy ahead of time and come up sometimes with creative solutions, how to move around in the kidney?

Dr. Alex Meller:

Sure, yes.

Dr. Bodo Knudsen:

All right, I'm gonna go through a few of our discussion slides, because some of the questions that have come in are actually some things that are on our slides. So let's talk a little bit about a few other points while we have some time yet. So this is an area that can cause some challenges, because if you don't have the right table for PCNL, it can make the case difficult. This was a paper we had published in 2009, when I was doing primarily prone PCNL's at that point, and we were using a split leg position. And we had worked with a company to come up with a table that was carbon fiber, so it had no metal on the sides, which was important because we were doing mainly fluoro at the time to get the metal out of the view. And then the split leg position was nice, because we would just position the patient once and had access from above and below during the case very easily. Interested to hear from our speakers today, what tips and tricks they have in terms of what tables they're using in the OR.

Dr. Alex Meller:

We don't have a specific table for prone plates. So we use the regular one. And we must... when you're doing prone, we have to move the patient from the table to another table, to change the position, to flip the patient over. So we don't have this kind of situation. And for us in Brazil it's not common to have a flexible stethoscope available. So it's hard to put the...for example, the ureteral catheter with the patient flipped. So first we need to move the patient.

Dr. Nadya York:

Yeah, this is a kind of Royce Rolls of tables that I can only dream of here in New Zealand at the moment.

Dr. Alex Meller:

I think that the most important advantage is the supine position. We are doing supine in our university. Almost 40% of the cases now in supine, and we use Bart's franc free position, he nn it's much easier to position the patient, the first year resident could position the patient correctly. So I think this is one of the biggest advantage in the supine position for sure.

Dr. Bodo Knudsen:

Yeah, and I think that brings us to our next topic ECIRS, Endoscopic Combined Intrarenal Surgery. So the ability to access the kidney from above and below and this picture actually here where we are actually treating the other side at the same time. So we're doing a PCNL on one side and then on the other side, two of the residents are doing ureteroscopy. But really the idea with ECIRS is to be able to pass a flexible reader scope up, this becomes pretty important when you start doing a lot more mini perks, because with mini-packs it becomes difficult to go in with your flexible nephroscope.

Dr. Bodo Knudsen:

So like Dr. York showed mapping the kidneys is very important. But some of the flexible system scopes don't fit well through the mini tracks. And if they do fit, you get very little outflows. So then you start to worry about pressures. So going up with a reader scope from below, is a really great way to kind of get around this, but does require you to have a skilled assistant, which not everybody has. So that's kind of a tradeoff. So being in an academic institution, we work with a great group of residents, and they're able to help with all of these procedures. Any thoughts from you guys on ECIRS? And how it potentially fits into your practices and maybe the role in the future?

Dr. Alex Meller:

York, please.

Dr. Nadya York:

Yeah, look, I can't do that at the moment, because of the prone table situation. I mean, the idea does make sense and there are some calyxes that you can't quite access with a flexible stethoscope from above. And then if you could do it from below and move the stone that would be very handy. Of course, because you can do bilateral PCNL in prone but you can't do in supine. But would be very tempting for some cases.

Dr. Alex Meller:

We've been doing in our university, the problem there is the disposable devices. So we try to minimize disposable devices, we are doing the flexible part without access sheaths, I don't know if you use both access sheets during the service, where they use the free scope, we put up the free scope. And the other point is, in the beginning, we had hard times to position the video equipments, because you have to have a very big war. To put the equipment in, we have two towers, two teams. So now we have we just brought from this other operating room a small video then we can position to do the flex part and the tower for the guys in the poor procedure.

Dr. Alex Meller:

But I think we lack some papers evaluating the stone free rate when you compared to the other procedures that but for mini packs for example, I think it's awesome if you have the this available. But I don't know your opinion. But I don't see a lot of papers, evaluating the real stone free with results. So I imagined that could be better than the stone free but I don't see a lot of people publishing it besides[inaudible 00:51:18].

Dr. Bodo Knudsen:

Yeah, so just answer your question on the access sheath, I don't tend to use an access sheet with it. And part of that is also related to our strategies in terms of standards and nephrostomy tubes after we're trying in the majority of patients to not leave neph-tubes anymore, and we try and leave a stent on a string.

Dr. Nadya York:

With a string coming out of the plank?

Dr. Bodo Knudsen:

Out of the urethra.

Dr. Nadya York:

So you are approaching it from below

Dr. Bodo Knudsen:

So if I'm putting an access sheath up, I have some concerns about pulling that stent the next day. So usually if I use an excess sheath, I'll leave the stent in a little bit longer. So we don't use an extra sheets, we just look up with a scope. Where it's helpful is with mini PCNL one of the risks is you can get some small fragments washing down your order. And if you don't catch them, then you can end up with a situation where that patient runs into problems after. So it's nice to also be able to clear the ureter by pulling out the reader scope at the end of the case to make sure you didn't get any fragments that snuck away on Yeah, going down. And then if the order looks good, we feel comfortable leaving the stand on a string tape to the Foley and if the patient has a good night, we just pull everything first thing in the morning. And for us that's really helped facilitate early discharge because our goal is to try and get the patient out before 11am. So we're able to pull things make sure they have a good voiding trial after and then and then go home. But it's a lot of subtleties and a lot of variations on how to tackle things, but you have to kind of work within your system and see what works well for you.

Dr. Nadya York:

Yeah, I just wanted to say that. Yeah, that a nice technique. You can of course put the [inaudible 00:53:18] from the top down. So if you're not able to access from below, you can put certainly it's very easy to shoot some contrast down from the PJ and just make sure that that's rebound to the bladder. And if there's any question you can put your stethoscope from the top down, you can sometimes use a short access sheet if you've got quite a bit of stones. So you can put the [inaudible 00:53:35] excess sheet through your PCNL access sheet to guide it down the ureter easily.

Dr. Bodo Knudsen:

Maybe a couple of quick questions. Well, we have a few minutes that came up in the chat. One is I'm doing PCNL under spinal anesthesia. Any experience with that or tips and tricks with that.

Dr. Nadya York:

I remember Dr. Lindemann doing it on some really sick patients, but it was kind of last resort from memory.

Dr. Alex Meller:

No, I've done it

Dr. Bodo Knudsen:

I have done a handful, you can do it. But we still do the vast, vast majority into general.

Dr. Alex Meller:

Yeah, I never did it.

Dr. Bodo Knudsen:

Any tips if there's a retro renal colon?

Dr. Alex Meller:

Well, in this case, I think the ultra sound window, it's still available, you can find out, try to establish some area that is safe. And in I prefer to doing supine because some papers show that the column will be a little bit superficial, so you can’t find a track. But I think my tip would be use the user saw or asked for our youth resell guy to come to your ward and find a route for you, I think.

Dr. Nadya York:

Yeah, and also, obviously, upper pole access.

Dr. Bodo Knudsen:

Yeah, that's a that's a great tip. Because usually as you get to the lower pole, it becomes more of a problem. You know, today we talked mainly about fluoroscopy. But one of the things I would encourage everyone to do, if you have access to it, start looking at your kidneys with ultrasound, because you know, you are able to see the windows with it. And as you get more experience, you're going to become more comfortable. And it's a nice adjunct to have. So if you're comfortable with fluoroscopy, then starting to incorporate ultrasound is a great way to learn that and can help you, look for that. Key anatomy around the kidney.

Dr. Alex Meller:

Yeah, yeah. And once it you know, the anesthesiologist, team, they have this portable ones. So just ask them to borrow for you. And it's easier to use, not complicated. So it's a good tip.

Dr. Bodo Knudsen:

So I think that's all of our time. You know, I think we could have had another hour talking about this is a really exciting topic. But thanks, everyone, for joining us. Thanks to the speakers you did a fantastic job. And also thank you very much to cook for supporting this event today.

Dr. Bodo Knudsen:

You must get assets. The good news is hated here.