Faculty: Brian Eisner, Roger Sur & Fabio Vicenti

Moderator: Tom Chi


Dr. Brian Eisner

Dr. Brian Eisner is the Co-Director of the Kidney Stone Program at the MGH. He specializes in kidney stone surgery, kidney stone prevention and related research.

Dr. Roger L. Sur, MD

Founder and Director, Comprehensive Kidney Stone Center
Program Director, UC San Diego-Kaiser Endourology Fellowship
Professor of Urology

Roger Sur, MD, is a board-certified urologist and founder/director of the Comprehensive Kidney Stone Center at UC San Diego Health that focuses on surgical treatment, medical prevention and research into causes of kidney stones. He specializes in percutaneous nephrolithotomy using the latest minimally invasive techniques.

As a professor in the Department of Urology, Dr. Sur instructs medical students, residents and fellows at UC San Diego School of Medicine, where is also program director of the joint UC San Diego-Kaiser Endourology fellowship. He also works as a urologist at VA San Diego Healthcare System and as an associate professor of surgery at the Uniformed Services University of the Health Sciences, a military medical school.

Dr. Sur's research interests include antimicrobial use in kidney stone surgery, use of minimally invasive surgical techniques and minimizing use of radiation during surgery with the use of ultrasound imaging. His work has appeared in medical and research publications, including Journal of Urology and Journal of Endourology. He has published numerous manuscripts and book chapters.

Before joining UC San Diego Health in 2009, Dr. Sur served 21 years as a naval physician in numerous overseas deployments and retired with the rank of captain in U.S Navy Medical Corps. He completed an endourology fellowship at Duke University (North Carolina) and a residency in urology at Naval Medical Center San Diego. Dr. Sur earned his medical degree at Eastern Virginia Medical School.

Dr. Sur is a member of the American Urological Association and Endourology Society.

In 1997, during Dr. Sur’s residency at Naval Medical Center San Diego, he had a vision of creating a dedicated kidney stone center in San Diego. He wanted something that would be comprehensive — covering complex and routine surgery, training young surgeons, and performing research into the disease. More than 20 years later, he helps to deliver the best in kidney stone surgery and train both residents and fellows who will serve the same care to patients at UC San Diego.

Dr. Fabio Vicenti

MD and PhD in Urology

Head of Endourology Section - Brigadeiro Hospital

Associate at Clinics Hospital - University of Sao Paulo Medical School

Dr. Thomas Chi, MD

Dr. Thomas Chi, MD, is Professor and Vice Chair for Clinical Programs with the UCSF Department of Urology. He graduated as a President's Scholar from Stanford University with a BA in Human Biology and Masters degrees in both Sociology and Music. Dr. Chi earned his medical degree from the University of California, San Francisco School of Medicine then completed urology residency at UCSF followed by a fellowship in Endourology and Laparoscopy.

Dr. Chi has been awarded grant funding from the National Institutes of Health and the American Urological Association Urology Care Foundation to research the fundamental mechanisms underlying the formation of urinary stones. He is the 2020 recipient of the AUA Gold Cystoscope Award, which is presented annually to a urologist distinguished by outstanding contributions to the profession within ten years of completing residency training.

His clinical expertise focuses on the care of patients with urinary stone disease, benign prostatic hypertrophy (BPH) and those in need of minimally invasive surgery. He specializes in performing endoscopic, laparoscopic, and percutaneous stone surgeries. Dr. Chi has used ultrasound guidance to create innovative radiation-free kidney stone surgeries for stone removal, representing the first program of its kind in the United States. He is also experienced in performing Holmium Laser Enucleation of the Prostate (HoLEP) - a minimally invasive operation to treat men with an enlarged prostate. 

For more info: https://urology.ucsf.edu/people/thomas-chi

 

Webinar Transcript 

Dr. Winoker:

Welcome everyone or welcome back to the Endourological Society's Masterclass in Endourology webinar. Of course today we'd like to thank your friends over at Cook Medical for their support of this activity today. So, as you all know we're here for what should be a great discussion on Ultrasound Guided Access for the removal of kidney stones. We have a star studded faculty panel led by Dr. Tom Chi.

Dr. Winoker:

Very briefly, Dr. Chi is professor and Vice Chair for Clinical Programs with the UCSF Department of Urology. He's a distinguished thought leader in endourology for his outstanding contributions to our field. Including but certainly not limited to research on the causes of kidney stone disease as well as the innovation in search of surgical technic, of course most notably ultrasound guided access.

Dr. Winoker:

Of course for such contribution he was the 2020 recipient of the AUA Gold Cystoscope Award. Today's lecture is being recorded so feel free to look back at this slide, this is an overview of today's CME program. Without further ado I'll turn it over to Dr. Chi. I just want to make sure that everyone knows to be sure to use our Q&A function as our panelists will keep an eye on that and try and answer all of your questions. Thanks.

Dr. Tom Chi:

Thank you so much Dr. Winoker and thank you to the Endourology Society and the Society for Robotic Surgeons to really put together what I think is going to be a really enjoyable hour for everybody. So, I am Tom Chi I'm at the University of California San Francisco and we're here to talk about one of my favorite topics in the whole world, Ultrasound Guided PCNL.

Dr. Tom Chi:

So, I'll just give you a couple of minutes overview, so these are my disclosures, I do do a lot of consulting with a fair number of companies but hopefully try to be even in my attitudes. So, when we talk about ultrasound and we talk about PCNL that's kind of our area of topic here. We've always as a urology group being fluoro guided. So in the world when you look back 10, 15 years the people who were using ultrasound and publishing ultrasound maybe parts of China, India, middle east, little parts of Europe, not very much out there at all really.

Dr. Tom Chi:

But when you actually think about the number of people sticking a needle into a kidney in the world, most of them are interventional radiologists. I would argue that everybody on this webinar right now, and I'm not trying to knock interventional radiologists, but we are not worst proceduralists than interventional radiologists. So, if they can do it and they're doing a ton of these, I think we missed the boat.

Dr. Tom Chi:

That would be my argument for why I think there's something to ultrasound. So, when you actually think about the world, everybody is doing an ultrasound and I think that we've been lagging a little behind. I think that there are advantages and we're going to go through a lot of that today, with some distinguished panel members.

Dr. Tom Chi:

What's really fun is that we started doing this work with ultrasound I collaborated with some terrific people Jianxing Li, in Beijing, some of the folks of the world who are really are masters in ultrasound. Then started talking about okay how do we teach this and how do we bring this out? Back then when we started, there were maybe a dozen papers out there and I just PubMed'd this the other day, if you just type in Ultrasound-guided percutaneous nephrolithotomy 245 results.

Dr. Tom Chi:

So I think that you can see there's a lot of growing momentum, a lot of interest in ultrasound hopefully that's why we're all here to talk about it today. This is what it looks like, so an unedited video footage when I came back from seeing somebody do it elsewhere and thinking God I could never do that. Then just kind of learning by video.

Dr. Tom Chi:

What you're watching is an ultrasound with a needle coming in from the upper pole and then unedited you got urine coming out. So, that's how I think everybody on this webinar can get to that point and we're going to talk to some terrific experts to see how you get there.

Dr. Tom Chi:

A quick introduction for our panelists so we're going to start with Dr. Fabio Vicentini from Brazil, he is a wonderful innovator and always interested in pushing the boarders. So, always offer some really interesting ideas and is willing to kind of test out new stuff. He's going to be talking about how to do prone ultrasound guided access.

Dr. Tom Chi:

Dr. Brian Eisner from MGH at the Harvard University is an amazing person who does a lot of device development. Often times thinking of questions you think to yourself, that's a strange question and then months later you think wow that was a really good question. He's going to talk about supine and how we can do that in a supine position.

Dr. Tom Chi:

Then we're going to close it off with Dr. Roger Sur who's down at the University California San Diego where he's the director of their Comprehensive Kidney Stone Center. Really a truly wonderful human being and very thoughtful. He has been doing this for quite a while and he's going to offer some thoughts on well what was this journey like and how do you get there, to actually achieve things that you're going to see in these next few talks? So without further ado we're going to start off with Dr. Vicentini, the floor is yours.

Dr. Fabio Vicentini:

Thank you Tom, I'd like to thank the invitation to be here today. It's a pleasure to be here with Tom, Brian and Roger are good friends. Today we're going talk about ultrasound guided PNL in prone. These are my complex of interest. It's very interest regarding prone PCNL that the first case came from the 70s. But today the puncture is done by urologist in only 30% of the cases it's around the world. We need around 60 cases to achieve competence. I believe that prone PCNL is a difficult surgery to learn. Mainly because of the puncture.

Dr. Fabio Vicentini:

We have very good techniques, very established techniques. The bull's eye that is more common. We have also the triangulation that I admit it's not very easy to teach residents this. This is a good technique. The bull's eye we know exactly the direction of the needle. We just go down. But we don't how deep we have to go because the C-arm is not perpendicular to the needle. So we don't know exactly how much we have to insert the needle.

Dr. Fabio Vicentini:

So the good news is that ultrasound makes prone much easier because it gives us the depth. So if we use a hybrid technique fluoroscopy and ultrasound it will be much more easier to learn and to teach residents. The learning curve for experienced urologists falls down to 20 procedures around that. So, ultrasound makes them much easier.

Dr. Fabio Vicentini:

Learning ultrasound PCNL we don't have to be radiologists. We just have to know a little of POCUS, the Point of Care Ultrasound. We have to learn some theory the buttons how to manipulate the equipment. It's good to have some hands-on training. I recommended to do some observership, this was mine with Tom Chi. Then we can practice ultrasound using clinics and in our PCNL.

Dr. Fabio Vicentini:

Here if you have the equipment in your clinic you can use with outpatient. Here we can see a ureteral stone, a residents conforming the position of the stone. So we basically have to practice using ultrasound. Well what's the ideal case for starting using ultrasound PCNL? A thin patient BMI less than 30, with a moderate hydronephrosis this kind of kidney. It's important to have a good ultrasound equipment with a good vision. Always keep the fluoroscopy around you, on the first case, no doubt about that and then how use in all cases.

Dr. Fabio Vicentini:

The position is the same for a regular prone PCNL. The patient and the surgeon will be in the same position. Here comes some technical aspects for using the ultrasound. So the probe should be handled by the non dominant hand. The needle will be in the dominant hand to be more precise with the small movements. The ultrasound screen should stay in front of the surgeon so you don't have to make a large movement with your neck.

Dr. Fabio Vicentini:

There's some debate regarding if we should use a hands free technique or if should we use a needle technique. I really prefer to use the hands free technique because let me say the needle guide facilitates a little bit, the procedure. However most of the times we don't have the correct guide and every probe has its own guide and it's one more cost. So if we learn hands free, we don't have this cost and we can use any equipment, so I recommend to use the hands free technique.

Dr. Fabio Vicentini:

Other important technical aspect is how we use the needle related to the probe. We can use it out of the axis is in transverse position where the needle goes on the side of the probe or on the axis of the probe so as a longitudinal way. Most cases we do with this technique, with the needle on the axis of the probe because we can see the needle throughout the insertion. In this technique out of the axis we just see the point, the tip of the needle reaching the target. That's why I prefer and recommend to use on the axis of the probe in a longitudinal fashion.

Dr. Fabio Vicentini:

So, here's the patient's position. Here are some line marks that we don't actually have to do this because we are using ultrasound. But this is iliac crest the part of vertebral muscle and the ribs. Here we start doing a longitudinal view of the kidney in this position,[inaudible 00:10:39] just below the 12th rib. Here we can see a lower pole puncture, and here upper pole puncture always putting the needle on the axis of the probe.

Dr. Fabio Vicentini:

It's very important to practice hands free and in longitudinal needle position. This is a good model that we can use that. I had to do some training again because I am also a supine surgeon but I did a randomized study, so I had to train again how to do a prone PCNL. This model is in prone and here we can see very well the kidney the needle comes in and the needle is in a longitudinal position so it's very good to practice before you do a surgery.

Dr. Fabio Vicentini:

Here we can see the same video of Tom Chi it's publishing Urology. Take a look the left hand the non-dominant hand is still, what moves is the right hand with the needle and then we can see on the screen the needle comes in. Here we have the kidney, the stone, this is the target and here is the needle comes in pushing the stone and then you are sure that you are inside the kidney. So, I recommend using the longitudinal approach because we can see the trajectory of the needle all along the procedure.

Dr. Fabio Vicentini:

This video actually is in supine but I just want to show the position of how it's important to see the needle comes in. How precise is to know that we are inside the collecting system. Here we can see the top of the needle, there's no doubt that we are inside the kidney. This is a big advantage of the ultrasound, moreover we know it's a safe puncture because I know here is the column here is free I will not have any kind of lesion and the puncture makes much faster using ultrasound. Even for supine or for prone.

Dr. Fabio Vicentini:

So, after we have the puncture, the needle inside we can do the dilation. Here is a little bit difference because if you use a Amplatz dilator here we can see the image on the ultrasound and it's not very easy to see the Amplatz Sheath comes in with ultrasound. Here we have the inside view the endovision. If we have endovision it's much easier to make the dilation, so we don't have to use the fluoro. But if we don't have the endoscopic vision doing the dilation with Amplatz dilators only with ultrasound is a little bit difficult. So I recommend to use fluoroscopy see how I'm doing dilation.

Dr. Fabio Vicentini:

This case we are using the balloon and we have the fluoroscopy together. I know Tom Chi does all cases without fluoroscopy but in the beginning I think the fluoroscopy will have. Even the balloon the image is not so clear. So if you have the C-arm and make fast shots, you'll be much more confidence regarding the dilation, even with balloon or with the Amplatz shift.

Dr. Fabio Vicentini:

Next slide. So, after the correct position of the balloon we just insert the sheath until the tip of the balloon we see urine comes out, coming out. Okay we can use the ultrasound to check but the image is very different from the image that we have with fluoro. So the ultrasound to check the organs is very good to make the puncture is very good, to make the dilation we need much a large experience.

Dr. Fabio Vicentini:

So as conclusions, using ultrasound for prone PCNL is possible and I guarantee you it's very nice to learn. It really reduces radiation and makes the procedure safer and easier. For the initial cases I recommend to use it combined with fluoro, use the longitudinal technique using it with hands free in a thin patient, in a dilated kidney. Before doing a real surgery, training with phantom, training with clinic and then training using all PCNL. I'd like to thank again this invitation. Thank you very much.

Dr. Tom Chi:

Terrific talk as always Dr. Vicentini, really wonderful. We'll have a time for a discussion and please remember for all the audience members put your questions in the Q&A we will get to them as we go. We are delighted to have next, Brian Eisner from Boston where he's sitting on top of a glacier just right now so it's a little bit cold right there. Brian's going to walk us through kind of the ideas behinds supine PCNL and then we'll look forward to a great talk, thank you.

Dr. Brian Eisner:

So, thanks again for the Endo Society, I'm very grateful to be here. Thanks as well of course Tom and to our co-panelists. You know I'll say this, five years ago I had never done the supine PCNL and never done an ultrasound guided PCNL. So, I'd say certainly personally in my practice I've come a long way.

Dr. Brian Eisner:

I was racking my brain as to think what can I contribute in ultrasound when I'm sitting here next to Tom Chi, Fabio and Roger virtually. What I thought I might do is talk about this a little bit from the perspective of a beginner. Not a beginner in PCNL and not a beginner in supine PCNL but a beginner in ultrasound PCNL. So I don't think I'm a beginner anymore but I would like to share my journey.

Dr. Brian Eisner:

These are the disclosures of course. So, why do I like supine PCNL? So, I do think there's several advantages I don't want to make this a debate about supine but I do love the ability to do ECIRS, I think that facilitates things tremendously. As Fabio showed he often will include ECRIS into his ultrasound guide puncture. Again, I think that can provide an advantage.

Dr. Brian Eisner:

So I do love the idea of having the patient in the supine position you could place flexible ureteroscope, you can watch your instruments go in, you can watch your needle go in, you can perhaps see the ureteroscope and in order to puncture kind of close to it. Then I also do like the fact that you can stay in the lower pole for many of your punctures and perhaps get better access to the upper pole, this is a study from Mario Sofer's group as well as Guido Giusti and colleagues Silvia Proietti just showing that in the supine position perhaps a lower pole puncture makes it easier to get to the upper pole than prone.

Dr. Brian Eisner:

So you know this is sort of classic, you know Valdivia Galdakao position you see a saline bag under the flank, you see the flank kind of twisted up a little bit about 20 degrees. This is obviously fluoroscopically based. We've adopted in our practice, I know Fabio likes this too is we do what we call flank free position and so what you can see is the patients really aren't very far rotated, I can barely even fit my fist under the patient's flank. You see on the left is the anterior superior iliac spine, the posterior axillary line, those are my landmarks and that's sort of where my start my supine PCNL puncture.

Dr. Brian Eisner:

For the males, we leave their legs flat on the bed we use a flexible cystoscope to perform our retrograde access. My oncology colleagues call this a sloppy flank position. For the females we put them in stirrups just because for facilitation of retrograde access. That does seem to be a bit of an advantage for the females not as much for the males. Again you can see my landmarks are the ASIS and the posterior axillary line.

Dr. Brian Eisner:

So what are we here to discuss today? So I'm here to discuss a few things, ultrasound for planning for supine PCNL, that will the first step. Ultrasound for guidance for supine PCNL that will be the second step. Then incorporation for whatever percent you want. So the Tom Chi's of the world can use it for maybe close to 100% of their cases or somewhere close to there, for others this is maybe lower.

Dr. Brian Eisner:

But to me the key is to incorporate ultrasound and sort of take advantage of its advantages to leverage the advantage of ultrasound. Then of course how do I get started? How do I as an individual surgeon get started? So this is Abu Dhabi. I think the last time I may have actually seen many people on this conference face-to-face which is a bit sad you see in the background Tom's on the off far left, I'm right next to him.

Dr. Brian Eisner:

To be honest Tom really got at me quite a bit. So, what I'm going to say is here's how I started, I started performing diagnostic ultrasound for every single case. So even cases where I got rid of ultrasound for the puncture I still performed diagnostic ultrasound every case, got familiar with renal anatomy, took some cues from the ultrasound text, learned to identified the liver and spleen, sounds easy. Sometimes it is, sometime it isn't. Learned what the limitation of ultrasound.

Dr. Brian Eisner:

The next thing Tom taught me was when you feel comfortable spend two to five minutes at the beginning of each case trying ultrasound. Can't do it? No problem do the other stuff, right again I'm going to sort of credit Tom for that. As Fabio pointed out, you have the fluoroscope in the room right. The idea is to use each to compliment each other. So use fluoro to compliment ultrasound, and ultrasound to compliment fluoroscopy.

Dr. Brian Eisner:

Finally, I'm going to quote my buddy Tom Chi who says, if it doesn't look like the kidney don't stick a needle in it. While he might not have said those exact words to me at that dinner he certainly said that to me beforehand, that's important right? If you have any questions you can always fall back on what you know, but I do use ultrasound a lot to show what me what the kidney is and what it isn't and to guide my punctures.

Dr. Brian Eisner:

So, first I'm going to talk about kind of the more basic approach of just using ultrasound for planning okay? So what I did, like I said, I started using ultrasound for every single case. What I did was I would use ultrasound to identify the zone of safety. What I like to do is use the ultrasound, I find the kidney, I find the surrounding organs, so that's what you see on the left there, you see the liver, on the left hand side of the screen on the upper left. You see a rib and you see the kidney.

Dr. Brian Eisner:

Then what I do, is I do absolute best to manipulate the ultrasound so the only thing in the field of view is the kidney. I mark this on the skin, I call this the zone of safety. Because we know that if I puncture along that line and I puncture directly into the kidney under fluoro or ultrasound and there's no other organs in the way, I think it's really hard to hit an adjacent organ. So, that's how I tend to kind of start when doing a diagnostic ultrasound so that I can guide a fluoroscopic guided puncture.

Dr. Brian Eisner:

This is what it looks like. So, this is actually the same phantom model that Fabio uses although it's now in the supine position for the model. I do think there's two ways to think about this. I do like to puncture with the ultrasound in a longitudinal plane, I know Fabio likes the opposite. So I like the ultrasound longitudinal. What you see on the left is pure longitudinal. What I tend to do is on the right hand of the screen. I tilt the probe, just to be clear, the head is to the right of the phantom and the sort of torso is to the left or the buttocks is the left.

Dr. Brian Eisner:

What I do is I tend to rotate the ultrasound probe a little bit so it's in line with the way kidney is titled in the body. But this is how I start with the diagnostic ultrasonography before I'm going to do a puncture. Then here it is in real life. So, what you see here is on the left hand side I have the ultrasound here, the patient's in the supine flank free position. I find that zone of safety where I see nothing but the kidney. Then I mark that line with the ultrasound or where that ultrasound is.

Dr. Brian Eisner:

So I take that marketing pencil and I basically mark each end of the ultrasound, I pull the ultrasound away and I draw that line and that is where I start my puncture. Now again for me and I've talked about supine puncture fluoroscopically as well, but I like to do that puncture parallel to the floor, and that's why I set up ultrasound this way. There's a lot of ways to do supine puncture, but this is going to set you up for a puncture parallel to the floor.

Dr. Brian Eisner:

That's not mandatory for supine, but I do find it's the sort of easier way to learn. I think it's the easiest way to learn fluoro and the easiest way to learn ultrasound. So, I am setting up for a puncture that's parallel to the floor here. So, you see that I've drawn the line on the right hand picture and you see, I've actually achieved the puncture there. But you do see that that needle for what it's worth is right on that line and parallel to the floor.

Dr. Brian Eisner:

So, this is what it looks like I basically the needle comes in C-arm's a little bit rotated again I've already done that diagnostic ultrasound and I advance that needle. Again I'm using ultrasound here just for the planning and then I'm using fluoroscopy for the puncture. The final adjustments to judge the depth again in this type of puncture are also done with a fluoroscopy.

Dr. Brian Eisner:

So I rotate the C-arm cephalad towards the head, if the needle position doesn't change I know I'm in the right spot. If the needle moves cephalad it means that the puncture must be directed towards a more anterior angle. If it's caudad it means that the puncture should be directed toward a more posterior angle. So this is how I started, diagnostic for ultrasound for everybody, fluoro guided puncture, fluoro adjustments and then I did the dilation. So that's sort of the most basic way and I would encourage people to start that way who feel that they are beginners.

Dr. Brian Eisner:

Option number two of course is to sort of move the ultrasound guide for the entire puncture. Again this is more I think what Fabio was talking about and [inaudible 00:24:57] to the matter. I do want to say that again, to quote Tom, I do really focus on keeping my probe hand stable. So what I like to do is I like to find the perfect place with the ultrasound where I want to puncture. But then I keep my probe hand stable and I manipulate my needle hand so that I can get my needle into the view.

Dr. Brian Eisner:

Again in find the target with the ultrasound, I stabilize the probe and I move the needle. Here you can see even a pretty delicate calyx and I've kept my hand still and again you can see my needle coming in, coming in and a target to enter that calyx. So that is how I ted to do the ultrasound guided puncture. I have the probe, I find a perfect picture, I don't have the needle in my hand, until I find a picture with a probe then I get the needle and then I start kind of moving along.

Dr. Brian Eisner:

As Fabio pointed out there are several kind of positions for the needle, one would be caudal to the probe again here's the patient's buttocks if this wasn't the phantom, here would be the patient's head. One would be caudal, one be sort of anterior to the probe and one would be cephalad to the probe. It's interesting for us, I do find the needle guide is useful especially when you start. For me our needle guide as Fabio pointed out they're all different, for us the needle guide actually comes from the cephalad portion of the probe, it's the sort of only way we can get for the ultrasound device that we have. So I have learned to use the needle guide from the cephalad portion.

Dr. Brian Eisner:

When I do that I obviously come from this direction. When I actually do it freehand, I have a preference for sort of inferior to the probe caudal it just sort of makes more sense to me with my hand in this. So I've punctured both from this direction and from this direction. I do that some puncture anterior to the probe, but as Fabio points out you see a lot less of the needle that way, so I think that could be more of a challenge.

Dr. Brian Eisner:

But again you see I'm basically setting myself up for a puncture that's parallel to the floor, here at this phantom. Again there's no right answer right? Any sort of orientation where you get a good puncture I think works. So this is summary. If you lack experience, I would start by diagnostic. Make sure you could be a great diagnostic ultrasonographer.

Dr. Brian Eisner:

Again I would do it before every PCNL right it's free, the patient's asleep you got a few minutes you could take care of it. I would increase the use of ultrasound as you feel comfortable. Again for me, for supine ultrasound guided-access I do think the simplest plan for puncture that's parallel to the floor, I think you can get used to any needle position you want.

Dr. Brian Eisner:

Again our probe guy gives us cephalad, a puncture cephalad to the probe, when I'm freehanded it I usually do it caudad to the probe. I do think that the needle guide maybe helpful for early learners. I think the biggest challenge for early learners is there's a big anxiety about seeing that needle, especially because you can always see it on fluoroscopy. So one of the things I liked about using the probe guide to start, the needle guide to start was that I had a really easy time seeing the needle and then I can burry and start doing it freehand.

Dr. Brian Eisner:

Again thanks to the endo society and to Tom and to Fabio and Roger for participating and inviting me this is certainly a big thrill and I continue to learn from this great three giants in ultrasound guided PCNL. Thank you very much.

Dr. Tom Chi:

Terrific talk as always Brian and he's very humble. Brian's a truly talented and experienced PCNL, so it's great to hear your journey. Then we're going to close out the talks and then move towards the discussion afterwards but Dr. Roger Sur is going to be our closer today, providing the guiding words of experience and talking about kind of the journey through ultrasound. So, Roger the floor is yours.

Dr. Roger Sur:

Thank you Tom and thanks to the Endo Society to Brad and Brian who are running the education committee and Michele Paoli who without her none of this would happen truthfully. So I'm just going to briefly talk about my journey and how I came to incorporate ultrasound frequently now in my PCNL practice.

Dr. Roger Sur:

These are my disclosures. So, my interest in this really started somewhere around 2015 I would say. I don't know the exact reason why I wanted to do it, other than I had heard about it historically and it struck me like well people have done it in the past why are we not doing it now? I've asked around to some of the experts in the field and they had mentioned yeah they've done it, they can do it but that was about it. Couldn't seem to really get anyone to really teach me.

Dr. Roger Sur:

Then that year, I had a fellow who really liked to innovate and when I mentioned it to him he's like let's do it. So, we started kind of like all the other speakers have mentioned I think every one of them has said, just bring the ultrasound into the room you have nothing to lose by trying to look at the kidney. You're going to do a perk, anyway assuming you get your own access you're going to get your access with your fluoro but why not spend one or two minutes to look at the kidney and start getting used to it.

Dr. Roger Sur:

Like everything that we do, the more we do the more comfortable we become. Really our eyes become kind of trained to see things that, the first time perhaps we wouldn't see, we kind of get rid of ... We can kind of really focus and hone down on the kidney and not be distracted by all the things you see on the scree right? So, that was the beginning of my journey here and that's what I would do.

Dr. Roger Sur:

I would say even if you don't get your own access, bring the ultrasound in. I mean you're going to dilate up, why not before you dilate up, take a look at the kidney, with the ultrasound. So, for me I'm not a pure ultrasound person only I use it as an adjunct. I think one of our other speakers had talked about it as well. I use it just to get the access and then I combine it with fluoroscopy to complete the procedure. I don't know I guess I could migrate to a pure ultrasound technique.

Dr. Roger Sur:

One of my challenges in my mind is that I do work with trainees and I worry that this won't translate over to their practice. In my mind I'm like I'm just hoping that they're going to continue to do this. So, that's why in my mind I do a combination, it's not a whole lot of fluoroscopy to be truth to you at the end of the day, but that's just kind of my take on it. I think obviously if you do a lot of it and particularly if you're not working with trainees, why not do pure ultrasound for everything if you can get that comfort level, I see no downside to that.

Dr. Roger Sur:

This actually was a looking at the fluoroscopy times. So what you can see here is when I was doing access just without ultrasound I was doing about 66 seconds here, dilating about 87 seconds in total on average about 146 seconds. Then when I used in combination with ultrasound you can see a dramatic drop in the fluoroscopy times. So, obviously the obvious benefit of incorporating ultrasound for not only the patient but for yourself as well on all your staff.

Dr. Roger Sur:

I will make the comment here, there is prior literature, particular the Duke group has looked at for current stone formers, they can get a pretty high amount of fluoroscopy. So, I guess we really shouldn't trivialize it, particular for recurrent stone formers. They may even exceed what is acceptable for those in the radiation industry the 20 millisieverts per year.

Dr. Roger Sur:

So, there's been a couple of questions here and I'm not going to go through all this but the point is, I early on my experience I think this is probably the best thing I did. I actually went down to radiology and I asked a technician, can I just coat tail you and just learn from you and show me the buttons? She just took me through like five things that I needed to know. Frequency, depth, focus, gain, time gain, compensation and dynamic range.

Dr. Roger Sur:

Then she had patients there and she let me just kind of be like a medical student, it was awesome actually I'll never forget it. It was priceless just spending that morning with her and her taking me through all the stuff that she does every day. I think there's a lot of benefit if you can find someone to help you take you through it, it's fun learning actually obviously.

Dr. Roger Sur:

Prone, versus supine. I have to admit, I do both of them with the ultrasound but I find the supine a lot more easy to see the kidneys. So, if you're struggling to see the kidney I'd be an advocate of the supine approach. I don't know exactly why that it, my gestalt is that the obliques external internal and transversalis muscles they're probably thinner in comparison to the paraspinal muscles. So maybe that's what explains why it's easier to see.

Dr. Roger Sur:

To that point, all my cases, all my perks, I always do an ultrasound in the clinic on the pre-op visit right before I'm going to take them to the OR because I want to know can I see the kidney? Because if I can't see the kidney, I don't have Brian's skillset on doing supine access. If I'm having them in the supine position I have to do ultrasound-guided access. So in that case I have to confirm, before the surgery that I can see the kidney's. So that gives me kind of that reassure and kind of drops the anxiety going into the OR that hey I've seen the kidney before in the clinic in the supine, I should be good to go.

Dr. Roger Sur:

You obviously you can do that for the prone cases, make sure you can see the kidney. Again all of this is cumulative [inaudible 00:35:03] the more you do, the better you get. So, each kidney you see for the rest of your life just ask your experience, over and over and over this will just make it easier for you. Needle guide people have talked about this, Fabio kind of talked about the advantages and disadvantages I'll just say for myself particular because I'm in a training situation, and a lot of times I only have the junior resident with me, I like the needle guide. I feel like it is a way to kind of lower that learning curve and the steepness of it kind of really gets leveled off with a needle guide.

Dr. Roger Sur:

Obviously it kind of forces you to go in certain directions, but I will say I have a PGY2 that works with me and he's done enough ultrasounds. The other day we couldn't use the needle guide and he goes I'll just freehand it and he got it in. So, I think to the extent that the needle guide gets you to be a free hander then I don't know. Again anything that ... I'll take any advantage I can take so that's my take on the needle guide.

Dr. Roger Sur:

So, in conclusion I think I made it abundantly clear, the more you do, the better you get. I mean if you can practice in the OR, on cases that you're not going to do ultrasound but hey just bring out the ultrasound take a look at the kidney, in the clinic pre operatively, patients love being ultra-sounded. When I tell them, they're like, "Oh you're going to look at my kidney?" I'm like, "Yeah I'm going to take a look." But they don't realize that there's a self-serving component to that for me.

Dr. Roger Sur:

I've done all the residents, they've done me, as long as you get consent from people. I would love to do Tom Chi if he would let me. So anyone I can do, I'll do everyone on the panel here. I've noticed also anecdotally that when I transpose the image to the larger monitor we use a striker monitor in addition to our ultrasound machine. For some reason that image gets much better. So, just food for thought just take your image and transpose it to your OR monitor and see if you get a better image..

Dr. Roger Sur:

The other thing is if someone is already had an ultrasound done by a radiologist I love this situation. Because that's when I love to take the ultrasound and go, okay, the radiologist has already told me that there's a three centimeter upper pole renal cyst, there's five millimeter stone on the lower pole, let's confirm everything.

Dr. Roger Sur:

Again the patient is like, oh you're going to take a look? I'm like yes, absolutely I'm going to take a look at your kidney and I'm like let me just see what they've already told me is there. So, it makes it really a great learning experience from a self-serving perspective. Again I've talked to you about getting some time with a technician and practice, practice. Thanks so much.

Dr. Tom Chi:

Fantastic talk Roger as always just a wealth of experience. I would just make the general comment you've got really internationally renowned experts in this area. Hopefully people were taking good close notes and I know this session is being recorded because every slide and every comment was a pearl, great job.

Dr. Tom Chi:

So we've left a lot of time for discussion which is terrific. So I'm going to run us through some Q&As and we have some polling that's going to go on. So, if you see a poll come up go ahead and answer it and we'll be able to kind of look and see what folks are thinking from around the globe. I've put that first poll question up.

Dr. Tom Chi:

While we're looking at the first poll let's get to some questions. So folks have talked about the needle guide I'm going to go there first since Roger has kind of left us with those thoughts. So I think what I've heard from Roger, Brian and Fabio is that needle guide can be helpful, it can help you just focus on the imaging side and it makes it a little bit easier to kind of get the needle where you want it go to.

Dr. Tom Chi:

So, I guess the question I've got is have people ... So Brian mentioned you transitioned away from the new guide and what's that transition back and forth like? To needle guide away from needle guide, when do you think it's helpful, when do you think it's not helpful? Maybe we'll start with you Brian?

Dr. Brian Eisner:

Yeah thanks Tom. So, I think what I liked about the needle guide initially is that especially when you're used to seeing every bit of the needle under fluoro it can cause a little of anxiety trying to find that needle. Even though you know there's nothing between you and the kidney, except for skin fat and muscle it just feels like without seeing that could be in the colon, could be in the spleen. I don't know.

Dr. Brian Eisner:

So what I liked about the guide is it keeps the needle coplanar. What I don't love about the guide that we use and this happens to be one that fits on the GE machine that we have at our hospital that is that angle is very acute actually. So, it's sort of a bit of a steeper angle than I'd like for my puncture. Again for me it always is coming from the top part of the probe. What I like about freehand is I can sort of based on where I can get the best image with the probe I can then sort of chose where I put it.

Dr. Brian Eisner:

So, I think it's nice in the beginning because you can see things. But I think that as you become more comfortable and you realize you can find your needle under ultrasound, freehand sort of just offers you a lot more options.

Dr. Tom Chi:

Terrific. Then let's move to a different kind of question. So folks are asking about kind of different approach to using ultrasound, whether it's in a different position or a different way to get into the kidney. One question that we get from Ian Metzler who's at Organ Health sciences in Oregon, what percentage are you doing ECIRS? Fabio you kind of talked about that a little bit. What percentage of the time do you use a endoscopic combined approach and why do you chose that when you do?

Dr. Fabio Vicentini:

Yes I think endoscopic combine surgery is probably the best way to treat a complex stone. So you can reach all calyx and look for residual stones even the small stones. There are two ways to use ECIRS, you can use since from the beginning to guide the puncture, it's not essentially really, we can do a very good puncture without endoscopic view. But sometimes you have to check before surgery if the stone [inaudible 00:41:08] you know?

Dr. Fabio Vicentini:

Sometimes you are prepared for a PCNL and then you start with a flexible and you check it's not so much stone. So sometimes you will start a surgery to check the stone [inaudible 00:41:19] and sometimes you go ahead with the flexible you don't need to do a PCNL. But after the end of surgery, after I think the patient is stone free, in this case it's very good to use the flexible ureteral scope from below to check out the calyx.

Dr. Fabio Vicentini:

So in the beginning around 30% of the case, in the end of case, pretty much all case just in the case that I staged the surgery so I know I have stone residual, stones for a next surgery, I don't do the flexible. Otherwise if I think the patient is stone free then is a good moment to check the flexible ureteral scope.

Dr. Tom Chi:

Roger so what I heard from Fabio is complex anatomy very nice use of ECIRS because you can kind of have a lot of different option and you can see a lot of different types of stuff. Roger what are you thoughts? Do you use ECIRS in your practice and if you do when do you do it?

Dr. Roger Sur:

We routinely also use ECIRS. I think there's some other advantages to ECIRS is having the scope up there you can create artificial hydronephrosis that may not exist pre operatively. It also helps you facilitate identification of a posterior calyx though admittedly using ultrasound often times I know you've made this comment that it kind of always helps you always get posterior access. But it just confirms that you're in a posterior calyx.

Dr. Roger Sur:

Then the third thing is, I think it's helpful to see things because if the scope is moving it's clearly visible on the ultrasound and all these things just drop your anxiety level and make you feel so much more confident. Because at the end of day all this stuff, this whole talk is about probably about anxiety right? But putting a needle into the kidney when in reality, for those of us who do a lot of it, we put of tons of needles into kidneys sometimes in a single case and I'm not advocating for treating the kidney like a pin cushion.

Dr. Roger Sur:

But the reality is it's pretty forgiving, overall and we're probably a lot more anxious than we need to be. But I guess that's a good thing as a surgeon but I do want to allay the anxiety a bit. I think many of us, or most of us are probably going to do fine with ultrasound.

Dr. Tom Chi:

I like the comments that I'm hearing from Roger. Relieve that anxiety, ECIRS can give you some surety and some accuracy and that's a nice kind of way to think about it. You touched on the idea of posterior calyx or kind of knowing the calyx you're in. We have a question from [Sam Toffic 00:44:05], who asked how do you know if you're in anterior or posterior calyx on your ultrasound puncture?

Dr. Tom Chi:

I know Brian kind of addressed that in the chat box but Brian what are your thoughts on that, how do you know anterior posterior, how do you think about that now that you're doing ultrasounds as opposed fluoro?

Dr. Brian Eisner:

Sure, so I think actually it has more to do with supine Tom than ultrasound versus fluoro. What I'll say is that Tom and I trained with the same guys so we have the same sense of this. But when we were doing pure fluoro in prone, I felt like the especially for middle and lower calyx puncture, posterior was very important. Because if you entered an anterior calyx it was very hard to maneuver the rigid instruments into the renal pelvis.

Dr. Brian Eisner:

I think in supine because you're approaching the kidney essentially from a lateral position I think it's actually very ... I mean as long as you're avoiding the colon I think whether you're in an anterior or posterior calyx is less important. But I think at the end of the day what I do is I think about the CT scan and I think about where I'd want to puncture and then I try and sort of recapitulate that from ultrasound.

Dr. Brian Eisner:

But you can imagine that because the ultrasound guided puncture in supine comes really from a very lateral position. I mean sometimes it's just inferior to the posterior axillary line. I think the differentiation of anterior and posterior calyx is far less important than it is in the prone position.

Dr. Roger Sur:

Can I make one comment there. I get the sense that if you're in the prone, almost invariably using ultrasound will give you a nice posterior. But I think Brian is kind of suggesting this and this has been my sense that in the supine, I think sometimes I am accessing an anterior calyx when using ultrasound guided access, so just a comment there.

Dr. Fabio Vicentini:

Can I make a comment?

Dr. Tom Chi:

Of course.

Dr. Fabio Vicentini:

Yes because I think if you are in supine and I just talked with Brian about that, I make the puncture with the probe not in longitudinal position but in transverse position. I turn the probe clockwise, and then I have the image in the screen and I see the colon and I can see the anterior calyx and the posterior calyx. So in supine, if you turn the probe transverse you're going to see in your screen, the anterior calyx and the posterior calyx. You have no doubt that you entering in the posterior calyx.

Dr. Fabio Vicentini:

I do that, I know most of guys do longitudinal that's correct for sure. But I heard recently two guys from [inaudible 00:46:40] and they said they had pleural lesion during a supine PCNL ultrasound-guided. I just asked what was your position? The probe was longitudinal. I think in supine at least if you do it longitudinal you have a higher chance to go over the ribs over the pleural or even 11th rib. You can go too down again you are in a danger position for the column.

Dr. Fabio Vicentini:

So I really prefer to do the puncture when in supine with the probe in transverse. I can see ... I run away from the ribs and the column and I know exactly that I'm going in the posterior calyx.

Dr. Tom Chi:

So I hear a couple of good take homes from people. One is that you can use ultrasound or try to correlate yourself to the preoperative imaging [inaudible 00:47:38] and study your CT scans very carefully ,rotating the probe and what you see is what you get. So you can choose anterior, posterior and pick what looks like the clearest and freest place. Then maybe the idea behind you have to be in anterior or you have to be in posterior like we think about for fluoro is maybe not as relevant in ultrasound because what you see is what you get. So, I like those comments.

Dr. Brian Eisner:

Hey Tom I have one thing for [inaudible 00:48:01]

Dr. Tom Chi:

Yeah.

Dr. Brian Eisner:

I think the other thing to remember is for those of us that trained in fluoroscopy, we're all very comfortable what we think a good needle position is fluoroscopically right? So, if you use the ultrasound and you puncture the kidney, step on the fluoro. When you starting do a plyelogram. If that needle looks like where it belonged if you're doing pleural fluoro you're probably fine. If that needle is in the wrong spot find a calyx that's more posterior.

Dr. Brian Eisner:

But remember, we want to go 100% ultrasound in the beginning right? We can spot check ourselves via fluoro and then you can increase the contribution of ultrasound and decrease the contribution of fluoro overtime and that's what I'd recommend, sorry.

Dr. Tom Chi:

That's a great comment it leads into another question that a few people have asked now really revolving around learning curve. Some people have touched on learning curve, folks have published we certainly have published that learning curve for ultrasound is shorter compared to fluoro. So let's get real with this. How many cases did each of you guys think that you needed to do, to feel like okay, this is making sense I got it now? Maybe we'll start with Roger how many cases do you think it took for you?

Dr. Roger Sur:

Well, let me change the question slightly, how many cases did it take my junior resident a PGY2 to learn the ultrasound? I would say it's in the single digits. Somewhere after about five they felt very confident like this is pretty straight forward. In comparison to fluoroscopy like bull's eye or triangulation that still is a challenge even for the chief resident sometimes though they're more facile.

Dr. Roger Sur:

So I don't have a number per se but it's clearly qualitatively a much easier technique to learn for a junior resident which I would imagine for you as an attending out there in the audience even easier.

Dr. Fabio Vicentini:

You know Tom, it can take a long time. My first case from 2013 and I learned by myself, after four or five years I said something's wrong it's not going on. Then I went UCSF I spent two days with you and I saw small details and I trained just a little with phantoms and it changed everything for me. What I mean is if you do this kind of course, learn some theory, train with phantoms do a quick observership it will be very fast.

Dr. Fabio Vicentini:

If you know how to do a puncture, if you do a PCNL and you do this kind of training you're going to need four or five case to get it, to know what you are doing. To insert the needle, to see the urine comes out and then you go to make the dilation with the pleural, you do the rest of surgery. So you need some steps. You don't have to do pure ultrasound with 10 cases or 20 cases that's not the goal.

Dr. Fabio Vicentini:

The goal is to use these two to avoid complications to use less radiation to make the procedure easier and to teach residents also. So don't do it just like [inaudible 00:51:22] do it by yourself, make a good training and you reach confidence with few cases.

Dr. Tom Chi:

Very real answer Brian what are your thoughts? Learning curve for you?

Dr. Brian Eisner:

Yeah it's interesting I mean perhaps this is a little bit modeling but I think I'm still sort of on the learning curve for a lot of the things that I do. I think we can always make it better. I will say that I think that I did a few things that were important for me. The first thing is, very frankly, we didn't do any ultrasound when I was a resident. The first time I held a probe was like five years ago, I really mean that. That was part of the deficit for me was that I didn't even know how to touch the machine, right?

Dr. Brian Eisner:

So I know Roger and Fabio and you have talks on knobology, I actually put in the chat. I actually worked with my some of my friends were ultrasound techs, like the people who used to scan my patients or my office visits. I observe them, I learn from them. So I think there's a lot of learning curves, just like what the heck is this machine? what are the principles of ultrasound?

Dr. Brian Eisner:

But then the other thing is if you think about it, you know if you break it really down it's two steps. I was talking to one of the participants on a side conversation. One be a great diagnostic ultrasonographer which I think we can ll learn, we know the anatomy of the kidney, we can get some tips from our techs. I think once you're a great diagnostic ultrasonographer, learning how to move the needle in plane. Which I think again, these sound basic, I think it definitely takes some time, but I certainly think it's a skill that one could master.

Dr. Brian Eisner:

I think when I consider that at least for me I did a fellowship to learn how to do fluoroscopic guided access and that was a full year, I do think that with sort of enough training you definitely could pair that down. So, I don't know if I can give you a number of cases but I think you can break it down it into steps and understand your knowledge deficits and get there rapidly. Certainly, I can get there as rapidly as fluoro if not quicker.

Dr. Tom Chi:

So, I think I'm hearing the theme from folks saying break it down into steps, bite off a small bite of the elephant not the whole elephant at once, and you can get there on your own. You can see from the last pole that many people I think are answering that well they wish they had more in-person training and not enough hands-on courses. So any of these guys in the panel, would be open I'm sure to observerships and hopefully in a time when we can actually travel to each other.

Dr. Tom Chi:

There's some AUA courses coming up this year, Interventional Ultrasonography that Dr. Roger Sur and I are leading and along with Jamie Landman and very nice [inaudible 00:53:41] entry to access course led by Rob Sweet, also are tools to help. So more opportunities for training which is great.

Dr. Tom Chi:

We're closing in on the last few minutes of the hour. So let's have some lightning questions then. So one question asked is what about the equipment? So, let's talk about the ultrasound equipment. Fabio kind of mentioned this a little bit. How good of an ultrasound machine do you need to have? Maybe let's start with Roger?

Dr. Roger Sur:

Yeah, I think different ultrasound machines are better than others full disclosure don't have a relationship with BK per se consulting wise. But I found the bk5000 an outstanding machine I find it better resolution. In fact my residents make the same comment, we've transitioned from that one versus, Aloka, I think it's a better picture.

Dr. Tom Chi:

We're going to stick with that lightening, Brian what ultrasound are you using?

Dr. Brian Eisner:

We use a GE model at one place, we use a BK at the other place. But I guess I'd say this, I say whatever the guys are using for intraop ultrasound for partial nephrectomy is going to be good enough for me. I mean there's a lot of other people that consume a lot, you know the people that are studying the renal vasculature there's a lot more high tech consumption of ultrasound so I just sort of say whatever those guys are using, I'll use the same. I admit I don't have a big sort of dog in that fight.

Dr. Tom Chi:

All right next lightening question is about how do you shove all that stuff in the room? You got your ultrasound, we've talked about being ready to do fluoro or doing fluoro for the dilation. Fabio how do you get all that stuff in a room?

Dr. Fabio Vicentini:

First of all we need a big room usually for ECIRS I use the C-arm on my side coming in the oblique position. I have the ultrasound close to that. So, I have these screens in my front. But it really depends what kind of equipment the tower if you have a tower with two screens, if you're having the screens coming from the ceiling. So it depends.

Dr. Fabio Vicentini:

But it's very important to have the ultrasound close to you and you have to look the screen of the ultrasound. So if you use the left hand to hold the probe then you turn this way, the ultrasound must be in front of you.

Dr. Tom Chi:

Roger how do you get it all into one room?

Dr. Roger Sur:

Yeah no question it's tight. Yeah I'll leave my email out there. I have a slide picture of how I do my set up in my room so if people want to email me I'll give them those slides. But it can be tight no question.

Dr. Tom Chi:

Brian any last word on the getting all that into one room?

Dr. Brian Eisner:

Yeah in our place I could tell you the lithotrite we use various lithotrites they actually sort of keeps that off to the side. When I'm in the kidney, basically when I put the nephroscope in, when I dilation and all that stuff's done and I see that I'm in they actually move the ultrasound just outside the room and sort of move the lithotrite while we use the Olympus ShockPulse or the Lithoclast Trilogy into the room. So, I will say we definitely trade something for something else once I'm in the kidney and I'm comfortable.

Dr. Tom Chi:

Well we're up on the hour, I'm going to say thank you to Brian, Roger, Fabio for really being terrific panelists. Chuck full of information I mean we could talk about this all day obviously. There's lots of opportunists to learn, I want to thank again the Endourology Society, and everybody here for attending. We really engaged in actually some terrific questions, hopefully everybody has taken away the idea that this is something that anybody here could achieve. So thanks for joining us today and be safe out there.

Dr. Fabio Vicentini:

Thank you very much.

Dr. Roger Sur:

Great job Tom, thanks so much. Thanks Fabio and Brian.

Dr. Brian Eisner:

Thanks to the society.

Dr. Fabio Vicentini:

All right bye guys.

Dr. Brian Eisner:

Thanks to the panelists, everybody appreciate it.

Dr. Fabio Vicentini:

Very nice Tom.

Dr. Winoker:

All right thanks everyone. Just a final reminder the webinar, rolls on again next week and we'll be discussion prostate enucleation discussing some different energies. You can register for this at the endourology.org website. You can also head to that website in order to re-watch this webinar today as well as all of our webinars so far.

Dr. Winoker:

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Dr. Winoker:

We certainly do encourage anyone who's not already a member to join the Endo Society. Enumerable membership benefits including full text online access as well as access to partnering conferences. Finally, of course remember to save the date for World Congress in Hamburg in September and a final remember that abstracts are due March 14. Thanks again and we'll see you soon.