Mantu Gupta, M.D.
Dr. Mantu Gupta is Professor of Urology, Icahn School of Medicine at Mount Sinai, Chair of Urology at Mount Sinai West and Mount Sinai St. Luke’s Hospitals, and Director of Endourology and Stone Disease for the Mount Sinai Health System. Dr. Gupta is recognized as a world leader in the research and treatment of urinary stone disease, ureteropelvic junction obstruction, urinary tract obstruction, and upper tract urothelial malignancies, having pioneered many of the techniques in current use. He is recognized as one of the leading endoscopic, percutaneous, and minimally invasive surgeons in the world, having performed over 10,000 major endourological procedures. Dr. Gupta is unique in that he employs a nurturing, compassionate, and holistic approach to the management of stone disease, utilizing alternative medical, nutritional and preventive strategies.

Kelly Healy, M.D.
Kelly A. Healy, MD, FACS, is an Assistant Professor in the Department of Urology at Columbia University Medical Center in New York, NY. She specializes in the surgical and medical management of nephrolithiasis as well as endoscopic treatment of upper urinary tract tumors. Dr. Healy earned her medical degree from Emory University School of Medicine in Atlanta. She completed a General Surgery internship and Urology residency at Emory. She completed an Endourology fellowship at Thomas Jefferson University in Philadelphia and then served as an Assistant Professor. Dr. Healy then joined the faculty at Columbia and treats complex kidney stone disease at the multidisciplinary Kidney Stone Center. Her research interests include dietary and medical therapy for kidney stone prevention, stone surgical outcomes, and ureteroscopic treatment of upper tract urothelial carcinoma. 

 

Webinar Transcript

Dr. Jared Winoker:

All right. So, of course, we first want to go ahead and thank our sponsors at Lumenis for their generous support for this educational activity today. Just as a reminder, this webinar is going to be recorded so feel free to refer back to this slide at a later date, as this provides an overview of today's CME program.

Dr. Jared Winoker:

Of course, today, we're going to be discussing soft tissue applications of the Holmium laser as it applies to the upper urinary tract. We're actually joined by an all New York City expert panel. Our surgeon is going to be Dr. Mantu Gupta. Dr. Mantu Gupta, in addition to being one of my personal mentors from training, is the Chairman of Mount Sinai West and Mount Sinai St. Luke's and the Director of the Kidney Stone program at Mount Sinai. Moderating his pre-recorded lectures is Dr. Kelly Healy. Dr. Kelly Healy is an Assistant Professor in the Department of Urology at Columbia University.

Dr. Jared Winoker:

Before we do jump in, I'd appreciate your patience. We're just going to run through a couple of housekeeping slides. First and foremost, reminder that at this time next week, we're going to be joined by Dr. Traxer and Grasso, who will be discussing the use of Thulium for retrograde intrarenal surgery. You can register for this webinar by going to the Endourology website. There should be a link available, both, on the homepage and also by clicking on the education tab, and then masterclass and endourology.

Dr. Jared Winoker:

With regards to continuing medical education for today's webinar, you're going to be receiving a survey from Michele Paoli at the end of each month. When you do receive that, just go ahead and indicate which seminars you've attended during that month and you'll be emailed your CME certificate. Importantly, please do fill out the questionnaire that will pop up at the end of this, and all of our webinars as this is important for you securing your CME credits. Of course, we encourage you all to participate in our webinar today. If you have any questions for our experts, we'll be happy to try and answer all of them. Simply, use the Q&A function on your screen, not the chat function.

Dr. Jared Winoker:

For those who are not currently members of the Endourological Society, we do encourage you to join. There are many member benefits, including full text online access to all of our publications. For more details, just go ahead and visit the society's website.

Dr. Jared Winoker:

Finally, never too early to save the date for September of next year 2021, where we will be resuming with the World Congress of Endourology and Uro-Technology. So, without further ado, I appreciate your patience. I'm going to turn it over to Dr. Kelly Healy and Dr. Mantu Gupta.

Dr. Kelly Healy:

So, thank you to the Endo Society and, my co-presenter, Dr. Mantu Gupta for this opportunity. Herein, today, we seek to demonstrate soft tissue applications of the Holmium laser for, both, benign and malignant diseases of the upper urinary tract, starting with the case by Dr. Mantu Gupta.

Dr. Mantu Gupta:

Thank you, Kelly. It's my pleasure to introduce this topic to the audience and I hope you learn something from it. Like to start by showing you a case that we have here of a 51-year old female with beta thalassemia minor, who had intermittent right flank pain and one episode of gross hematuria. She had a CT urogram, which I'll show you in a minute here, that showed a nonobstructing lower pole 5mm stone with mild hydronephrosis, possibly consistent with UPJ obstruction and no evidence of a crossing vessel.

Dr. Mantu Gupta:

Her renal scan showed 40% split function on the right with a [T one half 00:03:36] of 20 minutes compared to 7 minutes on the left. She presented for retrograde intrarenal surgery for the stones and possibly endopyelotomy if we truly found a UPJ obstruction.

Dr. Mantu Gupta:

This is her CT scan. I want to point out a few things here. So first of all, here's the right kidney. You see there is hydronephrosis with upper pole dilation, renal pelvis dilation, typically UPJ type configuration, but mild, and you'll see stone here in the lower pole. We discussed with the patient the options... that's showing it again. This is what it looked like on coronal. You can see, again, the hydronephrosis, which is mild. You'll see the narrowing at the UPJ and the kink there... right there at that point, there's a kink. You can't tell here, exactly where the insertion of the UPJ is, but when we did the retrograde pyelogram, you can see the [inaudible 00:04:45] comes up and joins the renal pelvis and twists around... actually, it twisted all the way around and joint like that. It's almost a 360-degree twist. That's what it looked like once we straightened it out with the structure that area.

Dr. Mantu Gupta:

So, in a case like this, with the UPJ obstruction, we don't want to leave any fragments behind. So, when I remove the stones, I want to make sure we get all the fragments behind or else the endopyelotomy, if we do that, could fail. Any fragment that gets stuck in the incision will cause failure. So, we want to remove these stones without leaving any fragments. The best ways to remove them intact... it turns out there were two stones, not one stone, but it was hard to get to that lower pole because of the dilated renal pelvis. You can see here, we're struggling to get into the lower pole because of the dilated renal pelvis, preventing it.

Dr. Mantu Gupta:

So, what we did here is, use passive deflection. You can see the passage deflection of the ureteroscope, allowing us to go down. Then I use a trick... by using a basket to hold open that infundibulum, it creates a little fulcrum. By passing that basket into the calyx, we use that as a fulcrum to get into that lower pole calyx and then grab the stone. Now, the intent here was to basket the stone and try to remove it intact. So, I pre-dilated the UPJ by using the dilator that comes with a 1214 access sheath. It's already been pre-dilated to 12, so we had to easily remove these stones through the UPJ before we did anything to it, such as cutting it.

Dr. Mantu Gupta:

So, here's the first stone being removed. You can see it's nice rounded, smooth stone, difficult to grasp and maintain. But, we're able to extract it in its entirety from the access sheath without having to fragment it, which is a big advantage. Going to move out here. This is now coming back and we're getting the second stone. That, likewise, too, was able to be basketed and extracted.

Dr. Mantu Gupta:

Now, we're trying to get through the UPJ, and you can see that we're struggling. We just cannot get through that UPJ. Even with the wire going through it, it's so tight and so angulated that we struggled and struggled and struggled to get through. Finally, I guess, got closer and closer to it. Once I could see the opening into the UPJ back into the kidney, I used the laser fiber to, again, create a fulcrum. You'll see here, there's the opening to the UPJ. So, these cases can be tricky. If you don't have good access with the wire, you can lose access. So, I like to leave a safety wire in these very difficult cases, just to make sure you have access through. You can always bail out and put a stent. So, you can see how much we struggled. Actually, I cut out a lot of video so we struggled for a good 15 minutes trying to get back in before we finally got back in. That indicates just how tight and angulated the UPJ was.

Dr. Mantu Gupta:

So, here you can finally see the opening. So, when I saw it, I put the laser fiber through. The laser fiber there went through and helped me get to the UPJ. So, I know in this case, I'm not going to be able to go in and out of that UPJ very readily. Every time I go out of it, it's going to be hard to get back in. So, I want to make my first cut as deep as possible. So, here's the laser fiber. Now, with the digital ureteroscope like this, sometimes the fiber does not come out where you want it to. I want to cut here laterally, true lateral, but my fibers coming out medial in the digital scope. This is the FLEX-XC from Storz. Here's the fiber coming out very lateral at around a one or two o'clock position.

Dr. Mantu Gupta:

So, a lot of this is going to be blind, you just have to realize it. So, I'm starting to fire the laser here. This is the MOSES laser fiber 200 micrometer. I'm firing it one Joule and 10 Hertz, to incise. Here we are blindly incising that UPJ knowing that I'm going poster-lateral to cut through. There, I made my initial cut, almost blind, but still struggled to get that through. You see, we were struggling here to get back through. Again, I use a laser fiber here to help with that. I don't want to keep doing this the entire case where I'm struggling to get back through the UPJ. So, I know this second cut incision has to be very slow and very thorough and very deep so that it opens up widely so I don't have to struggle again.

Dr. Mantu Gupta:

We see the opening, and then I put the fiber through, and then used it. There we go, to pop in. Now, you'll notice I have very little fiber showing when I make my incision. I know there's always danger, you're going to injure your ureteroscope, but there's a good five degree, at least, where you have the fiber out and can't see the tip of it. As long as I can see the tip of the fiber, I know I'm going to be okay. So I withdraw it, until just a little bit of fiber showing. That way I can direct the fiber to where I want. Otherwise, you can't direct it. By the time you pull through the UPJ, you no longer see it. So, now I hooked the UPJ with my fiber. See, the fibers hooking it even though I can't see. Now, I'm going to blindly cut and go through the same incision I made before. But this time, I'm going to go through very slow. So, this is real time here.

Dr. Mantu Gupta:

With the digital scope, you see this artefact you get when you fire the laser. So, I'm firing continuously here, even though you can't tell I'm doing anything. I'm firing the laser and not stopping. I'm staying in place because I know it's going to keep making that incision as I'm firing. Then, once I'm sure it's fired for sufficient time, I very slowly withdraw the ureteroscope. I don't want the ureteroscope to pop down all of a sudden, where I can't get back up. So, there I am making that incision. You can see the incision being made here at the one o'clock position. Now, I've cut through the UPJ much more deeply this time. Now, it's become easier to get through. I think the MOSES, here, has an advantage in terms of causing less bleeding and causing a smooth cut. You can see I'm firing the laser even though I haven't gotten to the spot I want to get to yet, because I want to make sure I don't miss it.

Dr. Mantu Gupta:

So, you see these strands, we're going through the incision we made before, and it spread apart already, and we're cutting those strands and going very, very slow through those strands little by little, aiming the laser where we know it has to go, even though we can't see the incision being made. I think with the MOSES laser and knowing there's no crossing vessel here, that we're doing the right thing. It also takes a lot of experience having done this for many years.

Dr. Mantu Gupta:

So here we are, it looks like I'm doing nothing but actually the lasers firing this entire time while I'm slowly withdrawing through the tissues. Again, I'll know when it's right, when I've gone through, when all of a sudden there's a give. Here we are continuously firing. Now, you see the changes, meaning that we're getting close to where we want to be. You can see that there's already an opening here from a prior incision, some small vessels, which are tiny little mucosal vessels that are of no consequence. Again, continuously firing and moving very, very slow because I won't have to do this another time. Then, you see a previous incision, we're going through the same one. Now, it's much more widely open, and now it's no trouble getting through.

Dr. Mantu Gupta:

Now, what I do is, I have the renal pelvis wall here, and I want to keep incising up the renal pelvis wall. So, with the endopyelotomy, you want to be at least one centimeter above the stricture and one centimeter below it. So, you can see, even though there's blood vessels here, with the MOSES laser, it's very hemostatic. I'm just going in and out of the renal pelvis. Inside is here to a one o'clock position and outsides here to a seven o'clock position. I'm cutting that leaf of renal pelvis up one centimeter, two centimeters above the area, just to make sure. I even used the ureteroscope to dissect some of the tissues outside the renal pelvis. So, I have a clear view outside the renal pelvis and inside the renal pelvis as I'm doing this.

Dr. Mantu Gupta:

There's the fiber again. Again, we're just cutting the renal pelvis wall, outside to inside, inside to outside sweeping back and forth and dissecting up. I know there's no vessels there because I've cleaned the outside and the inside. Now, we just continue the incision down one centimeter below the UPJ. You can see the cut being made here. Now, we're one centimeter below the UPJ-

Dr. Kelly Healy:

So, Mantu, it sounds like the MOSER laser, really, enabled you to maintain a single incision which is important in your hands, it sounds like, for efficacy of cut. Aside from that, would you talk about laser position in the scope, right versus left UPJ obstruction position, coming out at three or nine o'clock to, again, get a better angle on the incision based on laterality of obstruction?

Dr. Mantu Gupta:

Yeah. If you try to turn the ureteroscope upside down so the fibers coming out the other way. Whatever seems to work for me. I always find it's easier just to handle the scope exactly the way it was designed, and just have to twerk the scope a bit to get to where you want. I think the fiber optic has an advantage in that. So, my real go-to scope is the FLEX X2 by Storz. I love that. It's smaller, slender, you got great control. I used to get a nice picture with the digital but, certain times, it doesn't have an advantage like in this case.

Dr. Kelly Healy:

So, for right-sided UPJ's, for example, you could get the right side at 9 o'clock [inaudible 00:15:30] you're saying with the Storz FLEX X2. Got it. Thanks.

Dr. Mantu Gupta:

So, I'm pretty aggressive with these endopyelotomy's, so I really, really dissect until you see the fat. All these strands, I cut through those strands until there's fat all the way through the incision.

Dr. Kelly Healy:

So, cut to periaortic fat, minimize bleeding with the MOSES, really get one good deep incision.

Dr. Mantu Gupta:

You can see the fat out there now.

Dr. Kelly Healy:

Yes, it's nice.

Dr. Mantu Gupta:

So, I make layer by layer and just keep going until I know it's wide open. Then, what I'll often do at the end is, to use a balloon in case there's any strands left, and dilate that area to 24 French. Then, what I've been doing also, that we're going to publish on soon, is putting some steroid into the incision we make. I just take my FLEX urethra scope, go outside the renal pelvis and inject a little kenalog in there, let it sit there, and then I balloon to ingrain it in there, before I put the stent in.

Dr. Kelly Healy:

So, are you checking the intraoperative post incision and post dilation retrograde pyelogram to look for extravasation?

Dr. Mantu Gupta:

Not necessarily. If I know I have a full thickness incision, you can see it clearly, I don't always do that. This is the post-op ultrasound, after we took the stent out. You can see the complete resolution of her hydronephrosis, in this case.

Dr. Mantu Gupta:

So, these are some other soft tissue applications that I'd like to talk about. This is a case of an Infundibular Stenosis. You can see, it's a very tight infundibular. Here, I am putting laser fiber through. So, with an Infundibular Stenosis... and this is a Lumenis 80-watt laser that we're using here. Before, I had the MOSES technology. You can see it does a great job and you don't even need a high power laser. High powered lasers are mainly for bladder stones, prostates. I think you can do, almost just as good a job with a low power laser. Of course, there's less bleeding with some of the MOSES technology, and so forth. But, with Infundibular Stenosis, you always want to cut it at the six o'clock and 12 o'clock position. That's where there's least blood vessels showing.

Dr. Mantu Gupta:

Here's another case of a very dilated hydrocalyx. You can see there's a little stone poking out. Beyond that tiny little stone, there's a giant calyx. So, in this case, the access was not very good and straightforward, it wasn't upper pole, it was a middle calyx, so I put a wire through it just so I could get through. So, first thing here is, we tried to get through the stenosis, either, by dilating it with catheters or, here, I use the ureteroscope, directly, to go through and remove the stone. You want to get rid of the stone first, like before. Again, this is the 80-watt Holmium laser. No long pulse mode, no Holmium technology, but we're able to open that widely and with very little bleeding.

Dr. Kelly Healy:

Would you see a similar advantage for a, say, Calyceal Diverticulum, but, oftentimes, you don't know which of the two it is beforehand? If so, would you possibly ablate the cavity using the MOSES?

Dr. Mantu Gupta:

Yep, I've done that many times. The MOSES is nice because you can spray the inside of the diverticulum with the MOSES without directly touching, because of the dispersion of the bubble which we'll show you, the technology, a little bit on how that works. But, if you spray the inside lining, you can fulgurite it without causing bleeding and you don't have to be touching tissue so you're not digging in and creating divots into the [inaudible 00:19:04].

Dr. Kelly Healy:

It's often hard to get the right angle with the Standard Holmium laser.

Dr. Mantu Gupta:

Exactly.

Dr. Kelly Healy:

Yeah.

Dr. Mantu Gupta:

Here's a case of a Ureteral Stricture. So, you notice I use a railroad technique by using two wires to get through the stricture. Here we are, it's a mid-ureteral stricture, so we're cutting at the one o'clock to two o'clock position to avoid the iliacs which are crossing over, which are actually underneath the ureter. So, we don't want to go lateral and we don't want to go posterior, we want to go anteromedial. We'll make the incision. This is a 120-watt laser MOSES... not MOSES, it's the 120-watt Lumines. But, before we had the MOSES technology, this is a long pulse mode. The long pulse mode is very helpful, similar to MOSES, in that it causes less bleeding and gives us a very, very smooth cut, with good control. You can see here, we're cutting through the stricture. The point here, again, is... it's all I want to show. But the point here is, again, to make a full thickness incision through all the tissues and get to the fat, so that's what we did in this case.

Dr. Mantu Gupta:

Kelly, you want to talk about tumors now. We're going to move on to tumors.

Dr. Kelly Healy:

Right. So, we know that [ureteroscopy 00:20:22] is a critical role for, both, the diagnosis and also the treatment of upper tract urothelial cancer. Back one slide. We're going to back up there. See, there we go. Okay. So, in select cases of low-risk disease, we know that the oncologic outcomes fare well compared to radical NU. But, again, in a very select low-risk group as defined by the EU guidelines as being patients with unifocal disease, tumors of size less than two centimeters, low-grade cytology on [inaudible 00:20:56] cytology, but also on biopsy and no advanced disease on cross-sectional imaging.

Dr. Kelly Healy:

It's really important to know that not all patients are candidates for RNU, either because they have pre-existing comorbidities that preclude a major surgery, or they will be rendered dialysis dependent, which we know have poor outcomes for older patients of 20 and 10%, at five years, of ages 65 and 75, respectively. Then secondly, in patients with low-risk disease, we know that oncologic outcomes are equivalent to patients who undergo extirpative surgery. The critical part is patient selection.

Dr. Kelly Healy:

So, tumor biopsy is very essential because we know that the visual diagnosis is only 70% accurate. Ways to maximize tissue yield or minimizing trauma to the tissue... so, when feasible, based on the patient's anatomy, you should avoid to really put anything where you haven't seen. So, try to do a wireless technique to minimize tissue wounding and trauma which would confound visualization and mapping. Take multiple samples, both, before and after biopsy, as well as before and after treatment. Because, oftentimes, the post-treatment cytologies are the ones that come back to be the high-grade elements which can really make the decision making for the patient to go toward more extirpative surgery.

Dr. Kelly Healy:

Then, we do know that ureteroscopy can provide tumor grade in most patients, regardless of tumor size. Then, that workhorse of treatment is a Holmium laser. So, the Holmium laser does have a wavelength in a good safety profile. Basically, the depth of penetration is very shallow, which, again, is offering advantage for safety decreased risk of stricture. It has two effects, both, ablation and coagulation. A complimentary device, often, available in a dual foot switch is Neodymium. It does have a different safety profile, so it penetrates 10 times more deeply, which can provide oncologic benefit. However, you must wear eye goggles because it can cause permanent cornea damage. Again, especially used in complementation with the Holmium laser.

Dr. Mantu Gupta:

I'm going to talk now about use of the Holmium laser for tumors. This is a representative patient who had an Imperative Indication. She actually had a right nephroureterectomy and a cystectomy, and now had an ileal conduit exiting on the left-side and hydronephrosis leading to the conduit. See, the conduit went, almost, all the way up to the kidney into the proximal ureter and joined the kidney. Then, she was referred to me because she had panendothelial disease in this remaining renal units. Now, her bladder's gone, her right kidneys gone, all she had is this renal unit and it had TCC all over it.

Dr. Mantu Gupta:

Now, I'm pointing out here with the CT scan, you don't really see the disease too well, you see little bits and bits. What you really want to do, is try to use bone windows. I want to illustrate here, the same CT scan. Here, now we're using bone windows and you can more easily see the lesion. You can see, right there where the arrow is, you see all these little, little areas are filling defects. You can see them much better, the filling defects. A filling defect here. So, the bone window is very critical for getting a good estimate of the amount of disease in the kidney. You can see here, and then all along here is irregularity.

Dr. Mantu Gupta:

So, this is fairly aggressive disease, but, luckily, so far, all her disease has been low grade. This is the retrograde pyelogram, what it looked like. Again, not too impressive, but the ileal conduit is right here. You can see that we have to go around a whole loop to get into the ureter and then go up. So, we're going around tremendous loops to get up to the kidney. Not very easy to get up there. Very, very challenging. This is what her tumor looked like. There's carpet lesion almost everywhere. Every single calyx of the entire collecting system had these lesions and the renal pelvis as well.

Dr. Mantu Gupta:

So, I am illustrating here, use of the Nd:YAG laser. This is a 80/100W combined Holmium Neodymium YAG that Kelly showed you with a dual foot pedal. Nd: YAG laser, here, you see the white light, the digital scope, and it ablates the tumor without any bleeding. It has a nice depth of penetration. You can get nice coagulate effects. So, I, often, will start with this, just to feel out the tumor and can see how it's responding. You can see this tumor's responding very well to the Nd:YAG laser with very little bleeding at all.

Dr. Mantu Gupta:

The downside of the Nd:YAG laser is, it doesn't remove the tissue. It's not as ablative as the Holmium YAG so the tissue, often, just sits there and doesn't go away and gets in the way of a deeper resection. So, I, often, will use Nd:YAG for the superficial parts and then switch over to Holmium to actually remove the tissue. So, you'll see here, now, we've switched to the Holmium. You can see the difference. You can see, now, the tumor's actually moving away and we're resecting.

Dr. Mantu Gupta:

So, this is the Holmium laser. This is, again, the combination, Nd Holmium. I'm using very low energy. I always start with 0.5 Joules and 5 Hertz, until I feel out the tumor. Then, if I feel it's not bleeding and I can be a little more aggressive, sometimes I'll dial up the energy. But, you don't need much energy for tumors, I find. I think people are overly aggressive. So, I'm using 0.5 and 5, and just spraying the tumor with the laser. As we move along here, you can see this is a very small portion of the calyx. But, you'll see, the entire inside of the calyx is also filled with the tumor.

Dr. Kelly Healy:

So, with this disease, Mantu, can you comment on, I guess, the risk of intrarenal stricture with the Nd laser and Infundibular Stenosis?

Dr. Mantu Gupta:

Sure, yeah. This lady, likely, had a pretty wide open, calyces. But, yes, I think there is a risk of stricture development with the Nd: YAG. Coagulative necrosis can occur and lead to stricture formation. So, I'm very gentle with it. The Holmium is much less likely to cause strictures than the Nd: YAG. So yeah, you have to be very careful. Now, this lady had an Imperative Indication. This was 2015. So, by the way, it's now 2020, and she still comes. I scope her in the office, I get an ureteroscope up there every three to six months, and any disease that's up there, I zap with the Bugbee electrode in the office. So, she's going strong, no metastatic disease, and she's living on what's left of that renal unit without any issue.

Dr. Mantu Gupta:

Here, we're going along... the key here is not to be aggressive, and to take your time. You really want to be very slow and meticulous and, little by little, mapping everything out and not jumping around from calyx to calyx. You want to stay in that calyx until it's completely done. In a little bit of time, you see how it looks like at the end. This is, of course, edited video. So, this took much longer than what I'm showing, getting this all. This was just one calyx. You had 8 calyces like this and her entire renal pelvis full of this stuff. So, it took a good two or three hours. But, with that one resection, she was clean for a long time. You'll see what I did at the end here to keep the tumor from coming back. But, again, I found the Holmium to be more useful so I stuck with the Holmium laser. But, it's nice to have that Nd:YAG option. Something starts bleeding, you can switch right to the Nd:YAG and use it.

Dr. Kelly Healy:

But again, it creates that char effect which, then, you can easily clean off with the Holmium, itself.

Dr. Mantu Gupta:

With the Holmium, yes, excellent. I learned this, about this laser, from Demetrius Bagley, who I know is your mentor, Kelly. When I was getting a new laser, I called him up because I know he did a lot of upper tracts disease, and I said what's the best laser to get if I'm doing a lot of upper tract? He told me to get this. This is, at least, 10, 15 years ago, when I was at Columbia-

Dr. Kelly Healy:

But, you limit it to use of the kidney, correct? You don't use it in the ureter for the risk of ureteral stricture [crosstalk 00:28:54]-

Dr. Mantu Gupta:

I don't use the Nd portion in the ureter, unless I'm just vocally coagulating something that's bleeding. But, it's nice to have there. You can see this calyx is now done, but we'll move out and you'll see that there's disease elsewhere. All the Infundibular between the calyces, also, full of disease.

Dr. Kelly Healy:

Now, are you using [inaudible 00:29:11] mitomycin, or other agents based on your published animal studies and the current practice?

Dr. Mantu Gupta:

Yes. So, let me go back. I don't know why that stopped.

Dr. Kelly Healy:

I know there's been concern for a stricture [crosstalk 00:29:25].

Dr. Mantu Gupta:

Let me move forward toward the end, here, of the video. So, we did the entire collecting system in one shot. Here's the end, it looked very nice. You could see that there is no residual disease. I'm putting up an ureteral catheter here. So, if I can get away without putting a stent, I will. I put up an ureteral catheter because I give mitomycin post-up. This is the ileal conduit we're coming through. So, I leave the ureteral catheter up there and instill mitomycin over an hour in the recovery room. That really helps, I think, with preventing recurrences. Of course, mitomycin can cause strictures, so I'm very careful if they did anything in the ureter, about giving mitomycin. But, if the tumor is all intrarenal, then I think mitomycin's a very good option in these options.

Dr. Kelly Healy:

Okay, so one variation of the Holmium laser is called the pulse modulation. The Standard Holmium laser is a wavelength of about 2100 nanometers, but the Standard pulse width is 350 microseconds. However, depending on the platform used, that can vary between 350 and 700 or upwards to approximately 1500. It's available in, both, a low power laser... So, several vendors have a 30-watt option which is more affordable. It's also available as an option on the high power laser by Lumenis, the 120-watt laser.

Dr. Kelly Healy:

The advantage of this, fo stones, has been more investigated but it does minimize the risk of stone retropulsion, particularly, in the ureter. However, it also demonstrates some tissue benefit with tumors, as we'll soon see in the video by Dr. Mantu Gupta, about its tissue coagulated properties. So, basically it's delivering the same energy over a longer time, and you can visually appreciate the coagulation effect of this tumor, again, to minimize bleeding. Another advantage of this pulse width variability is that the laser fiber's compatible with this option have a green aiming beam, which offers advantages for visualization because it's discreetly different from any tissue that might be bleeding.

Dr. Kelly Healy:

Then lastly, it does offer the safety profile of the Holmium laser by its shallow depth of penetration so there's a lower risk of strictures. I, personally, have found it very advantageous for treatment of retinal tumors where you're going to get good coagulation, but, at the same time, also get good oncologic benefit.

Dr. Mantu Gupta:

So, I'm going to showcase here, now, of a high grade tumor. So, I like to use the no-touch wireless technique as I used in the last case. You can see, we used no guide wires. Here again, I'm going up the ureter with a... the digital scope was too big to fit up the ureter, so, here, I'm putting up the FLEX X2. It's not as good a view as you can see, but this is a high grade [inaudible 00:32:11] tumor, fairly aggressive. Here we are using the Holmium YAG. This is the 80-watt laser, without MOSES, and we didn't have long pulse on this either. Here I use like, a dancer's technique, I jab. Like, a boxer technique or dancer technique. I'm touching, touching, touching. Then, if there's a bleeder, I de-focus the laser and try to go away from the lesion to get coagulation.

Dr. Mantu Gupta:

So, again here, layer by layer, layer by layer, start superficial and go very slow through these high grade lesions because they bleed more. So, you have to be very meticulous with your hemostasis from the beginning. You get into bleeding at the beginning of the case, it's over already. So, very slow, layer by layer, and staying away from the tissue, one millimeter away, so you get more coagulation effect and less of the ablative effect. It's going to take longer, but you're going to get the job done.

Dr. Kelly Healy:

So, just a quick question here, for bulky ureteral tumors, do you find it necessary once you've identified the tumor, before you biopsy and resect it, to establish wire access? If so, I guess, where in the sequence of the other upper tract evaluation does that fit in?

Dr. Mantu Gupta:

Yeah, so that's good points. So, first thing I'd say, I map the entire collecting system before I do any biopsies or lasers. That means going up past the tumor as you saw in the video. I didn't show all of the video, of course. I went up to the collecting system, made sure there was no lesions up in every single part of the collecting system, do a retrograde if necessary, look at the UPJ, come down the ureter, and, then, once I've got good look at it, I use, either, a basket or [inaudible 00:33:51] biopsy forceps. The basket's nice, you get good, big pieces, but, sometimes, the tumors too flat or too sessile, you can't get good chunks, and, then, you have a Piranha to get into the wall and get some tissue. Then, I send that off.

Dr. Mantu Gupta:

No, I don't use any wires at all. I don't use a safety wire for these cases if I feel I have good access. Of course, if the tumors to obstructing and I think I might run into trouble, then I use a safety wire. But, it does get in the way of the laser resection. You're always worried you're going to hit the fiber. It also prevents good deflection if you're using a flexible scope. So, I prefer not to if at all possible.

Dr. Kelly Healy:

Then, taking your samples, your biopsies, with the basket, do you prefer to remove the whole device and block with the scope to maximize tissue preservation?

Dr. Mantu Gupta:

Yeah, because I use a wireless touch-less technique. I remove the entire specimen out through the urethra, put it into formalin, and, then, go back in with the ureteroscope, preferably a FLEX ureteroscope, up the ureter, and back up to the lesion. I'll go in and out several times till I have a good five, six biopsies, to make sure we have good specimen. Then, a good trick I learned from Mike Grasso, always get a cytology of these areas too, because, sometimes, even with that, the pathology could be negative. But, if you get high grade cells on a cytology, you can pretty [inaudible 00:35:00] sure there's a high grade lesion. You might not get with a biopsy or a sampling error with a biopsy. So, always try to get a wash cytology from the area. They're very useful.

Dr. Mantu Gupta:

We'll talk a little bit about MOSES technology here. So, I talked about it a little bit, but what I'll show you here is this video, showing the regular MOSES effect ends at this red bar. But, with the MOSES technology, with the double bubble techniques... Let me go back. Do you have control, Kelly? You want to try going back a slide?

Dr. Kelly Healy:

Let me see. I think you have control there.

Dr. Mantu Gupta:

Okay. There we go.

Dr. Kelly Healy:

See, there we go.

Dr. Mantu Gupta:

Okay. So, let me play this. Okay, so you'll see here that the regular bubble technique, you have a vapor bubble that's created. The MOSES technique, you have a second vapor bubble that goes through the first. So, you have a second firing of the laser that goes through the initial bubble, and because it goes through initial bubble, you have more energy that's transmitted and deeper. It goes to a further energy limit. So, what that does is, it allows you to be further away from the area you're treating. So, normally, you have to be right up against the stone or tumor, but with the MOSES technology, you can be further away. Therefore, you get a smoother and more coagulative effect on the area. I find, that's very useful for tumors, in particular.

Dr. Kelly Healy:

I think, also, especially, [inaudible 00:36:34] tumors. The goal is oncologic control, but, at least, initially, we need to biopsy the difficult [inaudible 00:36:39] tumor. This is a great option for getting post-biopsy coagulation.

Dr. Mantu Gupta:

Yes. This is demonstrating what a Standard energy transmission would be. You can see in the Standard pattern, as you get further and further away from the area you want to treat, the transmission goes down to almost 0 by 4 millimeters. So, you have to be less than 4 millimeters. But, the main energy transmission is at a short distance, 0.5 or slightly higher than 0.5. That's Standard. But, it goes down exponentially with the distance. With the MOSES technology, there's not that much difference at 0.5 millimeters. You see almost the same. But, the difference comes in when you come to 1 to 2 millimeters, in particular. You can see the big difference here between MOSES and Standard at 1 to 2 millimeters. So, if you stay 1 to 2 millimeters, you get better energy transmission. So, that means more ablative effect, a smoother ablative effect and more coagulation and less bleeding with the MOSES technology. So, key here, for tumors, 1 to 2 millimeter distance and for stones, too, very helpful in staying that distance.

Dr. Mantu Gupta:

So, I want to show a case here of using MOSES technology. This is an 86-year old male who had recurrent superficial bladder cancer, low grade Ta. Noted to have multiple papillary tumors throughout the bladder and tumor exiting the left ureteral orifice. So, the oncologist had already resected the UO... he resected the UO but still saw more tumor coming out of the UO. So, that's when he referred him. This is a pretty sick patient with severe cardiac disease, renal insufficiency. Of course, we couldn't re-resect the UO because, already, they've been resected so deep, I was worried about a further resection, leading to retroperitoneal.

Dr. Mantu Gupta:

So, this is what the lesions look like. You can see that there's multiple superficial bladder tumors. You see one over here. But, this is the ureteral orifice itself. You can see urine coming out of it. You can see the eflux of urine out of it. Then, there's disease around the UO, but also coming out of the UO. So again, in this case, I like to use no-touch technique. Here's the nice blast. You know the UO's open because you see a nice jet of urine coming through.

Dr. Mantu Gupta:

So again, in this case, I like to use no-touch technique. This is after we ablated all the bladder tumors with the laser, or a Bugbee. Now, I'm going up the ureter. So, here's a feeding tube. I like to go through the urethra with the feeding tube so you get continuous drainage while we're treating anything in the ureter. It also protects the urethra if you have a residence. I have them follow the green brick road, I call it, instead of a yellow brick road. They follow the green in the feeding tube. This is the opening. Again, using no pressure, just gentle gravity irrigation for all my cases... unless you're using sheath, no pressure. We just find our way through the tumor.

Dr. Mantu Gupta:

Luckily, this tumor was pretty distal. You can see further up... I inspected the entire ureter and then went up with a flexible scope. That's the next thing, map, map, map. Before you do any resection, you want to make sure there's no disease up there. So, now we're putting a flexible scope up, and, again, no wire, touch-less technique, and we view the entire collecting system, make sure we see every calyx, make sure it's completely free of disease. We don't want to be missing something up here while we're treating the distal tumor.

Dr. Mantu Gupta:

So, again, we mapped to the entire collecting system, make sure it was cancer free. This case is going to illustrate, I think, the advantage of the MOSES laser, especially. Because, here you'll see that we have very little space. You have a very distal tumor, and we're going to keep falling in and out of that UO. I cut out a lot of the film, but I kept on falling in and out of the UO because there are so little space. With the MOSES laser, there's a nice ball tip to it. It's not sharp. Here, we use, again, very low energy. We're starting at 0.5 and 5, because you don't want to create any coagulation or injury to the ureteral wall. Again, some of this has to be blind, you get a feel for it.

Dr. Mantu Gupta:

So, first, we started out at non-MOSES mode, and you can see the difference. I'm going to switch to MOSES mode. So, non-MOSES mode, very difficult, more bleeding. Now, we switch to MOSES. We see much more control. You start out at one section. Again, trying to get hemostasis by de-focusing, staying away when you can. In a case like this where there's no space, it's hard to stay away from the tumor. But, going in and out of the UO and just keep going, slowly ablating the disease. Again, I keep the vibrating very close to my ureteroscope tip because I get better control. I know exactly where the fibers firing. It's not often the distance and vibrating as I'm treating.

Dr. Mantu Gupta:

Then, go circumferentially. So, we started there, at about 10 o'clock position, we're going back to 12, then we're going around. You can see, what I'm doing is, twisting my ureteroscope. This is a semi-rigid ureteroscope. Now, I'm twisting it. So, when I twist the ureteroscope, the fiber also twists. So, I'm not twerking but I'm twisting. Now, we've gotten all the way down to the 7 or 8 o'clock position.

Dr. Mantu Gupta:

Finally, the most difficult part is, as you get very close to the very end of the ureter, right at the meatus. It's hard to see. So, I spray the tumor that's around the UO. You can see we've gotten pretty good ablation here. Move forward a little bit.

Dr. Mantu Gupta:

So, now, I'm treating the areas around the ureteral orifice with the semi-rigid. Then, we get the tumor that's coming out of the ureteral orifice, right, hanging out. So again, we sprayed at a distance. The MOSES technology allows us to be not touching the tumor, but spraying it from A millimeter distance, so we get the ablative effect without bleeding and with good visualization of what we're doing.

Dr. Kelly Healy:

So, in terms of scope choice, flexible digital versus fiber optic. Fiber choice, MOSES, say, verus the Holmium YAG option with Nd. Can you talk more about laser compatibility with different scopes?

Dr. Mantu Gupta:

Yes, I showed you a case where we use the digital scope, a couple cases. You can see you do get a little bit of artefact, and that varies from scope to scope, the digital scope to digital scope, and it also varies between what laser system you're using. So, the ones that have less artefacts, I believe, the digital scope provides an advantage, a nice view, but there are a little larger, a little more cumbersome. So, you get a better view but not necessary. I think you can do these cases with a regular fiber optic ureteroscope. Again, you can do it with a non-fancy laser. You don't need a high power laser. You don't need high energy for tumors, you need low energy. So, you don't have to have a high power laser.

Dr. Mantu Gupta:

The MOSES technology is nice, it causes less bleeding, can be further away, it allows you to do things a little slower and more meticulously, I believe, with better hemostasis. But, is it absolutely necessary, no. So, people in third-world countries where they can't afford some of these devices, you can still do cases like this. Just, take your time doing them.

Dr. Kelly Healy:

But, the Nd has that caveat of, it's somewhat interference with the digital scopes, which is a, pretty much, universal issue, not a fiber issue.

Dr. Mantu Gupta:

Yeah, the Nd specially, and you saw that. I think we have questions from the audience. You want to go over it, I have one more case here.

Dr. Kelly Healy:

Why don't we do more case... we have a few questions, I think, we can wrap up with.

Dr. Mantu Gupta:

Okay. This is a case... I didn't show all the films because it's a pretty long case. I want to show you a case of a Pedunculated tumor. The CT showed a pretty large 3.7 centimeter long polyploid lesion that was coming off the renal pelvis or proximal ureter and hanging down into the proximal ureter. You'll see exactly what this looks like when I go up to it. So again, no-touch technique. Going up, we mapped the collecting system, we took biopsies. This is what it looked like. You see, there's a tumor hanging down from the UPJ. You can see it's floating into the ureter. What you don't know is, how far up it goes. A retrograde pyelogram helps with that, but you don't know how far up it goes. You don't know exactly where the stalk is.

Dr. Mantu Gupta:

So, here what I'm doing is, going alongside the tumor, just to feel out where the stalk is. I tried, first, on the medial aspect, you can see here, and I couldn't go further. I've hit the stalk. So, I knew the best way up is not that way if I wanted to get into the collecting system. So now, I'm going to the other side of the lesion on the lateral aspect, and, here, there's a nice clear path of the tumor here and into the renal pelvis.

Dr. Mantu Gupta:

Then, again, map the collecting system and see where it's coming off. You can see it's actually coming off in the renal pelvis, right at the UPJ, then going down the ureter. So, I know it's got a stalk that's attaching medially. So, this is a very difficult case because of the size of the tumor. But, again, using the MOSES, we're able to get good hemostasis and progress slowly and slowly, till we got to it. So, in these cases, a baskets very nice but sometimes you can grab a whole big chunk of that Pollack that's hanging and just avulse a big piece of tumor off. Sometimes, you can even get it to that all that's left is a stalk.

Dr. Mantu Gupta:

In this case... I don't have a video of that, but we used a Nitinol basket. I've also used graspers. Like, a Dakota or NGage basket grasper to grab these and pull them off.

Dr. Kelly Healy:

Also, I think a flat-wire basket or a Segura basket... with the cutting wires, can be very helpful for that-

Dr. Mantu Gupta:

Very useful. I think it's better if you're using a semi-rigid scope because you have limited irrigation when you put it through a... and flexibility when you're putting it through a flexible scope. So, the Nitinol's nice if you have to go around to bend and it's a smaller caliber, but the Segura gives you a much better sample if you can use it.

Dr. Mantu Gupta:

Okay, so, again, showing a complete inspection of all the calyces. This is the tumor coming down now. So, now, what we've done is, revulsed a lot of the tumor off. Now, you can see the base of the tumor where it's attached to the wall. So, I'm putting the fiber up and starting below where I think. So, actually, the attachment comes down lower than you think. You see those abnormal vessels there, that's a sign that that's tumor. It may look relatively normal, but those funny looking vessels are always an indication that there's tumor there.

Dr. Mantu Gupta:

So, this is, I think, where the MOSES really helps. You can see here, we're putting up the laser fiber. Oh, actually, I'm showing the basket. Sorry, I forgot about that. So, this is the basket, I've grabbed a big chunk of tumor, taking it off for biopsy. Then, once I take that out of the patient and give it off to the nurse in formalin, I go back up and we do the same thing over. I did this about 7 or 8 times on this patient to make sure I have enough sample.

Dr. Mantu Gupta:

With that, we were able to remove a good portion of the tumor as well. So, now, we get to the base, and, again, you get these abnormal vessels because that's where it's attaching. So, here's the MOSES, and we're staying at a distance, we're spraying the area with the MOSES. You can see the aiming beam here was interfering with our view because you get a bright reflection from the aiming beam. So, I'll turn the aiming beam down when I see that. You'll see here, that we turn the aiming beam down, and, maybe, even, just turn it off. Yeah, we turned it off.

Dr. Mantu Gupta:

Now, you can see the base more clearly because I don't have the bright reflection with the green light and, then, slowly spray the area. You can see that you can just coagulate. You see the whitish area from blanching. At some point, sometimes, you can't see where you're going. So, I think, at some point, we turned the light back on but a very low level light. Because, we'd gotten the most of the tumor off with a basket, all we really had to do was get the base here. So, this whole 3.7 centimeter tumor, turned out to be a very, very low grade tumor. In fact, probably, more or less a PUNLMP, papillary urothelial neoplasm, of low malignant potential. So, good for her. We saved her a nephroureterectomy and her kidney. We're important in her because she had Lynch Syndrome.

Dr. Kelly Healy:

You mentioned that, in select cases, you use the access sheath for tumors. Can you describe more what are your deciding factors and what's the ideal case for a sheath with a tumor?

Dr. Mantu Gupta:

Yeah, so, a lot of tumor and multiple calyces, very, very extensive disease, and you're not going to be spending a couple hours, two, three hours or more doing it, that's when I think an access sheath is helpful. You're going to get continuous flow, you're going to get better irrigation, you're protecting the kidney by not putting high pressure. I don't use pressure irrigation anyway, but if I feel I'm going to need pressure irrigation to get a good visualization to do the job properly, then I'll use an access sheath. But, that's pretty rare. I, rarely, ever use an access sheath for any of my stones or my cancer cases. Almost never.

Dr. Kelly Healy:

But, you're always inspecting, first, with a no-touch.

Dr. Mantu Gupta:

Yes, no-touch [inaudible 00:51:03]. So, I think that's the end of the movies. I don't know if there's some questions we can get to now. I think there's one on... Kelly, do you want to take some of these?

Dr. Kelly Healy:

Yeah. One in particular, what is your post-treatment surveillance protocol? We know that EAU guidelines are heavily dependent on imaging and does have a protocol, but what's your personal protocol?

Dr. Mantu Gupta:

So, if I'm not 100% sure I got all of the lesion, I'll go back within a month... about a month later, to take a second look, and remove any remaining tumor and do more biopsies. If I'm 100% confident we got it all or if there was a lot of fluffy tumor left at the end, a lot of necrotic tissue that I need to slough off, I'll wait a little longer. Because, I want to give it a chance for that necrotic stuff to slough off and come out before I take a look. So, if it's a low grade, and we're not too concerned, I'll wait three months to do the second look. If I'm more concerned, it'll be one month. But, somewhere between one and three months is, I think, the right time.

Dr. Mantu Gupta:

I always take the stent down. So, the stent comes out. If I'm leaving a stent, I get it out pretty quickly. Within 7 to 10 days, I take it out. Because, when I want to go back up there, I don't want any erythema or inflammation from the stent. I want to make sure I have a clean as look as long as possible, the next time around, so I don't like stents. I think [crosstalk 00:52:26].

Dr. Kelly Healy:

I think for that exact visual confusion it can create, also, for the pathologist, it can create a lot of confusion and unnecessary angst when there's a stent-related edema inflammation.

Dr. Mantu Gupta:

Yeah. I think there's some question here about Mitogel. I think they spoke there about Mitogel. I have limited experience with Mitogel. I had good experience with mitomycin, and I've become soured on mitomycin more and more as the years have gone. I used to lose it more liberally, especially for the low grade disease. I think it's very helpful in the bladder and preventing bladder recurrences. So, I think it's very helpful in any of these cases to put some of the bladder at the end of the case, even if you don't put it up to the kidney. Let's say, you're leaving a stent in, for example, to prevent implantation in the bladder, but it does cause ureteral strictures so I'm always concerned about that.

Dr. Mantu Gupta:

I think in Imperative cases like the one I showed you, I think, Mitogel would be a good option for someone like that, who had low grade disease in so many areas, you just couldn't resect it all. I think Mitogel may be a good option. But, I can't speak much to it because I don't have that much experience. Kelly, do you have any thoughts?

Dr. Kelly Healy:

No, I guess what my concern, and based on some of the studies, is that the mitomycin [inaudible 00:53:38] does cause a stricture phenomenon, and that's concerning. So, it's no longer a standard part of my practice but I know it's still commonly done.

Dr. Mantu Gupta:

Yeah, there's a lot of questions about crossing vessels. Of course, as a crossing vessel, I don't do endopyelotomy. I always make sure there's a CT urogram. The vast majority of UPJ's I see, 95%, I send to my colleague to do a robotic pyeloplasty. I may select cases where they have stones, or a very mild obstruction and no evidence of a crossing vessel or a secondary UPJ in someone who's failed a previous lap of robotic pyeloplasty. Those are ideal cases. I'm very selective in who I choose now. We used to do so many of these, not so much anymore.

Dr. Mantu Gupta:

There's a question here about bilateral papillary hypertrophy in a young female with recurrent gross hematuria. I would check to make sure they don't have sickle cell disease. So, sickle cell prep, make sure that's not there. Rule out tuberculosis or other things. Some of these patients will just have a AV fistula or [inaudible 00:54:37] formation that's causing it. It can be very, very subtle. So, I look for any abnormal vascularity along those papilla, and if I detect it, I'll just treat it with a Nd:YAG laser or Holmium laser at a distance. Sometimes, just a tiny AV malformation that'll stop once you get lasering the areas that look abnormal.

Dr. Kelly Healy:

There's a few questions about Mini-Perc and how that might fit in with treatment of UPJ obstructions?

Dr. Mantu Gupta:

I just did one yesterday, I did a endopyelotomy antegrade with someone who had stones and we, incidentally, found a UPJ. I used the [Boolean 00:55:14] laser for that one, actually. We did it through a Mini-Perc. So, very nice through a Mini-Perc because the laser fiber doesn't vibrate around as much. So, I use a 365 micron fiber so it doesn't vibrate as much, 200 microns vibrate more, 550 limits the flow too much. So, 365, I think's, the optimal fiber for endopyelotomy.

Dr. Mantu Gupta:

I have my own technique where I cut through the renal pelvis, first, with the laser. I know the renal pelvis has no vessels in it, so I cut through the renal pelvis and once I get through the [inaudible 00:55:44] of the renal pelvis, then I dissect the ureter from the outside, top and bottom of it. Once, the ureter's completely freed up and I know there's no vessels on the outside of the ureter, then I'll cut the outside wall of the ureter going into the lumen of the ureter along a catheter. So, that way you can really control what you're doing and cause very little bleeding when you do it. So, yes, I'll do that in selective cases.

Dr. Kelly Healy:

What about tube management posts in endopyelotomy and, also, post upper tract tumor treatment?

Dr. Mantu Gupta:

With endopyelotomy, I always leave a stent, six branch stent. I like silicone stents, they cause less irritation, they're going to be in for six weeks. So, I use a silicone stent, six branch. I don't feel any bigger is necessary. I don't think endopyelotomy stents are necessary. I haven't found any difference in success rate with that-

Dr. Kelly Healy:

Or, with tandem stents? Not really.

Dr. Mantu Gupta:

Yeah, I don't think that makes a difference. [crosstalk 00:56:34]. Yeah. No good literature on that. So, I use a regular stent. I leave a Foley, always, for 24 hours in endopyelotomy patients because there can be extrapolations, especially when you're cutting that full thickness into the fat. There's going to be extrapolation, so you want Foley catheter but nephrostomy, too, if I'm going percutaneously. They don't need it and they actually do better without it. You don't want urine coming back up through the nephrostomy, you want it going down the right direction and you want their tract to seal, because their renal pelvis and calyces tend to be really dilated. They're going to take longer to seal that nephrostomy tract so you want, actually, no tube through it. You want it to start sealing right away with a good Foley catheter and a stent to drain.

Dr. Kelly Healy:

Some more questions on your mitomycin. I see for the upper tract [inaudible 00:57:22] out of installation of [inaudible 00:57:25]. The increased effectiveness of delivery by doing retrograde open-ended and single pigtail stents. Is that something you just do in the office or...

Dr. Mantu Gupta:

Yeah, so we bring patients into the office and I put up a Pollack Catheter 5 French flexi-tip catheter. Nice thing about Pollack catheters, you can go in without a guide wire because they're floppy tipped. I'll just do a cystoscopy, put that up to the renal pelvis. If I have fluoro, that's great. You can do a retrograde, make sure it's in the right place. But, generally, the first time, you want to make sure you're in the right spot. You may want to do a fluoro, then you mark... you know how far to put it up the next time. So, subsequently, I don't use fluoro. In men, generally, if you put the Pollack catheter through the last black [inaudible 00:58:09] in the anus, that's in the renal pelvis. Women, it's 17 marks up from the distal urethral meatus. 17 marks showing outside is about right for the renal pelvis in most patients.

Dr. Mantu Gupta:

The mitomycin's instilled in the office for an hour, and then I take the ureter catheter out and I let it sit in the bladder for another hour. Then, they come back the following week to do it again. I did a study, in ex vivo pig model, showing that that was much more effective than using a double-J to try to reflux it or a nephrostomy tube. With a nephrostomy tube, what happens is, peristalsis carries this fluid that you put into the renal pelvis or calyces right down the ureter very quickly and you get very little time of bathing. So, you need that contact time. You don't get any contact time with a nephrostomy tube.

Dr. Mantu Gupta:

With the double-J through a Foley, you get more contact time but you get skip areas. So, where you have those little holes in the double-J, those areas will get touched. So, what we did was, use indigo carmine or methylene blue in our study at high concentration to show the areas that were getting touched. You can see the skip lesions. We saw areas, along, that were touching, but the vast majority of the ureter and collecting system did not get treatment with whatever you're putting in. So, I think a ureteral catheter, it forces the fluid to go around the ureteral catheter... of course, you have to make sure you don't have any ureteral stricture or you could create pressure. We always use low pressure on the... no pressure at all, just gravity, and try to have the column of fluid less than 20 centimeters above the bladder, so we don't get built up pressure in the kidney when we do it.

Dr. Kelly Healy:

Got it.

Dr. Jared Winoker:

All right, fantastic. I think we're just on time. Any outstanding questions, I encourage all of our viewers to look back at the Endourology website at a later date, where we'll be uploading, both, the recording of today's webinar, a transcription, and we'll have our two experts go ahead and answer all those questions for you. But, of course, gratitude of thanks to, both, Dr. Kelly Healy and Dr. Mantu Gupta for being here. We also want to thank the entire endo organization, as well as the planning committee, headed, especially, by Dr. Adrian Joyce and Dr. Ben [Shu 01:00:15].

Dr. Jared Winoker:

Please do be sure to check back same time next week, we're going to be discussing the use of Thulium for Retrograde Intrarenal Surgery. Of course, we want to thank our sponsors at Lumenis for their generous support with this educational activity. Thanks so much.

Dr. Kelly Healy:

Thank you, everyone.

Dr. Mantu Gupta:

We're going to answer some questions here from the webinar that were posed by people listening in. Some of the initial questions are on endopyelotomy laser settings. I think I discussed this. I, generally, use 1 Joule and 10 Hertz with the MOSES fiber. If I'm not using mode fiber, usually, I'll start with 0.5 and 5 and then dial up slowly, just to see what effect the tissue is having. That's just my general policy, start low and then go higher as we need it. Never do endopyelotomy when there's a crossing the vessel, unless they've already had a pyeloplasty where the vessels been put on the other side. So, as we know, anterior crossing vessels are usually the ones that cause obstruction. But, if they've already had a pyeloplasty, sometimes the vessel will end up on the other side, posterior crossing vessel that are being referred for the UPJ that failed. In that case, I'll take it on, but I'll just make sure I stay away from the crossing vessels. So, if it's now posterior, I'll cut a little more anterior than I normally would, but always lateral.

Dr. Mantu Gupta:

"Is it okay to do blind firing of the laser?" That's not my preference. My preference is always to do firing of the laser under direct vision. In some situations, however, like we showed in the case, it's not possible because you can't get the fiber onto the area you need. In which case, you start very slow and do a superficial cut just to see where it is. Once you get a little groove going, then it becomes easier as you get to do it. But, of course, this should not be something you should be taking on unless you've got a lot of experience with lasers and have done this many times in the past. So, I would say for a novice or a beginning person doing these types of procedures, you should not be blind firing.

Dr. Mantu Gupta:

"Would it be easier to do a stone retrieval with a Mini-Perc?" I think they're talking about the first case when we did the endopyelotomy. Sure, but those stones were quite small, 5 millimeters. Actually, the two, together, were 5 millimeters, so quite a bit smaller than that. So, I think it was probably not a good indication for Mini-Perc. As you could see, the stones were able to be removed without any fragmentation at all.

Dr. Mantu Gupta:

We talked about stents. I prefer the 6 French stent. I don't think tandems stents make a difference. I don't have enough evidence to say the MOSES technology improves the success rate of endopyelotomy. I would just say it makes the procedure go a little smoother in certain circumstances, maybe less bleeding. But, I wouldn't say that it does a better job, overall, or that it improves the success rate. There's not enough evidence to suggest that. Again, I don't think you need a bigger stent.

Dr. Mantu Gupta:

Generally, for a endopyelotomy, I leave my stents for six weeks. There's no real science to that. It's just what was done in initial papers and it seems to work. I don't have strong evidence that four weeks or eight weeks would be any worse or better than six weeks, but just what I've started to do, long time ago, and I've just continued doing it. I remove the stent, I don't do a ultrasound right away, but, usually, we do a follow-up imaging about four weeks later. Unless, I'm really concerned, for some reason, I might do it after one week, but, usually, about a month later, is when we do our CT urogram or ultrasound for follow-up imaging.

Speaker 4:

Sorry, Mantu, can I ask you a question? You talked about, you really should be doing this if you have experience and not just taking this on casually. Even for the experienced person, what are your most worrisome pitfalls? What's the worst complication you can get here during the procedure and afterwards?

Dr. Mantu Gupta:

I think it's bleeding, is what we're just all concerned about. That you're going to run into a vessel. I guess, you can still get fooled even if you have a CT urogram vessel

Dr. Kelly Healy:

Mm-hmm (affirmative)-

Dr. Mantu Gupta:

I always look at it myself, because, a lot of times, they won't report on it. I don't think it's adequate to just rely on a report at all. You really need to look at it in all the different views. I go through it meticulously. Sagittal views, the axial views, the coronal views. I make sure it was a good study, that there's an arterial phase to it, look for that lower pole crossing vessel carefully. But, I still go gingerly into that good night. Just going layer by layer, and then using blunt dissection is very helpful. Once you get that initial position, you can put your ureteroscope through and just gently tease the tissues apart so you get some space to work and look in. Sometimes, you'll see a vessel and can avoid it.

Dr. Mantu Gupta:

But yeah, I think bleeding is a major concern and you can be life threatening bleeding. So, you have to be prepared to be able to take a patient to IR suite and embolize them if it's necessary. Fortunately, it's been pretty rare. But, I think that should be available. So, I think, yeah, a novice shouldn't be undertaking this and want to try to do one for the first time on the road without having some experience.

Speaker 4:

What about long-term structure rate... sorry.

Dr. Mantu Gupta:

Recurrence rates-

Speaker 4:

Sorry, stricture rate of the ureter.

Dr. Mantu Gupta:

Of the ureter, after an endopyelotomy or after... Yeah.

Speaker 4:

After saying, dealing with a urethral lesion.

Dr. Kelly Healy:

Oh, okay.

Dr. Mantu Gupta:

For tumors, yes. I haven't seen too many after the treatment of a tumor, but I've seen a lot after mitomycin. That's why I'm so careful about the mitomycin now if you've done anything with the ureter. Even, if you just have a tight ureter, you have to get through to get to a tumor, and then you get mitomycin. I've seen strictures from just dilating the ureter. In that spot, you had to dilate it. That's why I don't like access sheaths either, because I think they create more of a trauma in certain areas of the ureter. I've seen some patients who were referred to me after they've already had a biopsy somewhere else using an access sheath. Then, with the stricture, in my first look, already there. In those cases, it was the access sheath that caused it. But, the mitomycin definitely makes it worse.

Dr. Kelly Healy:

Also, tumor feature of... circumferential tumors, say, in a patient that's higher risk, that has more Imperative Indications for nephron preservation. I would be more inclined, even if it is circumferential to permissively stricture them and keep them off dialysis, knowing that they might become [inaudible 01:06:59], but that's a discussion to have with the patient pre-op, if you know anything yet about the tumor features. But, I think, largely, it's dependent on the tumor features, whether or not it's a stalk, plucking off, and treating the base. Then, with laser choice, selectively using Nd only for the kidney and Holmium for the ureter, again with long [inaudible 01:07:19] as been a good option, both, hemostasis and also a tumor treatment.

Dr. Mantu Gupta:

A lot of people asked about access sheath. I think I spoke to that. I prefer not to, but, again, it is helpful for a long case or where you feel you'll do a better job with one because of the amount of disease, or you worried about irrigation? You can't get good visualization because it's bleeding. Then, you have to use some pressure. If you're going to use pressure, I'd rather have an access sheath up there to minimize pressure. I'm always worried about tumor extravasation into the pilonidal sinuses, spreading into the collecting ducts of the kidney. So, if you have to use pressure always, probably, better to put up an access sheet up at that point.

Speaker 4:

You showed a really nice example of taking the whole tumor out on block afterwards with a basket, but what about people who are either using, like you said, a Piranha or the BIGopsy or even, just, some graspers to try and take pieces out during there. Wouldn't access sheath facilitate repeated biopsy removals?

Dr. Mantu Gupta:

Yeah, if you don't have experience with going up the ureter without an access sheet, then definitely an access sheet facilitates multiple biopsies.

Dr. Kelly Healy:

With the BIGopsy, you basically need that. But, you can [inaudible 01:08:37] the vocal tumor with a basket and that also provides oncologic benefit but excellent tissue specimen.

Speaker 4:

[inaudible 01:08:47], I know, especially, with that large papillary tumor which is quite bulky, and, I'm sure, daunting to anyone utereroscopically. Any thoughts with using a mini or regular perc access to, either, biopsy or [inaudible 01:09:01] of that tumor?

Dr. Mantu Gupta:

I didn't catch that. What kind of access?

Speaker 4:

Percutaneous.

Dr. Mantu Gupta:

Oh, percutaneous. Yeah, I do quite a few percutaneous resections. Just did one this morning, actually, for a large... it turned out to be a fibroepithelial polyp, but it was in the ureter. Percutaneous access is great. I think it does a great job for most patients. More invasive than you need to be for ureteral tumors. But, sometimes an integrated approach is the only way to get down to the stalk of a tumor and try to get it at the stalk for the beginning, especially with the fibroepithelial polyp.

Dr. Mantu Gupta:

Yeah. It's a great technology, it's, just, you have to select carefully-

Dr. Kelly Healy:

It sounds like mapping is very important for, really, getting the best uncompounded view of the tissue before you start biopsy and treating it. So, I always, just, was interested in, say, an initial percutaneous approach because, in a way, it's very different... not very traumatic but definitely wire manipulation before seeing the tissue. So, can you just go through the algorithm of ureteroscopy with mapping prior to the Perc, or would you upfront Perc someone for a tumor?

Dr. Mantu Gupta:

Yeah, I almost never upfront Perc a patient for a tumor. I've always looked up there, and I don't trust anyone else's assessment of what was up there. You'd always want to do it yourself before I even do a Perc. [crosstalk 01:10:28] same time or before, I prefer before, to know what you're getting into. But, yeah, obviously, with the high grade disease, bulky tumors, you can get into a lot of bleeding with Percs. So, you have to be very judicious and careful. Always try to get access into an area where there's no tumor, so you don't get into bleeding right away. The button has become my favorite tool for many of these tumors in the collecting system because it's nice coagulated properties, and because you can shave down a tumor, even a bulky tumor very nicely with very little bleeding. You can use sailing for the entire procedure. It's bipolar. So, I've used the button for many, many procedures. It's fantastic in the kidney. If you think the tumor is going to parenchyma, you can even reset the parenchyma with very little bleeding with the button.

Dr. Kelly Healy:

Those are more palliative patients. Is that correct?

Dr. Mantu Gupta:

No, I've cured many patients with that.

Dr. Kelly Healy:

Yeah, [crosstalk 01:11:31]-

Dr. Mantu Gupta:

Solitary kidneys, high grade tumors, going to the parenchyma. You can still cure it, you just have to be very aggressive, but it can be done. So, stricture recurrences after treatment of ureteral strictures, of course. Strictures that are longer than a centimeter are more likely to recur. Strictures that are associated with ischemia are more likely to recur. Strictures that are very deep into the tissue, full thickness, and going into fibrosis outside the kidney, or associated with stones that have become embedded in the ureter. Those success rates go down.

Dr. Mantu Gupta:

So, there's many different types of ureteral strictures and success rates vary quite a bit. I think the, overall, success rate of a short stricture that's segmental, and it doesn't have [inaudible 01:12:22] fibrosis around the ureter, is very good. I'd say somewhere around 70 to 80% success rate. That's with incising it, ballooning it, and putting kenalog. I think that's the best you can get. But yes, high recurrence rates. So, I wouldn't do it again. I think there's a question about whether you would ever do a repeat incision of a stricture that failed once. I think if you did it yourself the first time, did it well, I don't see a point in repeating it. If it's failed, the incision, I don't think the second time around is likely to be successful. So, I would usually refer that for reconstructive surgery.

Dr. Mantu Gupta:

Someone asked about Foley catheter. I only leave it for 24 hours, I've never had an issue with it. Obviously, with someone who's got a very, very massively dilated, renal pelvis, severe hydro, in those cases, you may elect to leave a Foley longer just to get better decompression. Maybe, 48 hours instead of 24. But, the vast majority of patients, I think, one day's fine. There's a layer that forms fibrin layer... that forms in the areas that even sized. Also, in the inner tract, you've gone through if you've done percutaneous. That usually seals, not worried about extravasation in those cases, for the most part.

Dr. Kelly Healy:

That's for, both, men and women or only for people with outlet obstruction at baseline?

Dr. Mantu Gupta:

Men and women, but, obviously, yes, you bring up a good point. Someone who's got BPH in a high pressure voiding, they may have more leakage from there nephrostomy tract, if you don't leave a Boolean, but you can longer than 24 hours. You can always put one back in, so, yes, I'd be extra careful on those. Some of those patients I have left the Foley catheter longer, ones who have [inaudible 01:14:03] residuals or very high pressure voiding, hold it for a little longer, it'd be helpful in sealing the nephrostomy tract. Or, if you're doing an endopyelotomy, making sure it doesn't extravasate.

Dr. Mantu Gupta:

NBI, that's a good question. So, I use the Storz system as you saw, and that's got CLARA + CHROMA which is not same thing as NBI, and it's not the same thing as blue light. Their own proprietary system. The blood vessels show up better with CLARA + CHROMA. You can see it. It's better lighting with the CLARA + CHROMA and sharper image. You can see the vessels more clearly, and that's what you saw in some of the videos I was using. But, it's not the same thing as NBI. I think NBI is better for seeing those tumors, and blue lights, probably, even better than that. But, in the upper tract, I don't think blue light has too much of a role because of its difficulty administrating it.

Dr. Mantu Gupta:

Narrow band, I used to use that when I was at Columbia, and I think it's great, I just don't have it. In the office, I have NBI. So, if I'm doing follow-up, ureteroscopy's in the office, which we do routinely, on these patients. I use NBI there, to see if we missed any lesions to see if there's any lesions to treat. But yeah, it's a limit of what we have. Kelly, anything to add on that?

Dr. Kelly Healy:

Not really a technique thing, but, more or less, how it really requires a vigilant patient and a compliant patient and a vigilant surgeon.

Dr. Mantu Gupta:

Someone asked about BCG. I don't do BCG immediately after any resection, just because of the risk of absorption and systemic side effects of BCG syndrome. So, you have to wait several weeks, three to four weeks minimum, after a resection to get BCG. Again, BCG's useful for high grade lesions. I don't think it has as much a role in low grade lesions. I used to use a lot more BCG that I use now. I think, now, we go right to [inaudible 01:16:14] you would [inaudible 01:16:14] me if it's a high grade lesion for the vast majority, unless it's a really imperative indication to give treatment.

Dr. Mantu Gupta:

Then, I've been using BCG interferon. I find that works a little bit better for me for upper tract. There's no science to back me up on that. But, we've published on it for CIS, and it works very well for CIS. As you know, there's a lot of risk with BCG sepsis, if you're going to get BCG, it's better to give it through a ureteral catheter and not through a nephrostomy tube. I think there's a higher risk of sepsis with nephrostomy tube.

Dr. Kelly Healy:

Did you try to get a sense of collecting system volume, which most patients can't accommodate it, but there is that risk of sepsis you've about?

Dr. Mantu Gupta:

Yeah, has to be a low pressure system and there's no good way of measuring it, but someone who's got obstruction of any kind, wouldn't get BCG in those patients. I always get it by gravity. Again, the bag is hanging by gravity. I use a [inaudible 01:17:14] chamber, actually, to give it, which is a chamber that you fill to a certain level and it drips in. A [inaudible 01:17:21] chamber, one drop a second. So, 60 drops equals one CC. So, one drop a second is equivalent to 60 CCs over an hour. So, I time it with the [inaudible 01:17:35] chamber to one drop a second. If you do that, then you're delivering it over an hour. Then, the height is, again, no more than 10 to 20 centimeters above the patient to minimize chance of pressure buildup. So, pressure starts to build up and it stops flowing. If it stops flowing, you don't raise it. It means there's an obstruction. Then, you know something's wrong.