Debators: Thomas Knoll and Evangelos Liatsikos

Moderator: Ben Chew


Dr. Thomas Knoll is Associate Professor of Urology at Mannheim University Hospital, Germany, and Head of the Department of Urology, Sindelfingen Medical Center, University of Tuebingen, Germany. Dr. Knoll was previously staff member and Head of Endourology and Minimal-invasive surgery at the Department of Urology, University Hospital Mannheim, Germany. Dr. Knoll’s field of expertise includes endourologic, laparoscopic and robotic surgery for urolithiasis, benign prostatic hyperplasia and uro-oncology.

His extensive scientific and clinical work focuses on the interventional treatment of urolithiasis and benign hyperplasia. He performed a large experimental work on the pathogenesis and prevention of calcium oxalate and cystine stone formation.

Dr. Knoll won a total of 9 awards pertaining to his innovation and research, including the Arthur-Smith-Award of the Endourology Society, the best abstract in stone disease of the American Urological Association (AUA), the 2nd best experimental abstract of the European Association of Urology (EAU) and the Felix-Martin-Oberländer Award of the German Urological Society (DGU)

Dr. Knoll has published over 140 manuscripts in peer-reviewed literature and 16 book chapters.

Dr. Knolls serves an Editorial board member of the Journal of Endourology, the World Journal of Urology, and Urolithiasis. He is board member of the EAU Guideline Office, the EAU Sections for Urolithiasis, Uro-Technology and Ethics in Live Surgery. He is Member of the EAU Scientific Committee. In 2019 he was appointed as Member-at-Large, Board of Directors, Endourology Society.

 

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

 

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

He has authored over 95 peer-reviewed manuscripts and book chapters. He is a member of the Endourologic Disease Group for Excellence (EDGE) research consortium (www.endoedge.net) and the Wisconsin Quality of Life (WISQoL) research consortium. 


Webinar Transcript

Dr. Jarod Winoker:

All right. Welcome, everyone. Thanks so much for joining us again today for our master class in endourology. Which is a course sponsored by a joint mission between the Endourological Society as well as the Society for Urologic Robotic Surgeons. Of course, we'd like to thank our sponsors, Karl Storz Endoscopy for their grant and support of this educational activity today. For future reference, this is an overview of our [CME Program 00:00:31] for today's webinar. Today's lecture is going to be recorded, so feel free to jump back to our website and review this slide if you have any other questions about the [CME 00:00:40].

Dr. Jarod Winoker:

And of course, today we're going to be hearing an interesting debate on challenging the papillary puncture, as it pertains to PCNL. And we have a wonderful panel with us. So our two debaters, we're joined by doctors Thomas Knoll and Dr. Evangelos Liatsikos. And Dr. Knoll is the head of the Department of Urology at Sindelfingen Medical Center, as well as, an Associate Professor of Urology at Mannheim University Hospital in Germany. And Dr. Liatsikos is a Professor of Urology, as well as the Director of Urology for the Department of Urology at the University Hospital of Patras, in Greece. And moderating our debate today, we're joined by Dr. Ben Chew. And Dr. Chew is a Director of Clinical Research at the Stone Centre at Vancouver General Hospital, and also an Associate Professor of Urology in the University of British Columbia in Vancouver, Canada.

Dr. Jarod Winoker:

So as a reminder, today's webinar, as well as all of our webinar's are recorded, as well as any unanswered questions. And those can all be found at the Endourology.org website. Simply click on the education tab, and then, find your way over to the master class in endourology. So without further ado, I'll turn it over to you, Dr. Chew.

Dr. Ben Chew:

Thanks so much, Jerrod. So thank you to our interesting panel. Thank you for joining us. And thank you to the over 500 participants who have signed up to join us here. So we're going to talk about something really interesting today. And it's this dogma that we have to puncture on the papilla? And we have a challenger who is challenging what we currently think and what we've always done with the papilla. And Dr. Liatsikos is going to talk about non-papillary puncture. And Dr. Knoll will sort of defend why we have to go on the papilla. So Dr. Liatsikos, why don't you start us off?

Dr. Evangelos Liatsikos:

Very good. So it's a pleasure to be here with you guys, good friends, everyone, and debate on this very interesting topic. But as you very well know, I've been advocating for quite a few years now. And everyone would say that the dogma exists because of the excellent studies and some [hierarchy 00:02:42] on the Brodel's bloodless line and on the caste inside the kidneys. But urology is full of misconceptions. What sounds correct should be correct, but is not always correct. And I would remind our generation of doctor's, when we were talking 20 years ago about renal biopsies for renal tumors, this wasn't normal. If you would be [raised 00:03:14] in [endourical 00:03:14] , and you had been to your final exams saying that you would do a biopsy on a renal tumor, you wouldn't pass your exam.

Dr. Evangelos Liatsikos:

And again, if you would have said that you have done an enucleation on a renal tumor, they would have killed you, because they would have said that it has to be a two centimeters distance from whatever, some millimeters, and then, [inaudible 00:03:34]. And other guys, with all this enucleation now, many people are doing enucleation of renal tumors. So we really need to define what is papillary puncture?

Dr. Evangelos Liatsikos:

Is this done on the right? But what is a papillary? It's a huge system, a huge papillae. Where is the papillae there? How can you be sure that you're going into the papilla or not? So defining what is a papillary puncture also is a misconception. The only dogma that you should respect is that you should never change something that works very well. So if you want something that works perfectly, and can give you solution always, you don't change it. But this is not the case with current PCNL papillary puncture.

Dr. Evangelos Liatsikos:

Are we happy? And with bleeding risks that you have in the literature with the trans-papillary punctures, severe bleeding up to 7.8% in some studies. How good can that be? How bloodless can that be, with 7.8% bleeding? So we're not at the perfect. How time consuming can it be when you're trying to go through a papilla, which is impacted full of [soot 00:04:42], and your wire doesn't go down the ureter. It really doesn't go down the ureter, and you try and you try again, and you try again. Is this the way you want to go? Are you happy with the learning curve? Is it easy? I mean, here we are all experts, but how easy is it to teach what we are doing with the young guys? And if it would have been easy, then everyone would have been doing PCNL, which is not the case.

Dr. Evangelos Liatsikos:

PCNL has been out there for many, many years and not everyone is doing PCNL. So the point is that if you want to improve the problem you will face in your practice, you need to come out of your comfort zone. You need to think differently. Being afraid, sincerely, and this is a very nice quote, "Being afraid of something, to change something that bleeds because you are concerned that it might bleed more." That doesn't logic to me. So the whole point here is, instead of going through the papillae to go to the stone, not necessarily like many people think on the infundibular. In this case, this is a very wide infundibular. You can go also to the pelvis, through the parenchyma. So the point that I want to prove today is that you don't really need to go through the tip of the calyx through the papilla.

Dr. Evangelos Liatsikos:

The [degree 00:05:59] that we are using is always the Bull's Eye. So the C arm is rotated 30 degrees towards the surgeon to get the direction of puncture. And then, the depth of puncture is controlled by the vertical direction. So you need two X-ray directions to determine one point. This is a technique, it has nothing to do with papillary or non-papillary puncture. Again, rotation 30 degrees to you, you mark your point of entrance. And then, the direction is commanded like this. And then, if you want the depth, you rotate your C arm to the vertical position. This have been out there for ages, this is nothing new. It's one of the ways of doing a puncture. So it's not the papillary and the non-papillary puncture. It's where you want to puncture and how to do it. So no philosophy on this. This is how I was taught from my mentor, Arthur Smith. And this is how I still do it regardless, of if I would like to do the papillary or the non-papillary puncture.

Dr. Evangelos Liatsikos:

But let's go and see this case here. Now, we are doing... we have the potential of doing 3D reconstructions, and have the real time image. And as you see here, when you're puncturing you can see the rotated image of a 3D reconstruction of the vessels. So if there's a major vessel you could avoid it. We very rarely go through the papillae, we do thousands of cases, and I must say that we go through the papillae very few times. Now, what we are working on doing now is superimposing this 3D images on the fluoroscopy while we're doing the puncture of the dilation. This will really be the next step, very important.

Dr. Evangelos Liatsikos:

So we started with all of this, and we started many years ago, and we did a retrospective study in the beginning, showing that the bleeding rate was exactly similar to the literature, and we have no severe problems. And we had a 2.9% of hemorrhages requiring transfusions, and no selective cases. We do tons of different cases. And we need to understand that when we're talking about the kidney, the kidney's not one type of kidney like in a book. You have different anatomies, you have different calyces, you have different [beverages 00:08:23], you have different stones. You cannot have a rule for everyone. So the point is, not papillary or non-papillary puncture always... I mean, I'm a big advocate of not going through the papillae, but a lot of other people have tried it because of necessity. Because they want to... they couldn't go through the papillae, and for many reasons. And it worked out perfectly for them.

Dr. Evangelos Liatsikos:

This is how it shows, so this is a papillary puncture, initially endoscopically, perfect papillary puncture. I wonder how many times we see this kind of papillary puncture? And this is the non-papillary puncture, it's in the pelvis, as I said, through parenchyma. It gives you a lot of mobility. It gives you a lot of possibility of maneuvers. And look at this, you have your wires down the ureter, you're in the pelvis, right now. And you bend down towards your calyx. The calyx is narrow and impacted with stones. If you would try to go through this calyx with your wire, it would not have been easy, it would have been a mess. Now, you put in your Lithotripter, you start creating some space. And then, you go in with no problem. And the stones cannot escape. You don't need to be afraid that you will break them in fragments. And then, they would fly out somewhere.

Dr. Evangelos Liatsikos:

You just go in, you break them, aspirate them, and in seconds, you're done. And after creating some space in there, you will see that you will be able to accommodate your nephroscope inside, also. Because you are injecting water from the inside out. Very nicely, you go in, you break the stones. The Lithotripter we have right now, are so efficient that they start to break and aspirate stones. You don't even need to take fragments out.

Dr. Evangelos Liatsikos:

Look at this, as we're again, we're in the pelvis, and there's a very narrow infundibular that we need to break and find our way through to the calyx. So look at this, it's not easy, but once you're in, the stone is trapped. You aspirate, you break and it's done. Now, the point is, to put your wire down the ureter. And if you put your wire down the ureter, and you go in initially, and on an impacted stone, many times you see this image. This mean you're not in it. So what you need to do is, re-create some space with your dilator, and follow your wire to be able to create some extra space to just see the stone at the end of your view. As you see here, I've advanced a little bit more of the Amplatz. And then, the seat on top of that. And then, now we can see the stone down there. So you have to break some of this stone to be able to create some space to work, nicely.

Dr. Evangelos Liatsikos:

Further, looking on this, when we're done with a lot of studies, but the most prominent one was the prospective run on my trial that we did, and it showed exactly the same thing. And another study that we're doing lately, we did lately, with the Department of Medical Physics, is calculating the [fluoroscopy time 00:11:25], and the [fluoroscopy time 00:11:26] with this technique is really, drastically diminished, when comparing it with other centers that have twice or three times more [fluoroscopy time 00:11:37]. The reason is that it's very easy to get access to the kidney. You just puncture, and put your wire down the ureter very easy.

Dr. Evangelos Liatsikos:

So having said this, this is 30 degrees again. This is not a pyelostomy. It's very important to show this to the people. So the whole point of the PowerPoint presentation is that this is not a pyelostomy. pyelostomy is what we used to do when we were doing Whitaker Tests. This is not a pyelostomy. This is going through the pelvis, through parenchyma. So this is 30 degrees, and you will see that when you rotate it vertically, nicely, it goes in. So the point that we wanted to prove here, is exactly whether this is safe or not. And I must tell you, that in our department, we do at least 20 PCNL's a week, then 20 PCNL's a week, and we always go non-papillary. I always tell the people that if we would be stupid enough a lot of complications and continue doing something that gives you a lot of complications, we would have been out of practice.

Dr. Evangelos Liatsikos:

So I'm sure that most of the people that are attending the course, have at least tried it once or twice because they had some difficulties, and they never had a problem. But they are afraid to continue and do it again. So this is a concern, and our final answer to this is clearly, that it's a safe technique in our hands. So Ben, I would say this, I rest my case for the beginning, and then, we have another discussion during [inaudible 00:13:31].

Dr. Ben Chew:

I think this is where you normally would drop the mike, and then, walk off the stage. Very nicely said. I think your arguments at the very beginning about these are things that we thought would be crazy years ago, are routine things. And in fact, partial nephrectomy is more common now than radical nephrectomy. So we do have to progress, you're right. And I think we're going to have some questions. And I think now we're going to turn it over to Dr. Knoll. And there's a poll that Dr. Winoker's put up just to vote, "Have you ever performed a non-papillary puncture, either on purpose or not on purpose? And do you do it routinely?" So Dr. Knoll, let's hear from you.

Dr. Thomas Knoll:

Here we are. Thank you, Ben. Thank you, Evangelos. Well, what you might have realized is that the PowerPoint transmission for the non-papillary puncture didn't work well. And maybe, that is the case, as well, for the non-papillary puncture. So being the old school guy, I start with history and Evangelos already mentioned the research works of [Sampaio 00:14:37], from Brazil, who did a lot of work on the renal vessel anatomy. And at the end, we came to the conclusion that the percutaneous puncture through the tip of the papillae, maybe as well as, the lower pole of the kidney is probably what we should do because of the lowest risk of vascular injury.

Dr. Thomas Knoll:

And that was true for all of us since maybe 20, 30 years. And if you do it, it may look like this. But we may go back even further back into history, and that is a citation of my mentor, Peter Alken. And he said, "Well, what Sampaio taught us, is what we learned already from open surgery." Where we [inaudible 00:15:20] at least, did radial nephrectomies if we did open surgery for such big Staghorn stones. And that's how it looked. I mean, PCNL is certainly not a part of nephrectomy, Ben. And we are happy that we don't continue with this open surgery, but it was possible. And if you did these radial nephrostomies, you could do a lot of them. And at the end, the kidney was doing well in most cases. Certainly, more invasive than what we do today, even if we do a non-papillary puncture.

Dr. Thomas Knoll:

But again, look at this image, with the Staghorn stone, and this nice angiography. And I think we have to respect the anatomy of the patients. And the green line is how I personally believe you should puncture, red line is probably something that Evangelos does. And it's not just the puncture, it's as well, getting us [great 00:16:16] access. And that is probably something we agree on. If you have a puncture like on the left hand, it's probably better to puncture again to get a straight access to the stone we have located in the renal pelvis. Not to bend your instrument, to have straight access to the stone.

Dr. Thomas Knoll:

And in this one minute video, I just want to show how I do the puncture. And don't focus on the ultrasound, just try to focus on the puncture site. And as you realize, I puncture very lateral compare to Evangelos, who punctures on the back, which is I personally believe, is not the right place. Because you have much straighter fixed access to the kidney if you puncture from laterally. That's exactly where the [Supine people 00:17:03] puncture, where I puncture. And you got a nice access through parenchyma. You rotate your ultrasound probe to get a straight access from the calyx through the infundibulum to the pelvis. And that is your way of action.

Dr. Thomas Knoll:

And as I always stress out, that is not ultrasound or fluoroscopy. What I do is a combination of both. And I usually get through and in best case, what you get out is their urine. And just another case, to show how I deal with a guide wire, I don't care if the guide wire runs down the ureter or if it runs in the upper calyx. Because I have straight access, it's very easy to dilate. I have almost no risk of kinking the wire. And if it's in the upper calyx, or the lower, I don't care, I usually don't use my [tract 00:18:01]. Evangelos has already shown this data from the CROES Office, with this severe bleeding and relatively high blood transfusion rate. And he was aiming to convince you that PCNL is a very dangerous procedure.

Dr. Thomas Knoll:

And what I would like to stress out is, yes, every surgery has this risk. And another [SAP 00:18:24] analysis of this CROES series shows, yes, it might be high, but there might be other factors that have an impact on bleeding. And [tract size 00:18:33] probably is one aspect that increases as a negative impact on bleeding. And what I always tell my residents is, "It's not this way or the other. The outcome of an operation is the sum of many, many parameters." And for PCNL, there are some and this list is probably not complete. And as you see here, site of access is clearly one factor, but others. Finally, the skill of the surgeon, probably as important.

Dr. Thomas Knoll:

What are the complications of PCNL in expert hands? [OE Series 00:19:09] from Mannheim, done together with Alken, and just as you see here, we have a transfusion rate of zero, or organ injury, like bowel injury, zero. And that is often difficult if you compare a new concepts of expert surgeons, like Evangelos, with real life data, you will get differences. Because there is one guy, even if he has chosen a different way, he is an expert, he knows what to do. And the learning curve is not as difficult as Evangelos has tried to convince you. And that is a paper from my department where we compared my series with one of my youngest of members. And as you see here, if you do a papillary puncture, if you do it as I have just shown to you, by ultrasound and fluoroscopic control, there aren't really more complications. But mainly, minor in the first cases. But as you see here, that is rapidly coming close to what an expert can achieve.

Dr. Thomas Knoll:

So, and when Evangelos does his puncture, he's looking in a dark room. And this dark room is just illuminated by fluoroscopy. And I remember he was talking about radiation exposure, and look how nice his bones in his hands appear here. I mean, that is not how you want to save radiation, it's clearly, maybe it's a little better for the patient, but I don't want to see his hands. If you do it by ultrasound, fluoroscopic control with a lateral puncture, you'll never see your hands in the fluoroscopic view, because they're just outside. And ultrasound gives you a better visualization.

Dr. Thomas Knoll:

You can see the blood and the flow out. You can see the bowel, the air. You can see the spleen. You can see the liver. And you will probably never see something like that. That is the endoscope in the bowel. And what you see is stool. And I believe, Evangelos is puncturing on the back because he's afraid of puncturing the bowel. And that, as I always say, does usually not happen if you do ultrasound. Still zero punctures of the colon. And Evangelos may comment on his numbers. So to finalize this part, look at him. We had a discussion on the perfect access four years ago, in Denmark. And it doesn't look like that he's completely convinced that the non-papillary access is the way to go. Thank you.

Dr. Ben Chew:

Thank you, everybody. So really good points. So Dr. Winoker's just shared the results of the poll. So certainly, some people have occasionally done non-papillary punctures, some never do it, and some rarely do it. So I would say about half of them, half the participants actually, rarely or occasionally do it. And what was the reason? About half the time, they didn't mean to. And if you did do it, was there any issues? 71% of the time, there was no issue. So that's really interesting. Interesting question from Dr. Denstead, Dr. John Denstead, to Dr. Liatsikos, what is your transfusion rate? Would you say, is it possible to get it less than 1%? Because that's kind of the standard we should be looking at.

Dr. Evangelos Liatsikos:

It is possible to get it less than... Can you hear me? I put on my earphones, now.

Dr. Ben Chew:

We can hear you. We can hear you great.

Dr. Evangelos Liatsikos:

Of course. Of course, it is possible to drop it down. And I agree with Thomas, bleeding does not come from the puncture, it comes from the dilation. So if you're doing a 30 French dilation on a big, infected stone, this clearly has a bigger bleeding rate, than if you're using a 18 French dilator to do a Mini-perc. And this is proven, and we see this in everyday practice. So in our hospital, we judge, before we do the [presental 00:23:08], we do the retrograde. According to the diameter of the calices, we have a normogram that we are developing right now, and we decide if we was going to go with a 18 French scope, clinical French dilator, or the 26 French scope, 30 French dilator. So this is what we're doing. It's clearly bleeding less with the smaller dilators. So the puncture is not factor of bleeding. The bleeding comes from torqueing your scope inside and from the dilation.

Dr. Ben Chew:

Dr. Knoll, how do you get your transfusion rate so low at your center? I mean, we do high volume, and I think we're pretty good. But we still have a transfusion rate between 3% of our patients.

Dr. Thomas Knoll:

Well, I believe the puncture site is a major issue. So if you puncture laterally, you have a low risk. We do a lot of miniaturized accesses. So with 18 French, that is what we call miniaturized, and we had to go smaller. I have to admit this, many patients in Germany, are easier than in the Stonebelt, in the US, or in the Arabic/Asian countries. So we rarely the complete the [consult 00:24:25]. Even though, we do a lot of Percs, I see maybe 10, 15 for seconds a year. And obesity is a problem in Germany, as well. But I think it's much worse in the US and Canada. So I mean, as I said, it's many factors that have an impact. And always, if I travel through the world, I always say, well, it's easier to say, "Well, I'm the best one because I have the lowest transfusion rates." But often, my patients are a little easier than elsewhere And that is something you should be aware of.

Dr. Ben Chew:

That's very kind of you to say, but. So for the next question for you first is. Someone has asked, "What do you use to stop bleeding?" And do you use... Is a ureteroscopy simultaneous, so basically, ESURGE, is that useful in the puncture?

Dr. Thomas Knoll:

No, rarely. So if I do endoscopic combined, it's usually a second look. So for the first look, usually I just pure percutaneous access. Because I mean, the idea is to always guide the puncture. But if you are able to access your puncture calyx by an endoscope, it's an easy case, because there is no stone. So I mean, if I have an empty calyx, I can easily do by retrograde contrast injection combined [inaudible 00:25:50] scopic access. So there is no advantage for me. If...

Dr. Ben Chew:

Do you ever use the, like some people for instance, Ralph Clayman describes using the Ureteroscope to sort of laser some of that stone out to create some space around there so you can get your wire out of the calyx?

Dr. Thomas Knoll:

I've never done it. So if it's a complex that I did not get stone free in the first session, with a lot of peripheral stones, in many calices. Then for the second route, it's a nice but cheap procedure, but not for the first step usually. So with that other question, how do I stop bleeding? If it's a venous bleeding coming out of my tract, it usually stops. So when I place the sheath, it stops. You have to make sure the sheath is correctly placed, and then it's fine. If it's not okay, and if no vision, then the procedure is usually to stop your PERC, place a nephrostomy, and come back later. It's different if it's arterial bleeding. That's usually not much you can do to stop. So if it's a significant bleeding that does not stop itself by clamping of the nephrostomy, then that is one of the few cases that has to undergo an angiography.

Dr. Ben Chew:

Evangelos, how do you stop bleeding, if there is any?

Dr. Evangelos Liatsikos:

Well, there are a couple of tips and tricks. When you stop your procedure, a lot of people... Bleeding comes in two sets. One is, you finish your case, and blood comes from your nephrostomy. So then, what you do is, you compress around your nephrostomy and you clamp your nephrostomy tube, for 5 or 10 minutes, and that's it. It's going to clot, it's going to stop. But the major problem of bleeding does not come from the evident bleeding in the beginning. Many people put a tube on the floor at the end of the case and bleeding is generated post-operatively. They don't see it. The patient goes on the ward, or goes in the some room. No one sees him, and the bag might fill up with blood. In our department, the bag always stays at the same level of the bed, never on the floor for the first couple of hours. It's like your nose bleeds, and instead of compressing it or keeping your head up, you put your head down. And this is really a stupid reason that has generated a lot of problems in PCNL.

Dr. Ben Chew:

Okay, great. [Yanik Desigh 00:28:22] has a question for you. So if you traverse the parenchyma less, the bleeding is less. In a non-papillary puncture, you traverse more of the parenchyma, and therefore, why wouldn't you expect more bleeding then? How do you explain that there's less bleeding in non-papillary punctures?

Dr. Evangelos Liatsikos:

This is what I keep saying, you do not transverse more of the parenchyma, because you go more laterally up, you go to the pelvis, and you transverse less parenchyma than you do in the papillary, or at least the same. People think that it's not papillary, and it's part of papillary or infundibulum. I showed you how it is, it goes more centrally towards an area, that gives you more maneuverability. So it has less parenchyma around it.

Dr. Thomas Knoll:

Then after the [creator 00:29:05] we'll see it in my next slide set. That is a negative aspect. It's indeed less parenchyma, but what you have by that is you have the connecting system instead of a usual puncture, I would call usual puncture. You have the collecting system not [sealed 00:29:23] by parenchyma. So we have much less parenchyma, and that is an issue in terms of [inaudible 00:29:29].

Dr. Evangelos Liatsikos:

But it's still sealed, Thomas. Because there is parenchyma. If you would go vertical to do a Whitaker Test, okay? And go to the pelvis with no parenchyma around it, yes? Then, there would be an issue. But here, you go through parenchyma.

Dr. Ben Chew:

What about not the puncture? Glen Preminger brings up a good point here. He thinks that the significant amount of bleeding is the result of the torqueing of the nephroscope to get to the stone, really not having the most direct route would be beneficial. Not whether you go through the papillae or not. So perhaps that would favor the non-papillary puncture then.

Dr. Evangelos Liatsikos:

Exactly. Because you go to an area... If you have a big pelvis, you have great maneuverability inside. You can move, you can go the anterior/posterior/lower calyces, you can go to the anterior/medial calyx, you can clear the pelvis with one puncture. This is one of the biggest advantages. Now if the pelvis is very small, then clearly, we also go through the papillae sometimes. It's not a must for us to go through non-papillary, but when we did the randomized study, we did both papillary and non-papillary cases. But the point that you have is that papillary is not a dogma. People should not stick on the papillary to puncture 10 times. In our center, even the fellows, and the residents, and everyone, one or two punctures, their in, because it's easier.

Dr. Ben Chew:

And you haven't noticed more complications. So Thomas, Doctor [inaudible 00:30:57] Shah says, "How do we assume, like we assume we're doing a papillary puncture every time we try to do it, because that's what we're taught to do. But how do we know we're actually getting on the papillae all the time?"

Dr. Thomas Knoll:

Well, I mean, what we try is to puncture the papillae. I mean, it's clear and you have seen this in the [poll 00:31:15] as well, sometimes we do not. Because we cannot or because it's too difficult because whatever. And I think if you try to puncture the papillae, it's not important if it's really centrally through the papillae or if it's a little lateral, it's still better than puncturing the infundibulum. And as of what I would never do is if I really puncture the infundibulum, I don't [tear 00:31:40] it. And then, what was just addressed, I mean, you have this kinking issue, you bend the scope, and you will have more bleeding. And I mean, sometimes, especially if you start with PCNL, it's difficult because I mean, you puncture maybe three or four times, and then, you are in. And you will see that you are in, but you realize it's really a bad puncture. And the decision then to say, "Well, I'm in but anyway I pull the needle out and puncture again," is difficult. I understand this. I've had the same, but I'm really convinced that it's worth the effort.

Dr. Ben Chew:

Dr. Andrea Lance Powers, from Canada, asked Dr. Evangelos, would you do a non-papillary punctures for multiple accesses for one PCNL? Is there any difference in transfusion rates when you do multiple accesses? Or urine leaks, in those cases?

Dr. Evangelos Liatsikos:

We do multiple accesses. A lot of times we do two accesses to dealing with Staghorn stones, with full Staghorn stones. So if we go through the upper calyx, and you don't do a papillary puncture, or you don't go... I won't say papillary puncture, I will say tip of the calyx, because I doubt that people can go through the papilla on their punctures, and most of them are non-papillary punctures, anyway. But if you want to go to the tip of your calyx, the upper calyx is, let's say, less forgiving for non-papillary punctures. Because most of the times, it is easier to go in the upper calyx if there a branching of the upper calyx, go in the middle somewhere, but you need to go in the upper calyx process.

Dr. Evangelos Liatsikos:

So the non-papillary puncture for us, is mainly, middle and lower calyx. This is the most, let's say, us in our department. Now when we would do a non-papillary puncture on the upper system, if the upper calyx is over the 11th rib, for example. If we need to puncture over the 11th rib, we won't do it. And we'll puncture the infundibulum lower down.

Dr. Ben Chew:

Dr. Densted brings up a question about this as well, too. So when you do do a non-papillary puncture in the upper pole, is there increased risk of thoracic complications? Hydrothorax, those kind of things?

Dr. Evangelos Liatsikos:

No, because the reason we do it is to come lower down. So if we would do a non-papillary puncture on the upper calyx, if we go over the 12th rib or if we go just above the 12th rib, so we really decrease it. And now what we're doing right now is when we puncture... we do two punctures, we would puncture the middle calyx for a big stone with a 30 French dilator, we do 30 French. And then, on the upper calyx, we will use a 22 French dilator, with 18 French scope. So we go with a smaller scope on the upper calyx.

Dr. Ben Chew:

So for Dr. Knoll, maybe you can comment on this. Dr. [Yanik Desigh 00:34:36] says, "You can puncture wherever you want, papillary, non-papillary, but then by the time you dilate up to 30 French, you put the sheath in, which really is 34 or 35 French on the outside, eventually it actually becomes a papillary puncture." So what would you say to that?

Dr. Thomas Knoll:

So I mean, if you use a 60 French access you may be able to put a puncture everywhere, that's papillary. Well, yeah, my exercise I usually try to remain 18 and 24, maximum 26 French. And I think to make it a papillary puncture, you have to puncture somewhere close to the papillae.

Dr. Ben Chew:

And then, for you to talk about that too, Dr. Liatsikos, really this isn't always just kind of in the infundibulum or just beside the papillae. Sometimes you're talking about further down the infundibulum or further down the calyx, or sometimes even into the renal pelvis. Is that correct?

Dr. Evangelos Liatsikos:

Yes. Yep. And [Yanik Desigh's 00:35:38] fully right. The dilation is what makes you bleed. And we see people doing papillary punctures and dilating infundibular that are so small and narrow into 24 French, and they [inaudible 00:35:49] people might start bleeding [inaudible 00:35:53] afterwards. So bleeding is a multi-factorial issue. It is not bleeding through the puncture.

Dr. Ben Chew:

Do we need to see those...

Dr. Evangelos Liatsikos:

... actual radiologist, when they put their tracts in for emergency use cases, do they ever go in through the papillae? Never. They put a tube in, boom.

Dr. Ben Chew:

Right. Well, it's interesting because we're sort of making sure we have to get it through the papillae even though that infundibulum is tiny, and if a balloon goes in there, it basically, just opens it up, and you end up tearing it. You either tear it with a balloon or you tear it with your scope by the time you get in there, because it's so small. What you're suggesting then, is we basically, just bypass that, so we don't go through that infundibulum.

Dr. Evangelos Liatsikos:

Exactly. Exactly.

Dr. Ben Chew:

There's a question here. Anonymous. Basically, it says, if you do go through the infundibulum, is there any chance of getting a stricture in that infundibulum? Regardless of bleeding.

Dr. Evangelos Liatsikos:

There is chance, as if you would go through the papillae through a narrow infundibulum and you tear it, there would be stricture. It doesn't change. The concept has to do with respecting the size of the infundibulum. If the infundibulum size is smaller than your dilation, then you clearly create a stricture, or there is a high possibility. So this has nothing to do with the puncture, it has to do with the dilation process. If you have a small infundibulum and you violate it, either with a non-papillary puncture or either with a papillary dilation, then you tear it and it creates a strictured segment. Common sense.

Dr. Ben Chew:

Dr. Liatsikos, last question for you before we go to our rebuttal slides. Dr. Mohammed asks, "When you have a puncture, what would actually stop you. What things would you see to make you stop and then, try another or a different puncture?" What are the things that tell you to stop and go somewhere else?

Dr. Evangelos Liatsikos:

First of all, when I puncture, if I get blood from my... you know, extremely bloody urine, then I will not dilate. I will change my position and go next [time 00:37:47], go somewhere else, you know? Second, if there's a completely impacted stone in the pelvis or in a calyx and I cannot pass my wire inside, I try tips and tricks, I want the wire inside the system so I will have to change my location or my puncture. These are the main issues.

Dr. Ben Chew:

Let's go with your rebuttal slides now, Dr. Liatsikos.

Dr. Evangelos Liatsikos:

So, rebuttal slides. It's always nice to do a rebuttal because you try to make it a bit more funny, and a bit more debating. Now Thomas and Ben, how will you do a papillary puncture here? What papilla will you puncture? And there's no such thing as a papilla here. There's a huge, dilated pelvis. And you have a papilla which will accommodate maybe a flexible ureteroscope. How would you puncture it here?

Dr. Ben Chew:

So these are the infundibuli. These are the spindly infundibuli that I would be quite concerned about. That I know I would end up tearing, either with my scope-

Dr. Evangelos Liatsikos:

Exactly.

Dr. Ben Chew:

... or with a 30 French. And-

Dr. Evangelos Liatsikos:

So you avoid it. You avoid it. You go almost centrally. [crosstalk 00:38:46]

Dr. Ben Chew:

Yeah. But Thomas may use a smaller sheath, which I think would be advantageous. But that would be a [crosstalk 00:38:51]-

Dr. Evangelos Liatsikos:

Even as-

Dr. Ben Chew:

... difficult for me.

Dr. Evangelos Liatsikos:

Even as using a smaller sheath, this infundibulum would not accommodate a smaller sheath. It's a very small infundibulum. If only [Yanik 00:39:00] could go through this. So you know, some do it purposely, and find the difference. And they can do also, as Guido Giusti, did here, he did the supine also. Supine, prone, makes no difference in the papillary and non-papillary concept. Some do it accidentally, and it is impressive how many do that. You saw it in the poll today. If you add up, the intentional cases and the non-intentional cases, they do more non-papillary punctures than the papillary punctures. It's unbelievable.

Dr. Evangelos Liatsikos:

So this means something because if the guys that did it unintentionally had problems, they would never do that intentionally. They do it unintentionally to resolve a problem they have, that they cannot access the kidney. And as I said, do you think that when we puncture or when the cases come for emergency, and we put a drain inside them, inside the kidneys, we go through the papillae or the interventional guys go through the papillae? So you must see this to believe it. Whoever comes to do see our courses, we train people from everywhere. They expect that we have a huge blood unit outside. That we have a communicating blood unit system, that the blood flows inside and we are vampires eating it and drinking. And they are completely maybe disappointed when they're leaving because this doesn't happen. So they'll remain.

Dr. Evangelos Liatsikos:

So it's a topic of discussion because it's not easy to break rules of decades, more than decades. It's essentially rules. But instead of a conclusion, look at what this guys saying, very simple, PCNL sometimes does not follow rules. There is no such a case as an uncomplicated PCNL case. Complications could come anyhow. And the complications do not come, in my mind, from the puncture. Now if you go down in size, as in this case, with 12 French, you can also coagulate vessels when you're coming out with your Thulium or Holmium laser. And you can do tubeless when go in smaller calibers. This is a non-papillary 12 French, PCNL, on the way out, we'll check and we'll coagulate anything that could bleed with a Thulium laser and we finish with it.

Dr. Evangelos Liatsikos:

And this is the last, I love this slide, this is the only bloodless PCNL that you can find. She sucks this down, stone out, no punctures, nothing. [crosstalk 00:41:24]-

Dr. Ben Chew:

I think we're all going to be out of business.

Dr. Evangelos Liatsikos:

... Thomas [inaudible 00:41:28]. Maybe I will do a fellowship. I will go and do my fellowship there.

Dr. Ben Chew:

Well, Thomas and I may also argue too that that's the only bloodless non-papillary puncture, too, so.

Dr. Thomas Knoll:

Probably [could 00:41:42]. Shall I continue?

Dr. Ben Chew:

Oh, that's great. Please Thomas, thank you. Entertaining and informative as always, Evangelos, thank you.

Dr. Thomas Knoll:

So well, that is the Liatsikotomy, it's a central, non-papillary puncture, wherever you like. And well, this guy certainly likes to swim against the current, which is not bad. I mean, you have to stay individual. On the other hand, you have to respect the individual's you treat. And when you sacrifice doctrinal purity, because of dogma. And we heard this terms, dogma, several times. I mean, if it's not the right concept to get away of one dogma and start to preach the next dogma of the guidewire down the ureter, I'm not sure, Evangelos.

Dr. Thomas Knoll:

So going back where everything started with Evangelos, there is a paper published 15 years ago on multiple tracts through a single incision for a Staghorn Calculous Treatment in a single session. And may I ask everybody here online, how often is this done today? And what we often see is, that the initial success of a new technique is published, the failures in other hands are not. And then, they disappear. Why? However, this guy certainly knows how to sell a failure as a success.

Dr. Thomas Knoll:

Going back to a famous musician, he only used non-wisdom tools for making funny music. If he was looking for a natural access, he used routine stuff. And that is what the calyx does, the calyx forms your access tract, and it gives you security. So why should you take a risk when nature already offers an access? So I may ask you, do we have to follow anatomy? Or do we do Liatsikotomy? That is citation of one those papers published by Evangelos group, and he has already explained the idea of easy access, safety wire, guide wire down the ureter, and access to all stones. And well, I'm not sure.

Dr. Thomas Knoll:

If you go into this papers and you see the stones, you see the site of punctures, and you see how the instrument is bending towards the lower calyx. And I may ask myself, who really wants to bend toward the lower calyx? If you can just puncture the lower calyx and take out the stone with a natural way? And we just discussed the problem of the sealed or non-sealed collecting system by [inaudible 00:44:28]. You might get what you see yellow here, you will [extravasation 00:44:32]:32] of blood. If you choose a different access and you see afterwards urine and blood [extravasation 00:44:40].

Dr. Thomas Knoll:

Last week, we had a very nice webinar with the EAU and Evangelos gave a nice lecture on his complications. As you see here on this slide, a nice arterial lesion. And maybe that was the reason why he said, "Well, I stay with non-papillary, but since after having done for years the different [inaudible 00:45:03], I now turn to Mini-Perc. Is it because of bleeding? Well, I don't know. It was very new to me and this paper isn't pressed in the World Channel of Urology. So again, my puncture site, and the Liatsikotomy is different. And the question is again, the patients are individual's we should follow the anatomy. So why not taking the door of Evangelos, instead of crashing through the wall? I mean, that is something you have to ask yourself.

Dr. Thomas Knoll:

And I mean, now I say, "Well, I have so many followers. We are on twitter, and it just show you all these guys on Twitter. Science on Twitter, is that what we want to do in two thousand and twenty? I mean, clearly you can publish everything. But that is really not how we should create evidence. I mean, there are famous politicians on Twitter, stating crazy stuff, and some of us might be convinced. And there are famous urologists on Twitter publishing that ultrasound is nothing that you need. But is that the evidence that we believe? Or should we go into the literature and there's just one group from Turkey, publishing in Italian Journal this year that they could. Well, we put you the results from Greece, and again, it's a retrospective series. And many of those are retrospective, they are underpowered. So be aware of non-papillary fake news.

Dr. Thomas Knoll:

Why should you stay with transpapillary puncture? Because it works since decades, and many, many hands. The dilation is easy, you don't risk to kink your wire, you can use every wire. You don't have to put it down the ureter. You don't lose your tract. You have a low risk of bleeding if you know how to do it. And you have a low risk of perforation, and the low risk of [extravasation 00:46:59]. And well, I stop here and I'm looking forward to the discussion because I believe the winner absolutely clear. Thank you.

Dr. Ben Chew:

My cheeks are hurting from laughing so much you guys. This is-

Dr. Evangelos Liatsikos:

Thomas. Thomas-

Dr. Ben Chew:

... hugely, hugely entertaining.

Dr. Evangelos Liatsikos:

... there is no natural way to kidney. Natural way is not touching the kidney. If you don't touch the kidney, this is the natural way. Now if you want to call it a [inaudible 00:47:27], or a [inaudible 00:47:28], or whatever you want. But if you want to convince yourself that you are going through the natural way, my God, I don't want to fantasize what you're doing in other natural ways in your life.

Dr. Thomas Knoll:

I won't tell you.

Dr. Evangelos Liatsikos:

But this is not a natural way, my friend.

Dr. Ben Chew:

Oh my gosh, the door crashing... or the car crashing through the wall was terrific.

Dr. Evangelos Liatsikos:

The best part, Ben, is that when Knoll has a problem when he's doing live surgery he moves to a Liatsikotomy, and then, he starts laughing, you know? But I haven't seen him have a problem when he does that during his live surgery. Never-

Dr. Ben Chew:

So-

Dr. Evangelos Liatsikos:

... had a complication with it.

Dr. Ben Chew:

... this brings up a two good points here. So one of them is, sometimes I'm doing something, for instance, I rarely do completely tubeless. And people ask me if I do that? And I say, "Well, not on purpose." But if the tubes all fall out? I say, "Well, people have published on it. It's safe, that's fine." And other times, I'm like, "Well, I've seen someone do this on Twitter, so it must be okay. I'll just leave it."

Dr. Ben Chew:

Now Dr. Peggy Pearl, did a commentary in the World Journal of Urology, or excuse me, Current Opinion of Urology, on one of your, on your randomized trial, Dr. Liatsikos, and said, "We need more studies on the non-papillary puncture. His transfusion rate is no different from the other one. Perhaps the numbers were a little low, but perhaps this could be a testament to your skill and expertise. And not necessarily the technique. So should we all be doing this? Or is it just someone that is good as yourself, who has high volume and the expertise?" That's the one question that I have.

Dr. Evangelos Liatsikos:

I will just tell Ben, that I had a fellow from Armenia, he stayed with me for three months. He had to leave Greece due to the COVID crisis. He went back to Armenia, he's doing full speed from the first day that he went back, non-papillary or papillary, whatever, punctures combined. But not being afraid of going through the papilla. The people that [read 00:49:31] it's much easier to replicate, much easier to replicate. Now the only sense of fear, as I told you, if we manage to get the 3D reconstruction with a vessel. And locate it overlapping the C arm, and following the movements of the C arm, or the ultrasound, or whatever, then you can also minimize [inaudible 00:49:55] zero possible damages to vessels there. So it's something that a lot of people that are coming to see us or a lot of people that have been our fellows or our residents, are replicating very easy. Every resident in our department does a puncture for PCNL. If it would have been so difficult, how could they do it?

Dr. Ben Chew:

I want to ask you very quickly, in the last few minutes that we have left, just a few things. This is from one of your publications, Evangelos. And I'd like to ask you this too, Thomas. We know that you've written in the top left corner here that upper [posing 00:50:36] increase plural complications, you can't access the lower calyx from the midsection. And like Dr. Preminger says, you're going to be cranking around and you can't access the area from there [inaudible 00:50:44]. When do you decide, what are the majority of your punctures first of all, upper, lower, mid-calyx? And then, when do you decide on each of these? Dr. Knoll, why don't you go first?

Dr. Thomas Knoll:

Well, usually, if it makes sense, I try to puncture through a lower calyx. If not, I puncture where it makes sense. So since some years I changed a bit, my strategy because I really try to get as many patients stone free in one session as possible, in my time frame of maximum two hours. And in the past, I always just kept one access and used a flexible scope. But as you know, often it's difficult. With a wide range of miniaturized scopes, I tend to do more and more multi-tracts. So if I have a really complex situation that is not a very complex situation. But if you think that you need several accesses I do as my [inaudible 00:51:41] told me, I do three, sometimes four punctures in the beginning. I place the wires, and then, I dilate how I realize. And sometimes, I just remove the wires at the end. Sometimes, I will lay another one. But usually I start to answer your question with the lower [pole 00:51:58].

Dr. Evangelos Liatsikos:

As you see in this picture here, most of our punctures, most of our punctures are middle, toward middle calyx toward the pelvis. So we treat the pelvic stone immediately, and then we bend down to the lower calyx, and bending down you can treat any stone in the lower calyx. And Anterior or posterior stone, so we trap the stones against the wall, as I showed you in the presentation, and this is 80% of the [pantras 00:52:31]. Now if we have full Staghorn's, then we go to other calyces and we go also to the upper calyces. It's the upper calyx is where about the 11th rib? Then we do a prone combined. So we use one access through the middle centrally, and then, we go up with the flexible scope and use a high power laser to break the upper [postal 00:52:54], just not to risk to go above the 11th rib.

Dr. Ben Chew:

And what do you guys typically leave after you do an upper [pole 00:53:02] puncture? Does that change at all, in terms of what you leave post-operatively?

Dr. Evangelos Liatsikos:

When I do an upper pole puncture, I leave, most of the times, I leave a nephrostomy with double J or a re-entry cope, stuff like this. I want a tube in the upper pole because if I've done an injury in the upper pole, then I wanted some fibrosis to collapse. Other people though, they think that if there's this minor damage to the pleura, if they don't put any tube, it closes easier. So I don't know that. I normally put something in the upper pole. Look at this, did you see the poll now, Ben? Did you see the poll? More willing to perform PNL through a non-papillary puncture, 43%.

Dr. Thomas Knoll:

They were all your followers on Twitter.

Dr. Evangelos Liatsikos:

But the Twitter followers are mostly against me, no pro. They are against me, most of them. They are criticizing me on Twitter.

Dr. Thomas Knoll:

Russian robots.

Dr. Ben Chew:

Russian robots. Yeah, they're all the fake accounts that Liatsiko had someone put together for him. All right. No, that's good. Oh, that's good. That's really good. I think we're going to end here. And thank you so much for both of you, for really informative, and even more so, s entertaining presentations. I'm going to let Dr. Winoker finish up here.

Dr. Jarod Winoker:

Yeah, of course, we want to thank our sponsors. Thanks everyone for participating, Dr.'s Knoll and Liatsikos, and of course, Dr. Chew, for leading our discussion. We're so glad we had so many participants join in today and stick throughout it, of course. We want to invite you back next week, where we're going to be discussing Robotic Radical Nephrectomy, particularly those more challenging cases that involve an IBC thrombectomy. And as you can see, we have an all-star panel set up for you. So if you're not already registered, I do encourage you to go ahead and visit the endourology.org website, you're welcome to do so.

Dr. Jarod Winoker:

Just as a reminder for your CME's, if you've been participating, you've been seeing emails from Michelle Paoli, at the end of every month, just go ahead and indicate which seminar's you've actually attended. And then, we'll go ahead and get you the CME certificate sent to your email on file. And then, also a reminder, please do fill out the evaluation questionnaire that pops up at the end of each webinar. As this is important for you actually securing your CME. And then, a final reminder, please do visit the website to re-watch this recording today. As well as, any of our many questions that appears weren't answered. They will all be answered by our experts and available for you to watch later. Thanks so much, have a good day.

Dr. Ben Chew:

Dr. Liatsikos, do you do most of your PCNL's in the prone position, or supine, as well too?

Dr. Evangelos Liatsikos:

Most of them in the prone position. I tried supine, it doesn't fit my, it doesn't fit my needs. I'm not a fan of supine. I'm not saying it's bad, I'm just saying that I can do everything with my prone. And I don't see why I need to change it, so. And I do run prone combined also. So I don't do something less with prone, but I will do with supine.

Dr. Ben Chew:

Yeah. Do you ever worry about the colon? And what are your strategies to avoid the colon?

Dr. Evangelos Liatsikos:

I always do a CT Scan before the operation. If before the operation, I have a [inaudible 00:56:27] renal colon, which is evidence, then I will ask for a CT [inaudible 00:56:32]. Because I never use the ultrasound, I always use fluoroscopy for both accesses.

Dr. Ben Chew:

We do our CT here in the prone position, that way when we get them on the table prone we know where the anatomy's going to sit. Do you do your CT's in the... You do your CT's prone too? Gotcha.

Dr. Evangelos Liatsikos:

We do our CT's prone. And also we try, we're doing a study right now, doing the CT prone with dilated system in relation to [inaudible 00:56:59] system. It changes completely the relation to the vessels and everything. And this is something that is very distinct.

Dr. Ben Chew:

Someone has a question, someone has a question here about using the retrograde wire, the Lawson wire from the Cook Set, that just go up where you put it up, and you puncture through and then, [take 00:57:17] it off the skin. Do you have any comments on that?

Dr. Evangelos Liatsikos:

I tried it when I was in the US. I must say that I don't like the fact that I cannot calculate the direction of where the wire is coming out, where it's going to go, I don't see why it would benefit. It makes me feel very insecure where this is going to go, which direction. Because the flexible scopes... Also, we're not dealing with the best image on where's the posterior calyx, where's the anterior calyx. If you make a mistake and put it through an anterior calyx, then the Lawson guide wire could go through any kind of organ. So it's too much philosophy. I like more simple things.

Dr. Ben Chew:

Evangelos, thank you so much. This is great. Jarod, did I miss any other questions. I think those are the ones that we have. I think that's it.

Dr. Jarod Winoker:

Everything. I did have one final question. I don't know if it popped up, but Dr. [Ross 00:58:10] goes, "I was curious when you do get your infundibular access, I was curious if you had mentioned about how you leave drainage from the system, just in general." I know we've talked about that before but do you have a standard way? Or is it something you're viewing that chooses whether or not you leave a certain type of tube inside?

Dr. Evangelos Liatsikos:

When I do a Staghorn calculus that is very infected pelvis, and sometimes you also make some damage through the pelvis, and you have just a messy system there, then I leave a Malecot. So I leave a big Malecot in because I want the pelvis to nicely heal around it and put down the ureter, and heals very nicely. When I do mini-PCNL, which is 18 scope, 20 French, 22 French, and I get done with the extended the first one, I always leave a tube though.

Dr. Jarod Winoker:

Thanks so much.

Dr. Ben Chew:

Liatsikos, I have honestly never laughed this hard during a [Zoom 00:59:07] webinar. Very, very enjoyable, both of you guys. And so informative, too. It was great.

Dr. Evangelos Liatsikos:

It was a pleasure. Pleasure for me, too. Pleasure for me, Ben. Pleasure.

Dr. Ben Chew:

I look forward to come seeing some non-papillary punctures with the Starbucks cup.

Dr. Evangelos Liatsikos:

That's okay. You're always welcome. Bye everyone.

Dr. Ben Chew:

Okay. Thanks everybody. Take care.

Dr. Evangelos Liatsikos:

Bye.