Surgeon: Dr. Manoj Monga, M.D.
Dr. Monga is Professor and Chairman of the Department of Urology at the University of California San Diego. He was awarded the Endourology Society “Arthur Smith Young Innovators’ Award” in 2007 and the Ralph Clayman Mentor Award in 2018. Dr Monga served as the Secretary of the American Urological Association from 2015-2019. He has also served on the Board of Directors of the Endourology Society. He was elected to the American Association of Genitourinary Surgeons (AAGUS) in 2016. He currently serves on the Board of Governors of the American College of Surgeons.

Moderator: Dr. Brian Matlaga, M.D.
Dr. Brian Matlaga is a Professor of Urology at the Johns Hopkins University School of Medicine and also serves as the Director of the Gerald and Helen Stephens Center for Stone Disease at the James Buchanan Brady Urological Institute. Dr. Matlaga is an internationally recognized expert in the medical and surgical management of patients with urinary stone disease.

 

Webinar Transcript

Dr. Jared Winoker:

All right. Good morning, everyone, or good afternoon, depending on where you are. I'm Jared Winoker. On behalf of Dr. Adrian Joyce, Dr. Ben Chew, and the entire Endourological Society, I want to thank you for joining us for the latest installments of the masterclass in endourology, and robotics.

Dr. Jared Winoker:

For your reference, this is an overview of our CME program for today's webinar. So today we're really in for a treat. We're joined by two thought leaders in the medical and surgical management of kidney stone disease and discussing PCNL with an emphasis on some tips and tricks for performing the procedure. We're joined by our surgeon, Dr. Manoj Monga, professor and chairman of the Department of Urology at UC San Diego. And moderating his prerecorded semi-live surgery is Dr. Matlaga, professor and director of the Stevens Center for Stone Disease at Johns Hopkins.

Dr. Jared Winoker:

Before we do get started, I just want to go through a couple of quick housekeeping slides. I want to remind you that next week at the same time, we're going to be joined by doctors, Manchu [Gupta 00:01:07] and Kelly Healey, who will be discussing soft tissue applications for holmium laser in the upper urinary tract. You can register for this session and all of our other webinars simply by going to the endourology website and click on education, and then the tab for the masterclass.

Dr. Jared Winoker:

With regards to continuing medical education for today's webinar and all of our webinars, you'll be receiving a survey from Michelle Paoli at the end of each month. Just go ahead and indicate which seminars you've attended during that month, and then you will be emailed your CME certificate. And just a quick reminder to please fill out the questionnaire that'll pop up at the end of each seminar, as this is important for securing your CME credits.

Dr. Jared Winoker:

I do want to encourage everyone to use the Q&A function to ask our experts questions today throughout the webinar. Important to use the Q&A function and not the chat function as those won't otherwise be seen. And just as a reminder on the website afterwards, we will be posting a transcription as well as a recording of today's webinar.

Dr. Jared Winoker:

We do encourage everyone who's not already a member to join the Endourological Society. Part of your membership benefits include full text online access to our many journals and details can be found simply by visiting the endourology.org website.

Dr. Jared Winoker:

Finally, a quick save the date for the World Congress of Endourology and Urotechnology, which will still be taking place in Hamburg, Germany, but has now been rescheduled for September of 2021. So just to keep that in your calendars.

Dr. Jared Winoker:

So without further ado, I will turn it over to Dr. Matlaga and Dr. Monga.

Dr. Brian Matlaga:

Thank you Dr. Winoker for the kind introduction. It's a great honor to spend this time with the audience and with my esteemed colleague, Dr. Manoj Monga. Dr. Monga thank you so much for being a part of this program.

Dr. Manoj Monga:

Good morning, and welcome to all our participants. Thank you very much to The Endourology Society, especially Jared, Adrian and Ben for organizing this wonderful series and for including me.

Dr. Brian Matlaga:

Yeah, I would echo those thanks as well obviously. This certainly is a very heavy lift to get this off the ground, and I think Dr. Andrew Joyce, the Director of Education for the society deserves tremendous credit for it. As Jared said at the intro, we really want this to be a very interactive program. We have about an hour together. To that end, there's going to be the opportunity for question answer, and really some of these questions we'll try and address in real time as we can. Others, we may reserve towards the end of the hour together where we can provide them more in a defined question answer period. But certainly as they come to your mind, please communicate those questions to us through the Q&A bar at the bottom of the Zoom window.

Dr. Brian Matlaga:

The topic today that we have to cover is broadly about percutaneous nephrolithotomy. As we get into the discussion, you'll see we've structured it around a very specific case, but I think it's nice to begin with just a very broad discussion of the surgical technique. And to that end, we're very fortunate to have Dr. Monga, who's probably one of the world's authorities in surgical treatment of stones, and then particularly with regards to the percutaneous approach.

Dr. Brian Matlaga:

So Manoj, I guess I would start with just a very broad question. If you can just share with us what role does PCNL play in your practice as compared to ureteroscopy and shockwave lithotripsy?

Dr. Manoj Monga:

Brian, thank you. I suppose, first of all, I'll just kind of give my opinion on the terms masterclass, or experts. There's many different ways to do things. I think out of our 168, 169, 170 participants on the call, each of you could give me tips and tricks on how to do things better. So rather than say that this is a masterclass, it's just one way to do it that has worked well. I'm sure that over the years, there'll be many things that I'll continue to adapt.

Dr. Manoj Monga:

So with that little disclaimer, I suppose you could say, the role of PCNL in my practice range primarily for larger stones. What shifted over the last probably 10 years is that my threshold for performing PCNL has dropped from 20 millimeters to 15 millimeters. As I think our techniques for PCNL have improved, the morbidity associated with his decreased and appreciations for the limitations of shockwave and ureteroscopy as well as the importance of patient selection for those two procedures has been refined. So the general threshold would be 15 millimeters or bigger, and then specific situations related either to the anatomy of the patient or the characteristics of the stone with regards to hardness and location so forth.

Dr. Brian Matlaga:

Within your practice, or I guess within your experience, because I think one of the great things as you really nicely put it is that, this is really a discussion it's not, there is one way that is the right way, but I think it'd be helpful for ... certainly I'd be very curious as to what has been your experience with PCNL in terms of the technique that you learned? Then has that broadened? Do you have various percutaneous approaches that you now offer to your patients?

Dr. Manoj Monga:

Yeah, so I suppose first I could describe what's been my journey through PCNL. It started with my training, at Tulane under the auspices of Dr. Ashley Thomas. He's a person I would definitely call a master. Our PCNL experience at Tulane involved a very rich and tight collaboration with our interventional radiologists, where as residents, we would go to the interventional radiology suite. We would be there scrubbed in as they got the access and we would pick up tips and tricks from them that were helpful in the event that we had to troubleshoot once the patient came up to the operating room and perhaps get a second access, or do something that was unexpected because of how the case progressed. It also allowed for rich dialogue in terms of selecting the most appropriate access, communicating to them, the importance of the angle and the relationship to the stone. So that type of tight collaboration not only was helpful for the patients, but helpful for me as a young learner to gain a greater appreciation for how important the initial access is in terms of the overall success of the surgery.

Dr. Manoj Monga:

From there, I moved to UCSD where we once again had a very rich collaboration with our interventional radiologists, and was able to continue the type of relationship that I had experienced, and benefited from at Tulane. Then from there, I moved to Minnesota, which as you I think, all are aware was considered perhaps the birthplace of endourology, had a lot of rich tradition of not only collaboration between radiology and urology, but also innovation. It was there that I started to get my own access with the help of Dr. John Hulbert, who was my senior faculty in stones and was very kind to mentor me through the process.

Dr. Manoj Monga:

Also, a lot of mentorship from David Hunter, who was one of the very established and senior intervention radiologists. So the two of them were very kind in sharing their knowledge in terms of, from that standpoint, I think one of your later questions will be, how did I end up with the endoscopic guided technique? That was fortuitous that one day in the OR we lost access, started thinking about, well, do we give up, come back another day? Radiology is not available to help us. It was at that point that we threw up a sheath and got access under direct vision. So it was that complex case that led us to consider well, wow, that was, I wouldn't necessarily say easy, but it was good. Let's see if maybe we should do that for every case.

Dr. Manoj Monga:

So I think that's perhaps a kind of a brief history of the evolution of not only how I learned, but how it's evolved.

Dr. Brian Matlaga:

Have you explored ... Obviously we'll be talking about the endoscopic combined procedure, just in the context of this case, have you explored other techniques of PCNL, mini perc, supine perc, ultrasound-guided perc?

Dr. Manoj Monga:

One of the collaborations within interventional radiology here in 1997 was that we started doing mini percs. With Steve Olvey in radiology, we would use a ureter balloon, so about I believe it was an 18 French balloon with a 20 French sheath from Cook, and we performed mini-PCNLs, mini-endopyelotomies, and we're very enthusiastic about that as procedure. So I would describe us as perhaps innovators, even before the stage of early adapters in terms of mini-PCNL. It happened around the same time as Steve [inaudible 00:10:55] was reporting it at Hopkins Uro Institution.

Dr. Manoj Monga:

From there, we organized a meeting at one of the AUAs, of about 20 thought leaders to talk about a RCT to evaluate the value of mini-PCNL versus standard. There wasn't much enthusiasm based partly on a study that came out at that time from Professor [inaudible 00:11:20] that demonstrated very minimal impact in terms of renal parenchyma and renal function loss by using 11 French versus 30. So I think it was that discussion that AUA along with the very well-designed animal study, that in America essentially put mini-PCNL to sleep. I think since then it's been a procedure that has evolved and been refined and adapted in many parts of the world. I think it is reasonable for America to reevaluate that as many of my colleagues, not only here in San Diego, but across the country are, and for me as a surgeon to decide, is that something I wanted to adapt? Do I have to first know what are my outcomes and where can I improve?

Dr. Manoj Monga:

So in terms of outcomes, my typical PCNL takes about an hour, access is with one stick, transfusion rates are 4%. So if I can improve on that 4% transfusion rate without compromising OR time and stone-free rates, then yes, it's something that maybe I need to reconsider. So I think that's kind of where I am in terms of mini-PCNL.

Dr. Manoj Monga:

In terms of supine, it, once again, becomes to work when we improve and to date, I have not had a patient who couldn't be ventilated prone, who could be ventilated supine. So I think that was the initial driver for supine PCNL. The other driver is the ability to access the antegrade and retrograde, which you'll see in the video that we'll discuss shortly, can be done very easily in the prone position. So it's a matter of really defining where the value is and changing your practice.

Dr. Manoj Monga:

So those are some of the reasons why though, I certainly don't think that ... I think for supine versus prone, I think they're essentially equivalent in the right hands and learning one technique well is good. I think for ultrasound-guided, has great value for patients that we can't get retrograde access. I think the impact on fluoro time and radiation is there, but relatively minimal because most people get ultrasound-guided access. So we'll use some fluoro to help guide the wire down and wash for dilation, and the amount of flora we use with the endoscopic technique I think is probably equivalent.

Dr. Manoj Monga:

So there had been a lot of innovations throughout the world, and I think each of them needs to be evaluated critically. I suspect if we do this talk three to four years hopefully things will change because we always want to continue to improve what we do.

Dr. Brian Matlaga:

I'm sure it would. So I guess, we could maybe move into the case discussion to share some of the semi-live surgery video. I think we can pause at various times through it, because I think there'll be a lot of discussion points there, but would you want to walk us through, I guess a little bit about this particular patient and how your discussion with the patient ultimately led to the [ECRIS 00:14:35] procedure being performed?

Dr. Manoj Monga:

Certainly. So this is a lady, of Russian descent, with frequent UTIs, urease-producing organisms. Has had multiple percs bilaterally and comes back with recurrence of her stones as well as recurrence of her infections. Relatively asymptomatic with the exception of these UTIs.

Dr. Manoj Monga:

So in this axial views of her CT scan, we'll start to see her ... let's see, play. There we go. We'll start to see her anatomy pointing out here the pleura. So as we start at the top, work our way down, we're looking at the relationship with the rib. You see a moderately higher nephrotic kidney, some small stones, and then shortly we'll see the reason why are we performing PCNL. So this isn't one large stone burden. This is probably about a hundred stones, each of which we will find measure about one centimeter.

Dr. Manoj Monga:

Certainly one could say, well, multiple small stones, maybe mini-PCNL be a good approach. Here the balance is, well, if you have a hundred stones to take out, do you want to take them out in one piece, or do you want to break them up and take them out through mini-PCNL, especially in a woman who has frequent infections and maybe at a higher risk for sepsis? So that was the thought process into performing a 30 French PCNL as opposed to mini. Though, I think if one were to consider the role for mini-PCNL, multiple small stones might be one appropriate indication.

Dr. Manoj Monga:

I pause here just to show you one of the things we do in terms of preparing for the surgery. The morning of surgery on a whiteboard here, we have these magnets, which are placed on the left hand column you see open. On the right hand column you see in the room.

Dr. Manoj Monga:

There's a number of reasons to do this. The first reason is that we'd like to be able to identify for the people in the operating room, what equipment we need, so that hopefully there will be no delays. We like to be able to show the or go through with our trainees, the steps of the procedure. So usually we try to put the magnets on in order of what we're going to open. As we're doing that, we're talking to the resident, well, if the wire doesn't go up, what do you do? If you can't find the stone, what do you do? That's in a way troubleshooting what the step might be, if things don't go as planned. So the goal is helping with training, decreasing the costs by not opening up things that we won't need, and then also making sure that we can minimize the amount of delays in the operating room waiting for equipment.

Dr. Brian Matlaga:

Is that list, is that populated, I guess, for each case, by the nurses with a pick sheath, or is it one of your trainees staff? Who actually puts that? Because it's an incredible idea to make sure everyone is on the same page with equipment, which is oftentimes expensive.

Dr. Manoj Monga:

This is, you could say, to compliment the preference cards, which most surgeons have because the preference cards we tend to lean on being over-inclusive. So we have what we need as opposed to under-inclusive, where we control cost. So those magnets are put up by me at the beginning of the case with the resident and or fellow standing beside me, and us running through that problem shooting. After a few weeks, the residents and trainees will start putting them up themselves and then I'll review them and comment on things that maybe are in the wrong order or missing. But yes, it's something that we do at the beginning of every case, because as I'm sure everyone on the call will agree, not every perc is the same. Someone with obesity, you might need specific equipment open that you wouldn't normally have. Someone who already comes with access there'll be things that you don't need. So it can be a fair amount of modification to the list depending on the specific patient's needs.

Dr. Brian Matlaga:

As we've been talking two questions have come through. Both about renal anatomy. One is just a question of, have you undertaken the ECIRS approach in a horseshoe kidney, if you have experience with that. Then the second is just regarding this patient in particular has thinner cortex, presumably from her kind of antecedent history of multiple stone procedures, but just to comment on both of those.

Dr. Manoj Monga:

The common in terms of a horseshoe kidney, yes. The procedure works just as well with the horseshoe kidney as it would with any other procedure. Typically, the UPJ is more cephalad, so it's a high insertion UPJ, but it's also usually fairly wide open, and it's a straight shot up to the upper calyx, which is typically where we get our access. I'm sorry, remind me the second question is?

Dr. Brian Matlaga:

The cortex on the kidney is just a little bit thin, was the observation, which I would agree with, and I'm sure you would, too. Is that you think just likely a consequences of multiple prior stone events and interventions?

Dr. Manoj Monga:

Yes, most likely related to her prior infections, as well as her prior surgical event.

Dr. Manoj Monga:

So here we pause the video just to show the setup in the operating room. So this view here, we have the patient prone, [inaudible 00:20:23] legged, and again, this is a woman. So in a man, we would be prepared with a flexible scope to perform a cystoscopy. In a woman will be preferred to prepared with a rigid cystoscope. These stirrups are made by STEERIS, so they'll fit on any operating room table. You don't need a special table to perform this procedure. You just need these adapters which will work with any table.

Dr. Manoj Monga:

The patient goes to sleep on a gurney on the side of the room, and then we flip the patient in a controlled fashion, coordinated with anesthesia. Typically, I'll have holsters under the armpits. So some people call these axillary rolls. Some people call them chest rolls. I would probably refer to them as axillary rolls because I think the main goal for me is to make sure that the brachial plexus is protected. I'm not certain that placing the rolls under the chest necessarily help with ventilation. If anything, it may impede ventilation. My other concern specifically in terms of the ipsilateral side, the side where we're operating is that if those bolsters are pushed in too far, could I potentially be pushing bowel backwards and increasing the risk of a bowel injury, which so far hasn't happened, and we would prefer for it not to.

Dr. Manoj Monga:

The one thing I'll point out is that once the patient is prone, we do put the bed in a bit of Trendelenburg. Basically, what we're looking for is for the back to be flat. Once the back is flat, that's the amount of Trendelenburg that we keep the patient in for the rest of the procedure. That was something that I adapted after listening to a talk by Ken Pace and John [Honey 00:22:01] in terms of them using a table that flexes to flatten the lumbar area. Because these tables don't flex, we were able to accommodate the same modification by placing the patient in Trendelenburg.

Dr. Manoj Monga:

Some of the things we've noticed is that our risk of pulmonary complications is much lower than what's been reported with supracostal sticks, even though in about 10 to 15% of the cases we're going above 11. I'm not certain if it's because of this repositioning into Trendelenburg or if it's because of the endoscopic approach that helps us really pinpoint the papilla, but fortuitously, the risk of pulmonary complications is lower though not zero certainly, something that we always pay close attention to when we're doing our preoperative planning.

Dr. Brian Matlaga:

All other things be equal, do you have a preference for upper pole lower pole, or do you really just kind of play the hand you're dealt if you will?

Dr. Manoj Monga:

Yes. I might not even say all things being equal. I would say I'm very unequally biased towards the upper calyx and it would only be if on the CT scan in the axial view, we can clearly see that we're going to be getting into the lung. In that case, I will modify my technique, but otherwise it's upper calyx.

Dr. Manoj Monga:

The other situation where we might go middle calyx would be if it's just a pelvic stone, or if we're just addressing a proximal ureter or ureteral stone. In those situations, we may not necessarily go upper calyx but we might go middle. It would be a rare situation where we would go specifically to the lower calyx though again, here, I have a lot of respected colleagues whose opinions I value who routinely go lower and never go upper. So it's one of those things where I think practice to a certain degree steers what you do based on getting better at the way you do it.

Dr. Manoj Monga:

One thing that I'll point out here is that the monitor it's helpful to have on a swivel so that you can not only move it into the field of view for the assistant who starts off in a sitting position here, that way there's less strain on their eyes while they're performing the cystoscopy and the ureteroscopy. But then you also can swivel this towards the surgeon who will be standing here at the time of not only puncture, but also nephroscopy.

Dr. Manoj Monga:

We then have our CRM, which will come in right beside the endoscopic tower. Then our CRM monitor will be here at the head of the table.

Dr. Manoj Monga:

Are there any questions about positioning? Here we're starting our cystoscopy in the prone position. One of the key things is to get all the air out of the tubing, because if we had air in the tubing on that top left hand, rather than seeing the ureteral orifice, we would be seeing air. Once you have air in the system, it's very difficult at times to be able to identify the ureteral orifice. In this situation, we're using a 5 French open-ended catheter to help us calculate the ureteral orifice with our guide wire.

Dr. Brian Matlaga:

Now if, hypothetically, if there was a obstructing ureteral stone, as well as a renal stone, would you approach that with prone, ureteroscopy and then proceed? Or would you do ureteroscopy in a conventional lithotomy position and then flip the patient? What would be your approach?

Dr. Manoj Monga:

The answer to your question, Brian, if the patient has a ureteral stone, if it's a woman I can usually perform semi-rigid ureteroscopy for distal stones, even in the prone position. Obviously that's a challenge/not possible in a man. So in that situation, we might still go prone but plan on ureteroscopy with a flexible scope and addressing the ureteral stone before advancing.

Dr. Manoj Monga:

So the presence of a ureteral stone won't necessarily dictate the use of this technique or not. If I did have an impacted stone in the ureter where I'm concerned that I may not be able to get past it, the options would be again to go prone retrograde, use the laser to clear that stone, and then proceed or consider using ultrasound to get access either at the time of surgery or prior to surgery, either by myself or with the assistance of a radiologist. But that is a good point and that might be one of the situations where over time it would be good to evolve to a supine approach where one could do traditional ureteroscopy to clear the ureteral stone and then proceed with the PCNL.

Dr. Manoj Monga:

So we're paused here just to show in this fluoroscopy image here, we have our initial wire up to the upper calyx. We're passing a dual lumen catheter down at the bottom to place the second wire. The initial wires used could be a PTFE wire or a hybrid wire, and then the second wire is going to be a super stiff wire to help us place an access sheath. If we could start the video, please.

Dr. Manoj Monga:

So one thing I'll point out is that here with the dual lumen in place, this is telling me how long a sheath I can place. So in a woman, typically it will be 28 or 36 centimeters. In this situation, we use the 36 centimeter sheath because the dual lumen's advanced a fair distance.

Dr. Manoj Monga:

The ease of placing the dual lumen will also guide me as to whether we can try a larger sheath or a smaller sheath. So here we're using a ureteral access sheath to advance over the super stiff. The motion for sheath advancement is like this, that's a trick I learned from our interventionalists, that when they're trying to pass anything over a wire, a motion like this is better than pushing it hard.

Dr. Manoj Monga:

On the upper right here, we see that the sheath is positioned at the UPJ, and now we're shifting-

Dr. Brian Matlaga:

I was going to say, what size sheath is your preference for this? Diameterwise.

Dr. Manoj Monga:

The preference is really guided by your ureteroscope. You'll see that one of the things that we try to do is bring a wire through and through the sheath, and that way we have access on either side so we don't lose our access.

Dr. Manoj Monga:

If one's using a smaller diameter sheath, like a bore or a Storz digital, or a Olympus P6, or a Storz FX, those would be the types of scopes where one could have a wire alongside the scope using a 12/14, or 11/13. On the other hand, if one's using a Viper or another scope that's a little bit larger, in those situations one might need a 13/15, or one might need to take the sheath out and replace it. So those are some of the things that guide the diameter.

Dr. Manoj Monga:

I think I [inaudible 00:29:15] 12/14 is sufficient in terms of getting the advantages of maintaining little intrarenal pressures, but there's that caveat about what type of sheath can you have a wire and a scope within the lumen?

Dr. Brian Matlaga:

Have you had the experience where you couldn't get a sheath up and then kind of, what is your sort of pathway then?

Dr. Manoj Monga:

If I can't get a sheath up, so one of the things is that over on that right hand column of equipment to have in the room, it would include having a J-wire and a [inaudible 00:29:45]. So I would be prepared to shift over to the fluoroscopic guided puncture in the event that I can't get a sheath. Those would be the two pieces of equipment that normally we wouldn't need if we were doing an endoscopic-guided access. The J wire, I think, is a good wire to have to avoid going through and through once you get access if it's not endoscopic, then the [inaudible 00:30:04], would be needed to place the second wire.

Dr. Manoj Monga:

The other option is to do a retrograded approach, but to place the scope over a wire as opposed to using a sheath. That would be another possibility, and which of those two to choose would depend on why the sheath isn't going up.

Dr. Manoj Monga:

I think you might've got a glimpse here that some of the stones are actually fairly small. What was unique, I think the first time I've seen this in a PCNL was that we had to go in and out a few times to clear stones out of the access sheath, and these are being cleared just by irrigation and that was needed to be performed. You can see there in my hand that the stones are fairly small. So we go in a few times here to clear our path for our scope to get up to the upper calyx.

Dr. Manoj Monga:

In terms of knowing that our scope is getting to the upper calyx, the first step is just advancing it straight and not deflecting. The second thing is knowing that from the fluoroscopic image, that the wire was in the upper calyx. The wire can be another guide to let us know that we're heading in the right direction. The third thing we'll see is that we're looking for an air bubble in the calyx to tell us that it's one of the more posterior calyces within the collecting system.

Dr. Brian Matlaga:

I've noticed you prefer to sit rather than stand. Is that ...

Dr. Manoj Monga:

The sitting is something that I do typically for all my ureteroscopies. I think it's more ergonomic, especially if one has one foot on the floor pedal or one foot on the laser pedal. So for longer cases, it most likely leads to less strain on the back, especially if one's wearing heavy lead for a long procedure.

Dr. Manoj Monga:

Some people have raised the question of whether there's more scatter radiation to the surgeon, if you're sitting as opposed to standing. I think that's something I need to consider, but yes, I typically sit for my ureteroscopic cases.

Dr. Brian Matlaga:

Just in kind of very tangential, so it looks like you also wear white glasses just since we're talking about radiation exposure?

Dr. Manoj Monga:

Yes, so these glasses radiation exposure leaded, some protection, I think from the laser, use of laser goggles for holmium I think is somewhat controversial, whether one needs them or not. But if there's a hospital policy to wear goggles which is satisfying protection from fluid, protection from laser, protection for fluoro, and what you can't see is there's a bit of bifocal built in there for me now that I'm getting a bit older.

Dr. Manoj Monga:

So here one could appreciate that there is a bit of abnormality in terms of her collecting system due to her probably her prior infections and surgeries, and as well as was alluded to the parenchymal thinning. So here we are starting to identify which calyx we would like based on the endoscopic view, and then we'll confirm up here on the right that fluoroscopically, it looks like a good calyx.

Dr. Manoj Monga:

If we could pause just for a second. So in that upper column, what we're looking for is number one, how straight is the scope? So if the scope is fairly straight, it means that we don't need to rotate the CRM. If that scope was curved, so let's say when we looked at the scope was here and the tip of the scope was here and the scope was curving, we would then rotate our image intensifier until the scope looks straight. That would be how we align our tract with the angle of the infundibulum. Typically for an upper calyx [inaudible 00:33:57] stick, the scope will be fairly straight so our punctual will be fairly perpendicular.

Dr. Manoj Monga:

The second thing we're looking for on this image is the position of the rib in relation to where we're expecting our puncture, which would be the tip of the scope. If when we did this image, the rib was overlying the tip of the scope, then we would rotate the CRM image towards the head. By rotating the image towards the head or the intensifier towards the head, then our puncture would be this way above the rib and avoid us from hitting bone when we advance our needles. So those are the two things that we focus on when we do that initial fluoroscopic view.

Dr. Manoj Monga:

If you could-

Dr. Brian Matlaga:

Since we're talking about scope, just a quick question that came through. What type of scope is this? Do you have a preference, single use versus reusable scopes with regards to ECIRS?

Dr. Manoj Monga:

Yes. This scope is a single use scope from Bard. Typically, we use a reusable scope. I like the Wolf Viper in terms of its optics and maneuverability, but we're fortunate as urologists now to have many good alternatives. The main thing that drives my decision about which scope to use at this point is really the optics. I think all of them have very good maneuverability. The size of the scope is one other consideration. So I'm looking for the scope that gives me the best optics with the smallest diameter that would allow me to use a sheath that won't be too large for the patients ureter.

Dr. Manoj Monga:

We could resume the video. Thanks. So now that we have our access identified, you'll see me there in the bottom left. I've moved over to the side of the patient. My esteemed colleague, Dr. [Kasher 00:35:56] is performing the ureteroscopy to keep the scope nice and stable as a target for my needle. Up here, you'll see that I laid my needle down in a horizontal view and then rotated the needle up to make a bullseye. You can also note that right there, my bulls-eye is a little bit off the mark, so I'll lift up the needle and move it back a little bit to try to get it more on the tip of the scope. It's all a question of millimeters really.

Dr. Manoj Monga:

The other thing I didn't point out initially was that we have the spine on top so we've rotated the image 90 degrees. That way, when I move my needle to the left, it moves left. When I move it to the right, it moves right, rather than doing a lot of this motion because we're working 90 degrees off.

Dr. Manoj Monga:

In this view here, you'll see that we're advancing the needle. It is really fairly perpendicular because of the angle of the tip. If anything, you can see, there was a bit of a curve so one might've gone towards the spine, as opposed to being straight up and down.

Dr. Manoj Monga:

But once we've made the bullseye and are advancing the scope, after we've gone in about this far, we then rotate the CRM, as you see here a little bit away from us, and that's so that we can judge the depth of the needle as we're advancing. Once you reach a point where we think we're in, it's confirmed by our assistant here endoscopically. We see that the needle has come in at the tip of the papilla, and we're looking down the barrel of the needle.

Dr. Manoj Monga:

Dr. Clayman and colleagues have reported a technique where they then advancing the wire through the needle. I think that's a wonderful adaptation if it's feasible, but I found it sometimes a little bit challenging to be able to thread that needle. So we will pass a wire through the scope, sorry, through the needle, and then grab it with that tipless basket that you saw and then come out the sheath. So then we have the through and through access.

Dr. Brian Matlaga:

Do you ever use an adjunct like air [inaudible 00:37:54] or anything to help better delineate posterior?

Dr. Manoj Monga:

I don't, because typically there'll be some air in this case, perhaps it was less than usual. But typically there'll be some air floating in the calyx that helps identify the most posterior calyx. But that stick was real time. You saw it was one stick. It took maybe I didn't count, but maybe a minute. And there was very minimal use of fluoroscopy primarily to judge the alignment of the needle initially, and then the depth of the needle as it advances.

Dr. Manoj Monga:

Then what you'll see is that from here really, there's no fluoroscopy used for the dilation. If there is, I mean, we were doing it mainly for teaching purposes, but I suspect without having reviewed the video recently, that you won't see anything in that upper right column, because with the endoscopic technique, the track dilation and advancement of the sheath is all performed with endoscopic guidance as opposed to fluoroscopic.

Dr. Brian Matlaga:

This may be more of an anecdotal observation, but have you noticed any benefit to having the scope in the kidney in terms of stabilizing the kidney? I'm sure you've had the experience of some patients with kidneys that are just incredibly mobile and as you stick the needle in, the kidney's just moving away from you. Has this helped reduce that, do you think?

Dr. Manoj Monga:

First I would say that we're fortunate that that isn't necessarily a common occurrence. In this patient perhaps, having had multiple prior PCNLs, her kidney's more stuck than usual. Perhaps why it's not a common occurrence might be related to having the patient study from Dillenburg. Maybe it's more mobile when you're trying to stick the lower pole than the upper calyx. Those are all theoretical things, but I would say I haven't had enough of a experience where its mobility has been an issue to comment on whether having a sheath in the scope up makes a difference or not.

Dr. Brian Matlaga:

Then one question just in regards to the needle, what were you using to hold the needle?

Dr. Manoj Monga:

We were using a product from Cook Urological. It's a radiolucent holder that allows you to keep your hands out of the field of view. So it's called the Amplatz needle holder from Cook.

Dr. Brian Matlaga:

Is that a reusable device or is it single use?

Dr. Manoj Monga:

It has evolved from a single use to a, sorry from a reusable device to a single use. Or you could say it evolved.

Dr. Brian Matlaga:

[inaudible 00:40:27] in your perspective.

Dr. Manoj Monga:

Yes. So here, I'll just mention, you're seeing us advance through the sheath to get it back up to our puncture point. You could see that the wire was coming in through the lumen of the sheath, and there's still sufficient room to advance our scope. Here, the challenge is deciding which of the two wires that are up the safety wire that was placed initially, and the wire that's run through, which of those two is the puncture one. Here we see that that is the one and Nevin is very skillfully centering the wire within the center of my view, which will then be how we perform our track dilation.

Dr. Manoj Monga:

So this point, the dilation could be performed either with a balloon with serial Amplatz dilators, with the alkyne dilators. So no matter what the dilation system, I think the endoscopic guidance allows you to make sure that you're not advancing too far and causing a perforation, or you're not advancing too shallow so that you look in and see parenchyma instead of stone. Maybe we could pause the video there so I could answer Brian, the question that you were about to ask.

Dr. Brian Matlaga:

I was about to ask just, I'm looking at the image in the lower left hand corner, do you drain the bladder during this procedure either with a Foley or some ...

Dr. Manoj Monga:

Yeah. We drain the bladder after we've placed the wires. That way the contralateral kidney is drained throughout the procedure, which again, will typically be an hour, but it most will be two to two and a half hours. I'll stop the PCNL at two and a half to three hours if we're not done. I think that's sufficient to keep the contralateral kidney drained because we have an access sheath in throughout the procedure that's providing drainage of not only urine, but also the irrigant for the ipsilateral kidney.

Dr. Brian Matlaga:

Then my other question is just your thoughts. Again I think as a field, we don't have a lot of scientific evidence on this, but there is increasing discussion about the role of intrapelvic pressures during surgical procedures. Does that have some effect on possibly whether it's pain afterwards, SIRS, sepsis, bacteremia, those sorts of things. Obviously, this is a fairly maximally drained procedure with a percutaneous access sheath plus the ureteral access sheath. Do you have thoughts on ... Is this a approach that may reduce the risk of infectious complications?

Dr. Manoj Monga:

Yeah. I think our data is fairly solid that high intrarenal pressures are not good, they're not good in terms of the risk of fluid overload, they're not good in terms of the risk of inoculation of bacteria into the bloodstream or other organs. So we know that high intrarenal pressures aren't good.

Dr. Manoj Monga:

We know that decreasing the track size increases internal pressures. So there've been, I think, fairly good studies that support both of those two things. I would agree that there is controversy in terms of the clinical relevance of the high intrarenal pressures, because there are a large series either with ureteroscopy without a sheath or with mini-PCNL that today haven't demonstrated at a higher risk of sepsis or a higher risk of complications related to the intrarenal pressures. So maybe an area of controversy, but I would tend to be in the school of thought that maximizing drainage and minimizing intrarenal pressures as long as it doesn't increase morbidity from another standpoint is probably a good thing.

Dr. Brian Matlaga:

Thank you.

Dr. Manoj Monga:

So if we could restart the video. Over in this side here, you'd see me advancing my balloon and we see it entering here. So here, I think it is important to consider what balloon you're using. Here, we're using a Bard X-Force. The advantage of that number one, it's the one balloon that it dilates to 30 atmospheres, which may not be important for all patients, but maybe more important for someone who's had prior retroperitoneal surgery and potential scarring. So that 30 atmosphere and facial pressure will hopefully mean that the balloon will inflate fully.

Dr. Manoj Monga:

The second thing to consider is that it's white, and because it's white, it's a bit easier to see. If this balloon was clear, transparent, which I've tried in the past, sometimes it's a bit more challenging with an endoscopic approach to really identify the balloon when it's clear. So those are two reasons why we're using this balloon.

Dr. Manoj Monga:

Now, we're advancing our sheath. You see here in a gentle, twisting motion, not a forceful motion and are watching the sheath come in. So again, just to emphasize the value of doing this endoscopically rather than fluoroscopically, both in terms of decreasing radiation, but making sure that the position of the sheath at the time that we're now inserting the scope will allow us to see the stones.

Dr. Manoj Monga:

Here, we're using a another product from Cook. I believe this is the Perc NCompass. So two products, one's a perc compass, one's a perc circle. The perc compass is helpful for multiple smaller stones, whereas the perc circle is good for larger stones. As we're removing these stones, again, one could reflect on the question of mini-perc versus standard perc. I think this may be a good demonstration of how the 30 French sheath helps facilitate the operative time in a patient who is perhaps at a high risk for sepsis.

Dr. Brian Matlaga:

The other interesting thing to notice is oftentimes in a conventional perc to enter with the scope and you spend that first 30, 40 seconds essentially sucking out clot from the collecting system. You really don't have that here.

Dr. Manoj Monga:

As we are talking, Mike, could you just rewind it a bit there? So here, I just want to show I go in, come back and then you'll see me there pull the sheath back a little bit. So it's important to have a sheath that's easy to maneuver. There was this upper calyx that's anterior that I couldn't see because the sheath was just a little bit too far. So I just wanted to point that. I don't know if that was apparent to the audience.

Dr. Manoj Monga:

Brian, sorry. The question was?

Dr. Brian Matlaga:

Oh, it was more of just a comment that oftentimes with the conventional non-ECIRS perc, when you enter the kidney, you spend the first 30 seconds just essentially sucking clot out to get visualization. And really, the kidney was pristine when you entered it here.

Dr. Manoj Monga:

Yes. If I see clot when I put my scope in, it means that I did something wrong. It could be that I didn't get an accurate access. It could be that I thought I dilated to the right place, but I didn't. But if I see clot, I did something wrong.

Dr. Manoj Monga:

So the rest of the video, I can't see exactly how much time we have left in the video. There's a bit of repetition here in terms of all these fragments. There'll be a point where we see actually some value in the access sheath in this patient, because some of the smaller fragments you'll see washed down the UPJ. There'll be a point where, so I think here maybe, where you'll start to see some fragments washed down the sheath. And we-

Dr. Brian Matlaga:

Do you like to position that access sheath up above the UPJ or slightly below the UPJ?

Dr. Manoj Monga:

Yes, that's a good question. We typically position it right at the UPJ. Here, I believe you'll see that we repositioned the sheath so it's actually a little bit higher there because we were starting to appreciate that, Oh, there's going to be some value here. We'll be able to have some fragments wash out. So you saw there how, just as soon as Nevin repositioned the sheath, some of those fragments started to wash out the sheath.

Dr. Manoj Monga:

In retrospect, watching this video one could say, well, maybe I should have removed that wire, and we would have had even better efflux with these small fragments, but I'm always ... You see that there how all those farmers were washing out? I'm always hesitant to burn my through and through access because once you get that, you don't want to lose it.

Dr. Brian Matlaga:

Yeah, the one time you do it is the time you regret it. A question came through about ClearPetra or the devices that promote stone evacuation?

Dr. Manoj Monga:

Yes, and I'll just point out here before I answer that question, you'll see me now trying to get down to that lower pole. You'll appreciate that over here, there's a bit of a lip. I think here also is one of the important things that the torque of the scope is going to guide you as to when do I need to switch to flexible? The key is to make that switch either at the time that you think you need to, or a little bit before. Because as soon as one pushes it a little bit far, that's when the bleeding starts.

Dr. Manoj Monga:

Sorry, the question about the ClearPetra. I think the ClearPetra is an example of a very good device. The currently I think, is being evaluated primarily for the mini-PCNL with regards to trying to improve clearance of fragments while maintaining low intrarenal pressures. I certainly think there may be value even for a larger sheath, but unless I'm wrong currently, that's not one of the emphasis of its development.

Dr. Brian Matlaga:

Then another question came through, which is a kind of another little bit of a discussion point. If hypothetically this stone was perfect for this approach, but if you had a staghorn stone that the calyx that you wanted to puncture, you just couldn't get the ureteroscope in. I guess one, has that happened, and then two, what do you do then?

Dr. Manoj Monga:

Before I answer that, maybe I could just point out now that we've switched to the flexible cystoscope to get to the lower calyx, you'll see that the lower calyces are relatively clean. So the pressure I think, has helped us to flush many of these fragments out from the lower pole and into either the pelvis or down the sheath.

Dr. Manoj Monga:

In terms of maneuvering the ... let me get my arrow back here, take the arrow. So in terms of maneuvering the scope, you'll see that it's all a matter of gentle rotation of the wrist. You'll also notice that I have the scope ... I'm holding the scope upside down. So my thumb is on the deflection. The reason for that is typically with a flexible cystoscope, you'll get better angulation, or the tighter angulation one way than the other way. By having that tighter angulation, you're oriented towards the lower calyx thus more likely that one can get into the lower calyx, if it's a tight angle.

Dr. Manoj Monga:

Here, we're seeing that fluoroscopically, we're just checking to see are there any large stones that we may have missed? We will eventually go to a high magnification view. This is just an image to show you that we're getting to those tough-to-get-to lower calyces. Sometimes one might find that pulling the sheath back will help with the angulation, but in this situation, it appeared that we didn't necessarily need to do that.

Dr. Manoj Monga:

Here you can see that I'm trying to hunt down that stone there, which we will eventually find over there on the left screen. There it is there. It was a little bit tough to get to. It looks like it may be more of a inner Frankwell. The stone, as we were suspecting was a struvite and the stone culture was positive. So indeed this was most likely the source of her persistent/recurrent urinary tract infections.

Dr. Manoj Monga:

So yes, Brian, sorry, you were asking.

Dr. Brian Matlaga:

One question was, when you can't get the ureteroscope into your ideal calyx at puncture due to a large like staghorn type stone burden, what your maneuvers are.

Dr. Manoj Monga:

The maneuvers depend a little bit on where are we getting stuck. If we're getting stuck say at the UPJ, in that situation, I'll most likely switch to a fluoroscopic [Ida 00:53:06] puncture. If on the other hand, we've been able to get right to the infundibulum of the upper calyx, but we just can't get to the tip of the papilla, in that situation, I'll use a laser to try to fragment the stone to reach the calyx.

Dr. Manoj Monga:

But if there's a fairly large bulk of stone between me, and the tip of the papilla, we'll typically switch to a fluoroscopic, or if one does ultrasound, one could do ultrasound guided puncture.

Dr. Brian Matlaga:

Then how do you drain these patients afterwards?

Dr. Manoj Monga:

Every patient we drain with a 7 French double J. This typically positioned in the real pelvis and a 18 French Foley catheter that stays overnight. If the next day their urine looks fairly clear, they haven't had a fever, then they go home. So typically 90% of patients will go home within the first 23 hours. Then they come back five to seven days later for their stent removal.

Dr. Manoj Monga:

Patients where I might leave the Foley catheter longer would be patients who've had a history of retention or have significant LUTS because of BPH. The most common reason we'll encounter delayed bleeding will be they've gone into retention because of lower urinary tract issues.

Dr. Brian Matlaga:

This hour has absolutely flown by. We have three minutes left. So Manoj, what would be your take-home points from kind of what we've talked about over the past hour?

Dr. Manoj Monga:

I think the first take-home point goes back to my disclaimer that this is one technique that myself and others do, that has worked well for our patients. It doesn't necessarily mean that this is the way that everyone should do it. I think each of us has a lot to learn from each other and it's good to have openness to trying something new or watching or learning and deciding is it something one would like to adapt.

Dr. Manoj Monga:

I think the second take-home is that in my mind, keeping intrarenal pressures low so as one looks at modifying techniques, considering the impact on intrarenal pressures is important. The third take-home is that The Endourology Society is a wonderful society who's provided a lot of opportunities for all of us on the call. It continues to innovate in these difficult times so I would like to again thank The Endourology Society as well as all of the participants for taking the time to join us today.

Dr. Brian Matlaga:

Thank you Manoj. I'd like to thank you for making this such a easy session for me to moderate. It's clearly masterful, what you presented, and again to echo for The Endourology Society. This is obviously a large initiative with many hands in it but Adrian Joyce's leadership as the Director of Education, putting it together, Debbie [inaudible 00:56:01] and Michelle Paoli from the Society who've handled the logistics of this and then [inaudible 00:56:08], Evangelos Liatsikos, Ben Chew, who've all helped with putting together the program.

Dr. Brian Matlaga:

So on that note, I'd like to turn it over to Dr. Winoker our host. Thank you again for allowing me to be a part of this.

Jared Winoker:

Excellent. Mike, if you don't mind just pulling up the other slide. But again I want to thank all of our panelists. We appreciate having Doctors Matlaga and Monga for an excellent discussion. As a reminder to all of our participants, I'm glad to see you're still on the line, there will be a transcription as well as a recording of this webinar all available for you on the website after a few days, so be sure to check it out. We'll also try and collect any of these unanswered questions that are still rolling in and distribute them amongst our masters to get those questions to you.

Jared Winoker:

A final reminder, next week at the same time, 12:00 o'clock Eastern Time, we're going to be joined by Dr. Mantu Gupta and Dr. Kelley Healey, who'll be discussing soft tissue applications of the holmium laser in the upper urinary tract. Thanks. Take care.