Surgeon: Dr. Guido Giusti
Guido Giusti is head of the Stone Center and European Training Center of Endourology at San Raffaele Turro Hospital in Milan, Italy. Since 2012 he has chaired the European Training Center of Endourology and has overseen more than seventy international courses.

Moderator: Dr. Brian Eisner
Brian Eisner is Co-Director of the Kidney Stone Program at Massachusetts General Hospital, Harvard Medical School. He has published over one hundred journal articles on endourology and stone disease.

 

Webinar Transcript

Dr. Brian Eisner:

Well, good afternoon and welcome to this webinar sponsored by the Endourological Society, a Masterclass in Endourology and Robotics. We're thrilled you're joining us today, and thank you for being here. This is our slide describing our CME program for this webinar today. So my name is Dr. Brian Eisner, I am the moderator for this session.

Dr. Brian Eisner:

In a minute I'll introduce our Speaker of Honor, but first I just wanted to show two things. The first is that there are several other of these masterclasses being held by the Endourological Society over the next few weeks. You see May 22nd, Amy Krambeck and Dr. Thomas Hermann talking about holmium laser surgery of BPH. Dusting technique on May 29th by Dr. Khurshid Ghani and Dr. Evangelos Liatsikos. And then Dr. Zeph Okeke and Andreas Gross will talk about thulium laser treatment of BPH on June 5th. You can register at www.endourology.org and click the masterclass in endourology. So please join us for those sessions.

Dr. Brian Eisner:

With regards to CME, Continuing Medical Education, you will receive a survey from Michele Paoli. Please indicate which seminars you have attended. You will get a CME certificate, and please fill out the evaluation questionnaire at the end of each seminar. I also want to remind you to please use the Q&A function to ask questions today.

Dr. Brian Eisner:

And now it gives me great pleasure to introduce a great friend of mine, a man who is truly a modern endourology master, suited to teach this masterclass. Dr. Guido Giusti is a urologist at San Raffaele Hospital in Milan, Italy, and the head of the European Training Center in Endourology. He is a world leader in all aspects of endourological stone treatment, and is known for his passion for surgery as well as innovative surgical thinking. I know that I'm very excited to learn some tips about ureteroscopy from Guido today, and we are thrilled to have him. So Guido, I'm going to turn it over to you, and I look forward to a very informative hour.

Dr. Brian Eisner:

The one other thing I want to tell you is that we will be launching poll questions. Please feel free to answer them. And again, type your questions in the Q&A. That's all I have to say for now, so Guido, please take it away.

Dr. Guido Giusti:

Okay, Brian. Thank you very much for your kind introduction, which I found a little bit exaggerated, but anyway, thank you very, very much. And let me also thank the Endo Society for this honor, to be part of this wonderful initiative, which is this webinar about how I carry out, usually, a ureteroscopy using high-power holmium laser in my daily practice.

Dr. Guido Giusti:

First of all, I want to introduce some news about the patient. The patient was a 55 years old male, with a negative past medical history. And because of left recurrent renal colic, he discovered to have a left 12mm stone in the renal pelvis, with a density close to 1,000.

Dr. Guido Giusti:

This is how the stone looked like on the CT scan. As you can see, in my hand, it represent the ideal case for a flexible ureteroscopy, which is a midsize stone, I would say, perfectly in a mildly dilated renal pelvis. So I would say, in my practice, this is a good indication for a flexible ureteroscopy.

Dr. Brian Eisner:

Guido, do you mind if I ask a quick question here to get us started?

Dr. Guido Giusti:

Yes, please.

Dr. Brian Eisner:

So the first question I just wanted to know is, when your radiologists give you back a CT scan report, do they routinely report the Hounsfield units and the stone dimensions? Or do they just report the size, and you measure the Hounsfield? What's a routine radiology report? Or, what would you like to see from your radiologists?

Dr. Guido Giusti:

Well, honestly, I have a very good relationship with my radiologists, so actually they are recording always both Hounsfield density and also the volume of the stones. But unfortunately I would say that 50% of the CT scan of my patient are not done in my hospital, so of course I don't have this data available. So, usually, I always refer to Horos, which is a program for Mac computer, and I can do all volume calculation and all density calculation by myself. Because, I think that it is very important to have these parameters when deciding which is the best surgery for this patient and for this stone.

Dr. Guido Giusti:

So, Brian, do you agree with my indication, first? Or, would you choose something else?

Dr. Brian Eisner:

No, I would agree. And thanks for asking me, Guido. I would say, in my own practice, although one could consider shock wave or Miniperc or ureteroscopy for this, I personally don't love shock wave for stones this large, because I think there's a risk of being obstructed with the fragments. And I think one could either consider ureteroscopy or Mini-PCNL, but 12mm, I would agree with you. My first line would be ureteroscopy for this.

Dr. Guido Giusti:

Okay. So that's why I decided for flexible ureteroscopy, and I think that we can start with our video. So, as you can see, this is actually my normal practice. I use only flexible ureteroscope. Of course, the semi-rigid ureteroscope, and also a cystoscope, is always available in the OR, but I open all of them just in case. Because, at least in my practice, Brian, you know, when you have a [inaudible 00:06:21] with six or seven flex ureteroscopy, you can imagine that, if you don't use all the other equipment, you save some reprocessing for all our scope, and it is also a lot of a workload for my nurse team. So usually it's very easy. I start with my flexible ureteroscope, I identify my ureteral orifice, like in this case. Usually I start to cannulate the ureter without a guide wire, but this [inaudible 00:06:50] was very, very thin, so I preferred to introduce just few centimeter of the guide wire.

Dr. Brian Eisner:

[crosstalk 00:06:56] You know, Guido...

Dr. Guido Giusti:

Yes.

Dr. Brian Eisner:

One quick question right here. I'm sorry to stop you so soon.

Dr. Guido Giusti:

No problem.

Dr. Brian Eisner:

In the States, I do know of people who go in right with the flexible scope, although I would say the majority of people I think place guide wires first with a rigid cystoscope. And it seems to me like you and [Silvia 00:07:16] have now adopted the practice of going directly with the flexible ureteroscope. What cases would you start with the rigid cystoscope? Because this does seem like a very logical technique, but I think at least in the States we're still stuck on starting every case with a rigid cystoscopy.

Dr. Guido Giusti:

Well, Brian, honestly this is my practice since one year now. Before this, I started always with the semi-rigid ureteroscope. Honestly, I always start like this right now, but I keep them just in case. Sometime I have to take my cysto, because maybe you have some bleeding. If you have a big [inaudible 00:08:00], maybe just the traction with the scope you can cause some bleeding, and if the vision is a little bit impaired, of course sometime I still have to take my cystoscope. But believe me, it's only the method of [inaudible 00:08:13]. Because in the beginning we used to do so, but believe me, if you start to do like this, it's very easy, very fast and straightforward in the vast majority of the cases. And at the end of the day, you didn't use an extra cystoscope, an extra semi-rigid, so it's a real advantage. You will see that your nurse team will love this.

Dr. Brian Eisner:

Okay. And there's a few great questions already from the audience, so maybe I'll just ask. Actually, your good friend Mario Sofer from Israel wants to know, does it matter if we know the Hounsfield units for flexible ureteroscopy? Or, why are the Hounsfield units important if you're choosing flexible ureteroscopy?

Dr. Guido Giusti:

Well, if the stone would have been 1,600, for sure, I would have placed the patient in position also for Miniperc. Meaning that I would have started the same ureteroscopically, but if I had the impression that I was not doing a good job, patient was already in position for a good supine PCNL, and I would shift to supine on the way. So this is important. For 1,000, of course, flexible ureteroscopy is supposed to be by far the best indication. In the meantime, we go [inaudible 00:09:31].

Dr. Guido Giusti:

So, Brian, you see, once I am into the ureter, beyond the intramural ureter, I remove the guide wire, and I go up without guide wire, only with my scope. Here, as you can see, the scenario was a little bit different from the CT scan, because we found the stones start at the UPJ, and not in the renal pelvis like in the CT scan. That's why, in this moment, I prefer to start without guide wire, without ureteral access sheath, just to try to remove the stone from this position, which is a little bit risky. [crosstalk 00:10:18] In order that...

Dr. Brian Eisner:

[crosstalk 00:10:19] Two...

Dr. Guido Giusti:

Tell me, Brian.

Dr. Brian Eisner:

Two questions, my friend. So the first question is, yes, when I reviewed the video, I noticed that you were going to get a little bit of a surprise, because this looks like more of an impacted upper ureteral stone, as opposed to a stone floating in the renal pelvis. So my first question is, if you perform a CT scan and tell a patient they need ureteroscopy, but there is some time delay between the choice to do the operation and the actual execution of the operation, what time interval are you comfortable with without repeating the imaging? Or to say it another way, did it bother you that this was a surprise, or how could we not be surprised by this? I know of course you can handle it, but is there a certain time between the initial consultation and the surgery where you say, I might want to repeat my imaging to make sure that the things haven't changed dramatically?

Dr. Guido Giusti:

Well, Brian, this is a very good question. Usually, we consider three months a perfect period not to ask for another exam. But honestly, sometime we do some exceptions. Because actually, and you will see in the future, we're going to have a much longer waiting list. So most of the time otherwise we have to repeat many CT scans. So we have also to keep in mind that we have to keep the radiation exposure of our patients low, so maybe we have to extend a little bit. But for sure, sometime you have to be ready to find some surprises like in this case. What about you, Brian? Do you consider three months reasonable?

Dr. Brian Eisner:

I would agree. Unless we're waiting for someone to expel a ureteral stone, like 6 or 7mm, we'll rarely repeat the imaging. So if I have a patient with a pelvis stone, unless it was more than five or six months, I probably wouldn't repeat the imaging, I would agree with you.

Dr. Guido Giusti:

Okay. So...

Dr. Brian Eisner:

[crosstalk 00:12:17][inaudible 00:12:17] ... about the guide wire, Guido. I'm sorry, but there's so much rich information here. I notice you chose to not use a guide wire, and you explained that the stone was impacted. And I understand this perfectly, and I've done this in my practice as well. But of course, you are a master teaching a masterclass. And I know you also spend a lot of time training people with less experience in endourology. There's always safety wire versus no safety wire debates in endourology. And so I'm curious, maybe for the user who is not as facile with flexible ureteroscopy as you, would you have advised to try to pass the hydrophilic wire there? Or is the impaction of the stone for you concerning for a perforation with the wire, such that you'd really advise anyone to go wireless at this point?

Dr. Guido Giusti:

Well, Brian, you know, I am a strong supporter of the extensive use of safety guide wire, but my practice actually is to take a first look with a ureteroscope without guide wire, then to place the guide wire, then the second one, then a ureteral access sheath. But in this case, the stone looked very impacted. So usually when I see this, the stone really impacted, I prefer not to place the guide wire, because many times when the stone is so impacted, you think to have the guide wire in the kidney and sometime it is outside. So usually I prefer to start breaking the stone, and then when I'm sure that I have a full and safe access to the kidney, to place the safety guide wire. That's why I did this in this case. But, believe me, I don't want that this message would be delivered, "Don't use safety guide wire," because this is not my habit. I use always safety guide wire.

Dr. Guido Giusti:

Look, Brian, you see this stone is according to what we have seen on the CT scan. These look like calcium oxalate dihydrate stone. You see that the typical octagonal crystal on the surface of the stone, which means that this stone is coming from a program of hypercalciuria, rather than hypocitraturia. So look, I started to break the stone with this low-power setting, so it is 0.4, 50. And as you can see, this is a setting for pulverization. Honestly, with this modality, using a Quanta Cyber Holmium laser, which is one of the [inaudible 00:14:51] by this Italian company, the name is Quanta. Here in Italy and in Europe, are quite established, maybe in US a little bit less. But now you will see that it will be established also in the US, because recently they signed a joint venture with Cook Medical, so this machine will be marketed by Cook Medical in the future. And this Virtual Basket is, I would say, a kind of MOSES technology from Quanta laser. Honestly, I use this modality very, very frequently, even though in this case it was not so useful, because the stone was just impacted. So the retropulsion of the stone in this moment was not really important. So, as you can see...

Dr. Brian Eisner:

Sorry, Guido, just to clarify. This Quanta laser, it sounds like it has a setting that is similar in technology to I think what is the well known MOSES technology from Lumenis, but they refer to it as Virtual Basket. But is it predicated on the same physical principles as the MOSES technology?

Dr. Guido Giusti:

Yes, it is a double-pulse emission of the laser. So basically there is a first emission, with a formation of a big bubble. When you have this maximum expansion of the first bubble, a second pulse will go through the bubble directly on the stone. So this is similar, again, because you can deliver a higher amount of energy on the stone, and to have less retropulsion. Even though I told you, Brian, in this case the stone was impacted, so it was not so important. It was just because I'm used to using this technology.

Dr. Brian Eisner:

[crosstalk 00:16:39] And... [inaudible 00:16:39]

Dr. Guido Giusti:

[crosstalk 00:16:39] You know, what I... Sorry.

Dr. Brian Eisner:

No, I was going to take some questions about your laser settings. Is that okay?

Dr. Guido Giusti:

Yes, please.

Dr. Brian Eisner:

So I see you choose 0.4 and 50, and I also see that you remarked about the composition of the stone when you saw it. So maybe I would start by saying, is 0.4 and 50 your standard settings for the ureter? Is it your standard settings only for a dihydrate stone? Or if you saw, let's say, what looked more like a monohydrate stone, or uric acid stone, in the ureter, would you start with the same settings? Maybe we could spend a few moments on this, since it seems to be a very important topic.

Dr. Guido Giusti:

Yes, this is a very important topic. For me, this stone, again, was still a stone in the kidney, not in the ureter, because it was just at the UPJ. So I used this high-frequency, because as you have seen, I had the stone under full control, visibility was very good. Usually I don't use such a high frequency in the ureter, because in the ureter there is the risk to damage the ureteral mucosa. So usually I start with a little bit more power, but much less frequency. And as you have seen, the difference... In the real ureter, I start from firing in the center of the stone. Instead here, I start from the surface, as I do usually in the kidney. I always use these [inaudible 00:18:13] by myself. I think that there is no standard value for a good treatment. I always tell to my young colleague, I always taste the stone, because you don't know how it react really to your laser.

Dr. Guido Giusti:

So usually I start like this in the kidney, but then you have to react. If you have the feeling that you are doing a good job, I go on with this. For sure, I don't use, as many American friends are doing, 0.2. Because for me, 0.2 is a little bit too... The energy is not enough. Usually my minimum is 0.4. Because don't forget that what breaks the stone is the energy. So 0.2 sometime is a little bit not enough. What about you, Brian? Do you do the same, do you have different habits?

Dr. Brian Eisner:

I would highly agree, Guido. I would say that for actually the majority of my cases in the kidney or the ureter, I tend to start at 0.4 or 0.5 and 50. And then, like you said, I like to taste how the stone is going to break, and then adjust my settings accordingly. So they're very similar. I also do agree, I have some people I respect tremendously who do use settings like 0.2 and... Oh, you're video [inaudible 00:19:38].

Dr. Guido Giusti:

Sorry.

Dr. Brian Eisner:

0.2 and 80. But I find that for me, I prefer a little bit more power, I prefer 0.4 and 0.5. Would you mind telling me, Guido, what would be the absolute highest settings that you'd be comfortable with in the ureter? Or do you have such a thing?

Dr. Guido Giusti:

Well, in the ureter usually I don't exceed 20Hz and 1J. Usually I start with 0.6, 0.8, 10-15Hz. Then it depends on how you have the control of the ureter, because don't forget, high-power setting is for kidney, not for the ureter. Because in the ureter, it's risky. Don't forget that we have to break only the stone, and not the mucosa. So usually, I use high-power setting only in the kidney.

Dr. Guido Giusti:

Look, Brian, I want to highlight this movement that I'm doing with my right hand. You see, this is called painting. It's a very delicate movement. It's, I would say, a result of a pronation/supination of my hand, in order to stay always on the surface of the stone. Because as soon as you go in the center, you have the risk to generate big fragments, and to take care of a big fragment is always much more cumbersome than to take care of a big stone and painting on the surface.

Dr. Brian Eisner:

And just to emphasize that Guido, and I actually had made a note about that. It seems like in this picture you're doing the majority of your movement with your dominant hand, the hand that's on the scope, and really it looks like you're just using your left hand to brace the scope. I have seen other techniques where people like to use their left hand to twist the scope, but it sounds like your preferred technique is to use your dominant hand on the scope, and really do most of the rotation there. Is that correct?

Dr. Guido Giusti:

Yes, I use mostly my dominant right hand. I use only the left hand sometimes to have an extra rotation, in order to do a rotation with my left hand with the part of the scope close to the beginning of the ureteral access sheath, or to introduce back and forth of the scope. But all the movement in the kidney, with my right hand, because for me it's much more comfortable.

Dr. Guido Giusti:

Another literal detail, as you can see in the video on the bottom, is that I operate sitting down, because for me it is much more comfortable. What about you, Brian?

Dr. Brian Eisner:

You know, I have to tell you, Guido, there's many things you and I do alike, partly because of our friendship and collaboration, but I stand for PCNL and I stand for ureteroscopy. It's just how I was trained and how I do it. But when I've seen you do sitting supine PCNL, I do get a little bit jealous.

Dr. Guido Giusti:

But you know, Brian, that Italian people are a little bit lazy, so for me it's much more comfortable to stay sitting down comfortably. Honestly, I am also to fight a little bit with my co-worker Silvia, that you know very well, because she stands up like you, and she always says, "Guido, I stand up because Professor Traxer operates standing up." He is the king. So for me it's a little bit difficult to defend this position. But apart from [inaudible 00:23:14], it's much more comfortable. And, as you can see, I use one leg of the patient just to put my arm, and just a little bit elbow. Just to see what we do in the same way and what we do differently.

Dr. Brian Eisner:

[crosstalk 00:23:33][inaudible 00:23:33]

Dr. Guido Giusti:

[crosstalk 00:23:33] So now, Brian... Sorry.

Dr. Brian Eisner:

No no, go ahead. Go ahead.

Dr. Guido Giusti:

So Brian, I stopped the video in this moment, because for me it's important to highlight the best scenario for a good popcorning. When you have plenty of fragments at the bottom of one calyx, with our laser fiber just in the center. And this is the ideal scenario for a good popcorning. So for a good popcorning, we need to increase the energy. In theory, at least, a good popcorning is a [inaudible 00:24:14] just firing in the center of this big amount of fragment, hoping that one by one will hit the tip of the laser fiber, in order to make small fragment even smaller. So you see, this is the ideal... And I raised the energy to 1J, and frequency decreased to 30. And as you can see, this is ideal for popcorning. Do you do the same, Brian? You have a different setting for doing this, or what?

Dr. Brian Eisner:

No, I think it's quite similar. And I think that part of it is, as you mentioned, is it depends how the stone's fragmenting, but this seems to be working, and so I certainly would use very similar settings, and vary them if the stone was a different composition. One other question I may ask is, while we're talking about laser settings, are there other laser manipulations, either on this Quanta console or on others that you do? For example, do you pay attention to the pulse width? Do you use the Virtual Basket or MOSES for every single case? Are there other things we can talk about in terms of your preferences for all the features of a laser console? And then the second follow-up question, sorry Guido, is for people who don't have a high-power laser... So there's about 30% of our audience right now, says they don't have access to a high-power laser. So first, what would you do to optimize your high-power laser settings? And then what do you suggest to the people who do not have a high-power laser?

Dr. Guido Giusti:

Well, Brian, this is a very nice question. I would say this. I like, I have it and I use it, I like high-power laser. But remember, basically because with this I can reach very high frequency. We don't need high energy. This is important, because we need high energy only for BPH treatment, not for stones. It's rare for me to exceed 1, 1.2J when I can reach with my Quanta laser up to 70Hz, which is very, very high, and useful during laser lithotripsy. On the other hand, we have to keep in mind what Professor Traxer is saying, that basically there is no difference in terms of outcome if you use high-power laser or low-power laser. And since I have it, I will say that you don't need a Maserati every day to go to the hospital, but remember if you have a Maserati you can go fast, but you can also go slowly. Instead, you cannot do the same with a Fiat machine, you cannot go fast. So if it is possible, I would say it's better to have a high-power laser also, because you can do all BPH treatment. But don't forget that maybe, in a little bit longer time, just because you cannot reach such a high frequency, you can do anyway a good job also with a low-power laser.

Dr. Brian Eisner:

That's great, Guido. And while you're still paused here, I notice that the tip of your laser fiber has burnback, which we see all the time, especially in difficult cases, and the blue cladding is protruding at the end. There's also been a lot of talk of, do you strip, do you cleave, do you cut the tip of the laser fiber? It looks like you continue to proceed here, so what are your thoughts on the tip of the laser fiber and burnback?

Dr. Guido Giusti:

So of course this is my practice, and does not mean that it's the best, but usually I just cut it with a metallic scissor, I would say every 10 minutes. I don't remove the blue coating, because for me to have the blue coating near the [inaudible 00:28:15] of the fiber is very good to keep always the fiber under control. I really don't like to have 1cm of transparent fiber, because sometime you lose the control of this. In the beginning, I was doing this together with the metallic scissor, I would say not officially, because I was aware all the companies suggest to use ceramic scissor. But then there is a paper by Professor Traxer in which he has demonstrated that basically it's just the same apart from the first minute. So usually I feel comfortable to cut with this with a metallic scissor.

Dr. Guido Giusti:

Look, Brian. So in this moment I have still some major fragment in the kidney. That's why I decided to place a ureteral access sheath to do some basketing. In this moment I'm using a Flexor Parallel by Cook, which is actually not so brand new, but it is this ureteral access sheath by Cook. Basically, since it has this lateral hole, you can place only one guide wire, and to use this in this [inaudible 00:29:39] way. You see, I place the first, it was a 10.7, and I couldn't place because the ureter was very thin. And my trick in this case is to dilate first only with the inner dilator. So with the inner dilator, I dilate just a little bit, and after that you see that I didn't have any other problem in placing the ureteral access sheath. You see, always under X-ray control, it went up very smoothly, and in this moment you see I remove the inner [inaudible 00:30:13]. And by doing this, the working wire will be our safety. So you see, when I place the ureteral access sheath, going back to the [inaudible 00:30:24] concept, I always prefer to have a safety guide wire. Not everybody is agreed on this concept, but I do think that in endourology the limit between a masterpiece and a nightmare sometime is very, very small. So, safety is never too much.

Dr. Brian Eisner:

I agree. Can we pause for one second, Guido? There's so much good information here, and before we get to basketing, I wanted to discuss ureteral access sheaths with you for a few moments, because there's a lot of questions also. So I guess I might start by saying, if you were going to tell one of your trainees, "These are the cases that I use a ureteral access sheath in routinely," what would those cases be?

Dr. Guido Giusti:

Well, honestly I use a ureteral access sheath I would say a majority of cases, but always respectfully. This is very important. Because, believe me, I use only if I'm sure not to have a problem. So when I place this, and I feel friction, remember, endourology is not a macho man surgery, you don't have to push harder, but you have to downsize the dimension of your ureteral access sheath. So usually I use always ureteral access sheath around 10Fr, more or less, and I use 12 and 14 only in case of pre-stented patients. Honestly, actually, I'm a little bit fearful about the practice of my mentor, Professor Clayman, that as you know is giving some [inaudible 00:32:06] one week before, and he's placing 14/16. And honestly, Brian, I have to tell you that I don't feel brave enough to do so. What about you? Have you some experience about doing this or not?

Dr. Brian Eisner:

14/16, definitely not. We don't happen to stock those in our hospital. I'll tell you, Guido, I used a lot of 12/14 access sheaths early in my career, and then the 11/13 sizes became more popular. I couldn't really find 11/13 early on, but now I use 11/13 for almost every one of my cases. And with the except of, if someone already has a stent and they have a larger stone burden, I will use the 12/14. I am interested in understanding how renal pelvis pressures are lowered by the access sheaths, and how the access sheath sizes contribute to that. So I tended to stay away from the 10/12s, I feel those are a little bit small, and use the 11/13s, is my middle ground.

Dr. Brian Eisner:

And we in our practice, I would say, use access sheaths about 50% of the time. So I routinely use them in patients who've had a history of infection, and I routinely use them in cases where I want to extract fragments for larger stones. And then for cases that aren't either of those, so maybe like an 8mm stone with no history of infection, I might try and do a pure dusting technique and extract one fragment and not use an access sheath. But we do use them about 50% of the time. But I do realize that I think we use access sheaths by routine a little bit less in the States than in other places.

Dr. Guido Giusti:

So, Brian, honestly my preference is to use the ureteral access sheath, because I feel more comfortable. I am always scared about high pressure into the kidney, because remember, according to our publication, sometime we underestimate this. But I think that the mortality of flexible uteroscopy is higher than that of PCNL just because of this. So for me, I am always really concerned about the high pressure into the kidney, so I prefer in my usual practice to use this. But again, if I have the feeling that there is excess friction, of course I give up to the placement of the ureteral access sheath, and I go without a ureteral access sheath without any problem.

Dr. Brian Eisner:

Perfect. And then before we continue to basketing, because I'm sure there's going to be a number of questions more, I just might ask. I see there, it looks like you're using the STORZ digital flexible ureteroscope. And so my question would be, what is the role of reusable digital, reusable fiberoptic, and single-use ureteroscopes in your practice? So which do you use for what, and why, and when?

Dr. Guido Giusti:

Well, Brian, this is a nice question. I use, like the majority of urologists, single-use only for difficult cases, in which the risk of damaging my scope is very high. But at least in Italy we have the problem of reimbursement. So basically, if I do a flexible ureteroscopy with public patient, I will lose money. So I have to select cases not to lose too much money. About the reusable, I would say 80% of my scopes are digital, and only 20% are fiberoptic. Usually I say they are just the same for stone surgery, but honestly, Brian, I use 99% of the time only digital scope, while I oblige my young colleague to use a fiberoptic, just to reduce the risk of breaking a digital one. But don't forget to keep in mind that the deflection of the very terminal part of the scope sometime is better for the fiberoptic. So at this moment I feel more comfortable to keep still some fiberoptic scope, and from this point of view FLEX-X2 by STORZ is my favorite. Because just sometime in very dependent and very difficult lower calyx, sometime I still need a good fiberoptic just to overcome very, very steep angle in very difficult lower calyx. What about you, Brian? What is your rate of single-use scope? It is close to 100, or what?

Dr. Brian Eisner:

No, Guido, I would say number one, the practices in the States are very different even from hospital to hospital, and even from location to location. At our main campus at Mass General Hospital, we predominantly use the STORX FLEX-XC, the STORX FLEX-X digital scope. We sort of have the same practice as you. We keep fiberoptic scopes on back-up, but we're predominantly using the digital scope. And then we're using the single-use ureteroscope for difficult lower pole cases, and also for some infection concerns for patients who have multi-drug resistant infections or transmissible diseases, or for people with immunosuppression, like transplants who could receive... It's more easy to get infection for contaminated scopes. So I would say our single-use scope rate at our main campus in Mass General is probably about 10%. We have a smaller, ambulatory surgery center where they actually prefer the single-use scope, and a lot of that has to do with the fact that it decreases their burden of sterilization there.

Dr. Brian Eisner:

So these choices, at least in the States, are also highly governed financially. There's a lot of financial input that goes into both a reusable or a single-use scope, and I find it highly varied among institutions. But at our main campus, we're using it about 10-15% single-use, and at our ambulatory center we're using almost 90% single-use. So even in two hospitals owned by the same company, we have very different usage patterns.

Dr. Guido Giusti:

So, Brian, going back to my flexible, in this case there were many fragments but small. So I prefer to use this basket, which is NCompass by Cook, which is a 12-wires basket. And it is ideal to remove small fragments. In this case I was also lucky enough to have an involuntary clot [inaudible 00:39:10]. You see just a little bit of blood that was able to interrupt some fragment, and this facilitated the removal of this fragment. So Brian, now I have a question for you. When you have plenty of these small fragments, you see these fragments are around 1-2mm, tell me about your [inaudible 00:39:32] device that you have developed. Because I'm really curious, because every time when I am in this situation, I always wonder, it would be ideal to have a kind of endourological Hoover in the kidney. Tell me, Brian.

Dr. Brian Eisner:

Thank you for the question, Guido. So I do have to disclose that I am the inventor of a device that's owned by a company called Kalera Medical, which is a flexible aspiration device. But it was designed to treat this exact problem, dozens and dozens of fragments in the kidney after surgery. And what do we do? How do we know what to leave behind? Are the fragments left behind risky for recurrence? And especially when you have small fragments that are too small to basket. So what I'll say is that I do think that aspiration of stone fragments is going to be an important topic as time goes on. We've seen it in other systems, like PCNL, and some of our initial data was presented at WCE, as well as accepted to AUA, which of course unfortunately we canceled this year. But the product is in further development to try and create an excellent stone aspiration device. So thank you for the question, and again I'll disclose that I'm the inventor...

Dr. Guido Giusti:

[crosstalk 00:40:55] Because look, Brian, in this case, these fragments are too small to be entrapped with the NGage, I changed my basket, or with the other, but it is not dust. Because according to the new definition, which I agree a lot with Professor Traxer, 1mm is not dust. When you have dust at your home, you don't have a small fragment, you have dust. And dust is much smaller than this. So if you leave all of these in the kidney, I'm sure that the patient won't be stone-free at the end of the surgery. So this can be the ideal scenario for your device, I think. Of course, this should be tested and demonstrated, but look at this. I am not able to remove all of these, even with my favorite basket, which is NGage, but they are too small. And also a little bit of flushing is enough to flush them away from your basket.

Dr. Brian Eisner:

Guido, I might ask, you talked about two different baskets. It sounds like these are both from Cook, but from a mechanistic perspective, one is an end grab, and one is a side grab, right? The first basket we would call the side grab, and the second one we call the end-on grab, or the front grab, I think. So if you had to choose one, which would be your preference? Or, maybe to say it a different way, which is the ideal scenario for each basket?

Dr. Guido Giusti:

So, Brian, this is a nice question, because for our manager, one flexible means one basket. But unfortunately it does not work that way. So there is no ideal basket. For sure, in the kidney, usually I prefer the NGage, which is this basket, whose mechanism is a frontal mechanism. Because in the kidney, you have always the stone in front of you, and you have to grab like this. That's why I like it a lot, instead of a traditional zero-tip basket. Instead, a normal tipless basket is ideal to relocate the stone, for example, from the lower to the upper calyx, or to remove big fragment in the ureter.

Dr. Guido Giusti:

But what we have to explain to our manager is that a universal basket unfortunately does not exist. So usually I have three to four different baskets, and all of them with a dedicated feature. And sometime I would say that in my service we are around 25% of the cases in which I open two baskets. I remember, I do think that the judge of my profession is the patient, and not the manager of my hospital. And of course they are not happy, but at the end of the day, I want that my patient is happy, because if the patient is happy, it means that you have done your job. If the manager is happy, sometime it means only that you saved money, and does not necessarily mean that you did your best for the patient.

Dr. Guido Giusti:

So another question could be, "Guido," usually at the meeting a lot of colleagues ask me, "are you a duster or a fragmenter?" I think that you cannot be one or the other, because all the stones are different, all the surgeries are different, the laser are different. So usually I say that I am a duster indeed, but basketer in need. So I always start to dust my stone, but a lot of the time I have to face with some big fragments, so I prefer to remove all of them.

Dr. Guido Giusti:

And I would say also something more. I don't know if you agree with me, Brian, but if the stone is smaller than this, let's say more or less beyond 1cm, usually I start directly with basketing or better. I fragment the stone in four, five, six pieces, and then one by one, pum, pum, pum. Because by doing this, at the end of the case, the patient is stone-free. Because sometime we say that the patient is stone-free, but really is fragment-full. And this is something that I want to avoid to my patient. Because we always say, "You're going to pass all the fragment," but we know that the reality is a little bit different. Do you agree, Brian, or you always [inaudible 00:45:34] pulverization first?

Dr. Brian Eisner:

No, I do agree with you, Guido. And in fact I would say that when I get in there, and I see a dihydrate stone... I mean, this was a tough case, but the dihydrate stones certainly do dust easier than, let's say, a monohydrate stone, or a calcium phosphate stone sometimes. I do get happy that I can probably accomplish it with dusting, with no sheath, with maybe minimal trauma, minimal basketing, but I do like your figurative concept of tasting the stone. Because if I enter, and I see a dark, black calcium oxalate monohydrate stone, or if I know a patient has a history of calcium phosphate stones, then I often start with fragmentation.

Dr. Brian Eisner:

So, I do think it depends on the stone composition, and to an extent the stone size. And I would agree. For me, there's no one specific technique. I would say, of course you can accomplish surgery with one specific technique if you like, but I prefer to cater my technique to the individual stone, I think much like you're saying as well.

Dr. Guido Giusti:

Okay, nice. Now you see that I finished the case, and I always check the ureter at the end of the surgery, especially if I placed a ureteral access sheath, because sometime you can have some bad surprises. Unfortunately, complication-free endourology does not exist, but for me it's paramount to recognize a complication as soon as possible, not to recognize the complication by the consequences. So you see, I check the ureter. The ureter so far is perfect, just a little ecchymosis due to the presence of the ureteral access sheath. And by doing this, I have only 1cm of the scope outside the ureteral access sheath, and I retrieve both of them simultaneously. And you see that the ureter is perfect. Just a little erosion. And you see, at the [inaudible 00:47:38] the ureter becomes oval, it means that I am in the intramural part of the ureter. That's it. And another question, Brian. An endless story. Do you always place the stent as I do, or you select [inaudible 00:48:04], no stent...

Dr. Brian Eisner:

It's very interesting, Guido. You know, I was asked to be the moderator, but I'm also getting as many questions from the guest speaker, which is a lot of fun. Thank you for firing them back at me. What I would say, Guido, is that I do do some stentless ureteroscopy, but those patients are highly selected. So I do it only in sheathless cases, so only if I omit the access sheath, only if I feel that there's no injury to the ureter, and only if I'm very, very confident that I treated the entire stone. So if it fits those three, I will do it. I will say, that ends up being about a quarter of my entire practice. So, about 25% do not get a stent, and about 75% do.

Dr. Brian Eisner:

But now, of course, I'm going to take my moderator's privilege and ask you a few questions about your stenting. The first thing I'll say is, I notice you don't perform a retrograde pyelogram in this case, which I find very interesting, because although you got a very nice look at the ureter, I do find occasionally that sometimes I'll miss an abrasion when I'm pulling the scope out that can be identified by a pyelogram. Can you explain a little bit about that?

Dr. Guido Giusti:

This is a nice question. Well, historically, in the beginning, I was forced [inaudible 00:49:26] to perform pyelogram in the beginning. Now, I don't do it any more, and honestly, I did it again only in case of very prolonged surgery, or when I have the feeling that I had some problem during the surgery. I agree with you, maybe I have already shown you a wonderful feature in which, in the beginning almost of the case, I inject contrast through my ureteroscope, and I [inaudible 00:49:59] perfectly renal vein and vena cava. So we know that this can happen. But usually, I am always very concerned about extravasation. This case, it was easy... Not easy, I would say straightforward, no complication. I skipped do an extra X-ray for this patient, so I was quite confident that no major damage to the kidney. Ureter was perfect, so I didn't check. But honestly, if you want to be in full safety, I would say that this would not have been a mistake to inject some contrast just to be sure. Because you are right, if you have an extravasation, I would suggest you keep the stent for two weeks instead of only five days.

Dr. Brian Eisner:

I'm going to ask one last question, and then I think you probably get your turn for your parting words, as we're almost at the end of the hour, Guido. But my last question is, I would say stent discomfort is a common complaint we get in the States. In fact, our healthcare system, depending on how you look at it, one could argue that stent complaints actually cause more problems after your ureteroscopy than stone complaints, if you will. And so my question here is, and thanks for waving at us, number one, do you have a specific both diameter and length of stent that you prefer for this case? And the second question is, even in the absence of extravasation, of contrast or injury, does the fact that that stone was very impacted in the upper ureter change how long you like to leave the stent in?

Dr. Guido Giusti:

Well, in the past I was selecting a lot of the length of the stent. Honestly, in my hospital, in order to render the job of my nurse team easier, I have only one size, 6Fr, and two lengths, 24 and 26. So most of the case I use this, and I have no major complaint. I like very much the concept of a silicone stent, because I feel that it is really less painful for the patient, and also now I'm starting also to do a study with an innovative stent by Rocamed, the name is JFil, which is a stent that is capped in the middle, so there is only an upper part of the stent, and only strings on the terminal part of the ureter, so that we avoid some reflux, and also some pain due to the movement of the entire stent in the patient.

Dr. Guido Giusti:

But if I have to do the balance between a stent that is comfort and colic, in my opinion the balance is always in favor of stent with some pain. My trick is not to give my telephone number to the patient, but I always give the number of Silvia, so if they are in trouble, they're going to call Silvia, and not myself, and I will sleep safely during the night.

Dr. Brian Eisner:

That's fantastic, Guido. So I'll say this. I'll close in a moment, but did you have any final words? We're about four minutes to 1:00 PM Eastern Time. Do you have any final words or final closing remarks about your procedure here?

Dr. Guido Giusti:

One of my final remark is that I really love flexible ureteroscopy, and I hope to have been successful in contaminating all of you, not with COVID-19, but with my passion for endourology. But I do think that endourology should include all different procedures. Because this is a mistake that I see very frequently in Italy. Now there is the concept that you can do everything ureteroscopically. Instead this is not true. This was a good indication, but I think that a good endourologist should be familiar with flexible ureteroscopy but also with PCNL. And we have always to be ready to shift from flexible to Miniperc or standard perc every time we have the feeling that we are not doing a good job for our patient. This is a very important [inaudible 00:54:30] by myself. And for me, high-power laser is better, but don't forget that you can do a good job, maybe only in a lengthier time, also with a low-power laser. And remember, not all the cases are the same, and if you are in trouble, you don't have to push harder, but it's not a shame also to stop and reschedule a patient for a second time.

Dr. Guido Giusti:

And most importantly I want to say also thank you to you, Brian, for your moderation, for your kind word, and also to Endo Society for this wonderful opportunity that was given to me to speak to so much people around the world in this very, very critical time that we have just finished to experience in Milan. One last comment is to please remember all the colleagues that have passed away for this unprecedented and tremendous COVID-19 outbreak. Thank you very much, Brian.

Dr. Brian Eisner:

Thank you, Guido. I think what I'll say is that I echo your sentiments. First let's thank our audience, let's thank the Endourology Society for putting this on and for inviting us. We do wish that you and your families and loved ones are safe in this time, and of course we need to remember those who have not fared as well. Guido, I would have much rather had this conversation over perhaps a glass of wine or a beer at AUA or WCE. I hope we can do that in future times. But in the meantime...

Dr. Guido Giusti:

Hopefully.

Dr. Brian Eisner:

... I'm very grateful to the Endo Society who has put together this fantastic educational series. And I do want to remind everybody to join us next Friday, one week from today, at the same time, so that's 12 PM Eastern Standard Time, same time as this, for Holmium:YAG Laser in the Surgery of BPH, featuring Dr. Amy Krambeck and Dr. Thomas Herrmann. So thanks again to the Endo Society for their support. Guido, thank you for sharing this hour with me, and audience and participants...

Speaker 3:

[crosstalk 00:56:39][inaudible 00:56:39] ... thank you, 2,500.

Dr. Guido Giusti:

Thank you.

Speaker 4:

And just a reminder to everyone that you will be taken to a post-survey right after the webinar. Thank you very much for joining.