Surgeon: Thomas Tailly

Moderator: Michelle Jo Semins


Thomas Tailly

Thomas Tailly graduated as a medical doctor from the Catholic University Leuven, Belgium in 2007. He went on to complete his urology residency training under the wings of Prof. Van Poppel in 2013. During Endourology Fellowship from 2013 to 2015 in London, Ontario, at Western University under the supervision of Dr. John Denstedt, Dr. Stephen Pautler and Dr. Hassan Razvi, he also finished a Masters of Science in Surgery. Afterwards he took a position as consultant urologist in the University Hospital of Ghent in Belgium. He has a special interest in urological stent and catheter design, biomaterial and coatings, uroradiology for stone disease and training in endourology. Apart from his clinical work as the primary endourologist of the hospital, he is currently involved in both clinical and translational research on urolithiasis and its diagnostic and treatment modalities. He is a member of the endourology subgroup of YAU (Young Academic Urologists) and ESUT (EAU section of Uro-Technology) sections of EAU. Additionally, he is the past chairman of the Young Endourological Society and he is still active in the Endourological Society as member of the Steering committee of the research arm, TOWER. He enjoys passing on knowledge and skills through courses and live surgery.

Bio for Michelle Jo Semins, MD

Dr. Michelle Jo Semins has been a staff urologist at the University of Pittsburgh Medical Center (UPMC) since 2011 and is currently Clinical Assistant Professor and Director of the Kidney Stone Clinic at UPMC Mercy Hospital.

She received her undergraduate degree from The University of Michigan in 2001 where she graduated with High Honors and High Distinction from the Honors Program and was selected to be a member of both Phi Beta Kappa and Phi Kappa Phi. She received her medical degree from the University of Pittsburgh in 2005. While there she received several merit-based scholarships and was awarded the Wayne G Cessna Memorial Prize for Finest Commitment and Achievement in Urology. 

She then completed her general surgery internship in 2006 and urology residency training in 2011 at Johns Hopkins Hospital with additional specialty training in the field of endourology.

Her primary specialty interest is in kidney stones and she started the multi-disciplinary kidney stone clinic at her hospital in 2012. In addition to her clinical responsibilities she is also very involved in resident and medical student teaching.

Dr. Semins has a clinical research focus in kidney stones and is a past awardee of the Young Investigator Research Grant by the Northeastern Section of the AUA. Her special interests are reducing radiation exposure to both patient and provider, managing kidney stones during pregnancy, and minimizing infections in the management of kidney stones. She is a published author of over 40 articles, over 50 abstracts, and 9 book chapters. She was recently named Deputy Editor for the journal Urology. She also routinely reviews abstracts and videos for the AUA national meeting and moderates those respective sessions at the annual conference.

Dr. Semins is very active in the NSAUA/AUA. She currently sits on the NSAUA Board as the Pennsylvania Representative and serves on the NSAUA Scholarship Research Committee, the NSAUA Committee for Nominations, and the AUA Quality Improvement and Patient Safety Committee. She was selected to participate in the 2018-2019 AUA Leadership Program. She is also an active member of the Society of Endourology, Society of Women in Urology, and Research on Calculus Kinetics Society.

Dr. Semins is a recognized leader in the field of endourology and has been invited faculty at conferences and courses both nationally and internationally. She was named Young Urologist of the Year by the AUA in 2016.

In her spare time, Dr. Semins enjoys spending time with her family, traveling, and being outdoors.

 

Webinar Transcript

Dr. Jared Winaker:

All right well good morning, good afternoon, good evening, wherever you are everyone. Thanks everyone for joining us for this latest installment of the Masterclass in Endourology and Robotics brought to you by the Endourological Society. We of course want to go ahead and thank our sponsor Karl Storz for their grants and support of this educational activity today. Just for your reference, you can always look back at this but this is an overview of our CME program with today's webinar. And of course, we all know we're here today to hear about Ultrasound Guided Endoscopic Combined Intrarenal Surgery. We're joined by a stellar panel. We have our surgeon is Dr. Dr. Thomas Tailly in the University Hospital of Gent in Belgium, and moderating Dr. Tailly's pre-recorded semi live surgery with [inaudible 00:00:46] Dr. Dr. Michelle Jo Semins from the University of Pittsburgh School of Medicine.

Dr. Jared Winaker:

As a reminder just like of our previous webinars, this one today is going to be recorded as well as a dictation. So anything you feel like you missed and you want to go back and check, please do go back to our website at the endourology.org and click on the education tab and then masterclass and endourology to find that. So without further ado, I will turn it over to our two panelists.

Dr. Michelle Jo Semins:

Thank you. Hello everybody and thanks for joining us. I want to first start by thanking the endo society for putting on this webinar series. I think it's been a fantastic educational opportunity during this pandemic, especially as all of our in-person conferences have been canceled. I also wanted to extend a special thanks to Dr. [inaudible 00:01:31], Dr. Joyce, Dr. Chi for inviting me to participate. Just to reiterate, this is an interactive session so I'm going to be asking a lot of questions throughout. There's a Q&A option at the end, but there's also a Q&A option on the Zoom box that the audience can feel free to ask questions throughout the session and we're going to try to answer those questions on a rolling basis. So our topic today is ultrasound guided Endoscopic Combined Intrarenal Surgery, or ECIRS. This is a technique that was introduced in the 1990s by a group in Spain and then Italy followed with publications.

Dr. Michelle Jo Semins:

The United States started putting it in their literature in the early 2000s, and then the term ECIRs was first coined in 2008 by Dr. Scoffone and Dr. Cracco from Italy. So, we're fortunate today to have Dr. Dr. Thomas Tailly here. As I mentioned, he's from the University of Ghent in Belgium. He is an internationally known endourologist, and he's really embraced ultrasound guidance technology. He also uses ECIRS regularly in his practice. So he's very keen on sharing this knowledge and teaching others to embrace the ultrasound guided technology as well as the ECIRS technology and techniques. I wanted to first ask Thomas to start a little bit about his career path and how his PCNL technique evolved from when he was in training to how you currently practice, and then just what ECIRS means to you specifically.

Dr. Thomas Tailly:

Jo, thanks everybody for having me here today. It's an honor really. So my career path, I just started doing PCNL when I went to my fellowship in London, Ontario with Dr. John Denstedt, Dr. [inaudible 00:03:26] and Steven Putler where all PCNLs were prone, fluoroscopy guided and 30 French, at least one tract. The main thing to remember here is that a good PCNL is not complete without a flexible nephroscopy and that's very important. After I finished my fellowship, I moved back to Belgium where I started a position in the University of Ghent and we didn't have the 30 French tracts. So we only had a 22 French tracts so I moved to that which was a change for me. I still punctured under fluoroscopy, but as we all had to put in our nephrostomy tubes ourselves, more and more I started doing ultrasound, plus I did all my ultrasounds on the outpatient clinic myself, which helped me embrace ultrasound in the OR as well.

Dr. Thomas Tailly:

And soon enough, I started doing most to all of my punctures under at least ultrasound assistance, meaning that I used ultrasound to assess whether or not I would have the right calyx if there's any organs in between the tract of the needle and the kidney. But I would still use a lot of fluoroscopy to guide my needle. And then I was still doing prone in the beginning and then I got a fellow so I had an extra set of hands then I switched to doing a lot of supine. And with the extra set of hands, it really helped me out because I had somebody capable of using the flexible ureteroscope or a nephroscope so it was really an added value to have both.

Dr. Thomas Tailly:

And it really helped me to reduce my tract size, because if you have any flexible nephroscopy, I would usually use a flexible cystoscope, which is a 16, 16 and a half French piece of equipment. But with the flexibility reader scope, you don't need attract anymore. That allows the cystoscope that it helped me to reduce my tract size. And right now I've been here for about five years, I think approximately 90% or more of my PCNLs are ECIRS. So that's where I evolved from 30 French prone fluoroscopy guided to supine ECIRS and I never do anything above 22 French really, so quite a change.

Dr. Michelle Jo Semins:

Very impressive. So in terms of ECIRS, what does that mean to you basically?

Dr. Thomas Tailly:

So I have a few slides on that if I'm allowed. I'll just see if I can share my screen here. So, first of all, what makes it a neurologist's happy? So if the patient's stone free, in as few sessions as possible, with as few tracts as possible, zero or one if necessary, leaving as few tubes as possible with as few complications as possible and the hospital stay as short as possible. And that road to happiness for me is mainly ECIRS. And what is that to me? That's PCNL by any tract size as long as it's below 22 French with a retrograde flex nephroscopy. Like I said in the beginning, really a good PCNL is not complete without a flexible nephroscopy, but instead of doing it with a stethoscope, I now do it with a reader scope. And how do I do this? I usually counsel my patients that I will start with the Retrograde Intrarenal Surgery and only switch to PCNL if necessary, but I always position them in a Valdivia [inaudible 00:07:14] position.

Dr. Thomas Tailly:

So I start within RIRS to really assess the stone burden and the collecting system to see whether it's necessary and feasible to do PCNL and to assess my tract size. Then I decide if I'm going to do a PCNL, yes or no? And if I do PCNL, I can really choose my ideal calyx and tract size endoscopically, you'll see that on the video. And if you look at the guidelines, you can do really anything for any stone in the kidney, upper pole, lower pole, whatever, PCNL, RIRS, Shockwave Lithotripsy. And it's always either or, but for me PCNL and RIRS, it's not a battle, it's rather a union so I use both. So for me, the guidelines may look like this honestly. You can do ECIRS for basically every stone.

Dr. Michelle Jo Semins:

I wanted to just ask maybe while you're pulling up the case to tell us, you made a huge transition from training to where you are today in terms of positioning and combo therapy. How do you get to this point in terms of training? I know this was probably most self-taught but there's got to be a steep learning curve for both the ultrasound guidance and getting her own access and changing positions from the prone position to the supine position. That's a lot to learn. How do you suggest people who are trying to make that transition, make it as seamlessly as possible?

Dr. Thomas Tailly:

That's a good question. So the positioning, I read a lot and I saw a lot of videos and then I just started doing it. But if you have a chance or an opportunity to visit somebody who is already using this position, most of the time, I would really advise to join them for a couple of days or a week to see how it's done to get the tips and tricks on positioning, patting the patients, how to get the angle right, do you use bolsters? Do you use an inflatable bag? So those kind of things are really useful to get us tips and tricks from somebody who's already been doing it. So a site visit is really useful. As for ultrasound, I just started doing a lot of ultrasound in the outpatient clinic to get acquainted with the machine and with the settings to learn how to identify the anatomy of the kidney, identify the surrounding organs.

Dr. Thomas Tailly:

And here as well if you can go visit somebody who is doing ultrasound guided PCNL, ultrasound guided punctures I started doing those with a needle guide which is quite easy because you have the needle guide on top of your ultrasound probe and you have the guideline on your screen. So wherever the line points it to your needle will go if you have the needle guide on your ultrasound probe. And then I went to visit with Tom Chi to see how he does it. So once again, visiting somebody who does it all the time is really useful, and he gave me a lot of tips and tricks on how to transition from using the needle guide to do free hand ultrasound guided PCNL. So that was a transition for me going from with the needle guide to freehand.

Dr. Thomas Tailly:

And that does take some cases and one of the pieces of advice that Tom Chi gave me is, give yourself five minutes or give your resident five minutes to get your needle in the place it has to be. And if it doesn't work in those five minutes, go back to the way you're used to doing it. And this is what I used to do in the beginning. I always had the needle guide on the table and if within five minutes I couldn't get my needle into the kidney, I would go back to the needle guide. But along the way, I practically didn't use a needle guide anymore. I usually have it around for when I'm teaching my fellow or residents, especially also for nephrostomy tubes where sometimes it really has to go fast. But that's how I transitioned. So there's definitely a learning curve. And if you can go visit somebody who is doing this all the time, you can see a bunch of cases, get tips and tricks on both positioning and ultrasound guidance.

Dr. Michelle Jo Semins:

Great advice. So you have a patient here. Do you want to start the video and tell us a little bit about the patient?

Dr. Thomas Tailly:

Sure. I'm just going to share my screen for a sec. I can share my screen. Okay. So in any case, this is a 30 something female. Okay. I'll start the video. I think she's 36 or 38. I forgot. This is about a year ago, year and a bit. She's a stewardess actually and she has cystinuria. She's known this for about 15 years but she had not been treated for cystinuria. They only had her stones treated so she was not on any treatment medically for that. She was not on alkalinization or any diet. This patient had had multiple procedures in the past and came with a fastly growing stone. And she's had ureteroscopies in the past, but not PCNL before. And this stone by the time I treated her was close to three centimeters. So I counseled her towards an ECIRS, which I would do with the psaltery stone like this. She had a big stone in the kidney, in the renal pelvis and a smaller stone in lower pole.

Dr. Thomas Tailly:

What I'm doing right here is, I directly go with my flexibility reader scope into the bladder to place my guidewire. I don't take or waste time with a rigid or flexible cystoscope which I would then have to switch over to my ureteroscope. This patient was not pre stented, but what she did have is one week of preoperative alpha blockers which I've routinely been doing for my patients for the past I think three years now after seeing a talk by Dr. Clayman, I think in 2015 or 16 at the WCE, and I do feel it that it does help with dilating the ureter. I'm just placing the wire here. And once I've placed the wire, I would go next to the wire with my flexible ureteroscope not necessarily needing a second wire. The reason I did this with this woman was because just prior to the procedure, she said that she was having some right growing pains as well, indicating that she may have had a stone passing in the ureter so I wanted to see that, otherwise I would just have one wire in go over that wire into the kidney.

Dr. Michelle Jo Semins:

And what if you can't get the flexible ureteroscope again, is this an important enough combined surgery for everybody that you would dilate the ureter distillate if you couldn't access the kidney with the ureteroscope or at that point would you just switch to the antegrade?

Dr. Thomas Tailly:

I do feel that having a flexible ureteroscope in there is useful. So if the ureter doesn't look extremely tight, I would try and dilate, but nothing too rigorous, I would use just a one-step dilator and see if I can get the scope in, maybe a railroad through second guidewire. But what I would not do is balloon dilate the orifice for instance.

Dr. Michelle Jo Semins:

Okay. And would you, if you still couldn't access in that small percentage of patients, maybe one to two percent, would you then present and come back and try the combined approach again?

Dr. Thomas Tailly:

Most likely not. I would probably just go for the PCNL procedure but that may influence where I would put my tract and the size of my tract. If I would get in with my flexible ureteroscope and see that it's feasible with a smaller tract then I would place a smallest tract that I would think is feasible, but if I can get my flexible ureteroscope up there and I have a large stone burden, I would go in with the tract that allows me to put in a flexible nephroscope afterwards as well.

Dr. Michelle Jo Semins:

Now I see you driving up and clearing the ureter.

Dr. Thomas Tailly:

Yeah. There's nothing in there. It's nice and wide.

Dr. Michelle Jo Semins:

Do you use ureteral access sheath?

Dr. Thomas Tailly:

That's a question that I get very, very, very often. I don't use access sheaths all that often. I think maybe 10% of my cases. And I use them in cases where there has been a clear history of urinary tract infections, for instance in a patient that had a lot of stone burden and came in with sepsis, that patient would be standard for let's say a month, and then to keep pressures as low as possible, I would probably use an access sheath. Having said that about pressures though, although there's a lot of circumstantial evidence about pressure and infections, there is no direct evidence to my knowledge that pressure or doing a flexible ureteroscopy without an access sheath causes more infections. So I would use an access sheath in case of a history of infections or if I will have to go in and out dozens and dozens of times mainly, otherwise the indications are quite limited in my hands for me.

Dr. Michelle Jo Semins:

Now I noticed that you had that UPJ stone and you were able to negotiate passed it.

Dr. Thomas Tailly:

Yeah, exactly.

Dr. Michelle Jo Semins:

If you weren't able to negotiate past it, would you laser it to try to get in and get a better lay of the land or at that point would you again just switch and start your integrate access?

Dr. Thomas Tailly:

It would depend on what I would see at that point on the ultrasound image. If the ultrasound image would show me a kidney that's easily accessible from different access points then I would get a nice and clean access to the stone. I would probably puncture the kidney and then go from there. I would still keep my flexible ureteroscope close because it would need it in the end to see if there's any residual stones in all of the calyces. But if I can get through the UPJ passes stone or anything like that, I would not waste time and laser my way to calyx if the ultrasound shows me a clean path to the kidney, to the stone.

Dr. Michelle Jo Semins:

Great. And then similarly, what if you had a staghorn and you couldn't evaluate your desired calyx, would you laser to try to get into that calyx or an obstructed calyx for example.

Dr. Thomas Tailly:

I've done that in the past and I feel that it takes a lot of time to get a calyx clean if this is a real staghorn stone, and it may be difficult to get the exact calyx free that you would want with your PCNL tract. So I would probably go with a PCNL first and like I said, previously keep my flexible ureteroscope there to assess the rest of the kidney as soon as I can. If I have a true staghorn, I would probably put in multiple guidewires in different calyces just in case I would need multiple tracts and I wouldn't get there with my flexibility ureteroscope. I've had that in the past that some calyces may have narrow infundibuli, and then I would need multiple tracts. So if I'm thinking about multiple tracts, a [inaudible 00:19:33], I would probably put in two wires at the start with ultrasound before I dilate anything.

Dr. Michelle Jo Semins:

I wanted you to show us what you're doing here with the ultrasound and your scope at this point. So if you can just walk us through.

Dr. Thomas Tailly:

I don't know if you've noticed but the stone is a clear cystinuria stone. It has that glassy aspect and that's in yellow shiny. And what I'm doing with the ultrasound here is looking at the kidney and looking at the anatomy of the kidney while I'm actually looking at the view of the endoscope of the ureteroscope. What I've done with your ureteroscope prior to switching to the ultrasound is see with which calyx I would be able to access the stone most easily. So I could probably reach the stone from that calyx most easily and get to all of the fragments and some other calyces from that tract. So in this case, my endoscope really helps me choose the calyx that I want to go into. And at this point, my very capable fellow, Ralph has taken control of the ureteroscope and he will help me guide the needle.

Dr. Thomas Tailly:

So with the ultrasound, I try and get the kidney in view as nice as I can. So I usually start horizontally and see if I can get the kidney nicely in my view, and then because the kidney is on a [inaudible 00:21:03] muscle, I'll probably tilt my ultrasound just a little bit to get it in the long view. And what you can see on the ultrasound image right now is the tip of the flexible ureteroscope jiggling in that calyx because that's the calyx that I have decided that I want to take. And I'm already trying to puncture through the skin here. And she's quite thin and her skin really gives way so I'm pushing her skin and tissue away from my ultrasound and after a while, it's going to be somewhat bothersome because my ultrasound probe doesn't stay in touch with the skin anymore which takes away my image.

Dr. Thomas Tailly:

I usually don't use gel anymore because it annoys me when I'm trying to put in my equipment but sometimes you just need some gel. I usually just to use salient after tip from Tom Chi. So I have my ultrasound probe in my nondominant hand and I'm trying to get my needle in the plane of my ultrasound probe. So this is a few months after I visited with Tom Chi so this was still transitioning from using the needle guide to doing free hand. I think I had done about 10, 15 cases freehand before this case was recorded more or less, I think. You see my needle, but I'm not completely happy. I'm going to try and target that calyx where the dotted line is pointing to and where you can see the tip of the flexibility ureteroscope in. So it's not the most dependent calyx, but it's, well let's call it door number two.

Dr. Michelle Jo Semins:

And how do you.

Dr. Thomas Tailly:

Jo? I lost you there for a second, could you repeat that?

Dr. Michelle Jo Semins:

I was just saying, how do you choose upper pole, lower pole, interpolar access?

Dr. Thomas Tailly:

Yeah. So in ECIRS, for me it doesn't really matter which calyx you have, lower, middle, upper for access to the stone. In this patient, you see that the liver is draped over the kidney quite a bit so an upper pole axis would not be possible. Usually I choose the calyx that looks nicest to get a clean tract to the stone. If that's an interpolar, lower pole or upper pole, it doesn't really make a difference to me. If I have multiple calyces in the lower pole that needs to be tackled, I would probably go for an upper pole because that gives me access from one end to multiple calyces in the lower pole. So I do like upper pole access even in supine position.

Dr. Michelle Jo Semins:

Now in the supine position, I notice that the tract seems really lateral where you're going.

Dr. Thomas Tailly:

True.

Dr. Michelle Jo Semins:

I know this is a thin patient, you mentioned that this is a thin patient, is the tract extra long? Does that pose a problem when you're trying to get your instruments in?

Dr. Thomas Tailly:

So the tract is somewhat longer but I've never really had an issue in the past even with obese patients to get my equipment in. There's a long scope if you need one and longer tracts if you need them. But I have not needed those. In the past I've done a patient with a BMI of 60 a while back and I was able to use my regular equipment. My tracts are 20 centimeters though and my scope is accommodated to that or they accommodate my scope. But what you would need is a longer needle. The needle that I'm using here is a locking, still a trocar needle from cook which I really like but it's only 15 centimeters. So if you have a larger patient, you would need a 20 centimeter needle.

Dr. Michelle Jo Semins:

Got it.

Dr. Thomas Tailly:

So I think I'm close to getting into the kidney here. I'm just going to skip forward just a little bit. Yeah. So you see me pushing onto that papilla and I'm almost there. She has very elastic tissue, and you'll see the tip of my needle come in in a few seconds here and then it'll slip out just a little bit and I'll fast forward just a little bit. Okay. So I'll pull back. So this is maneuver I do with my needle from time to time. If I'm in but not exactly the place I want it to be in, I can just retract my needle a little bit, and with my flexibility ureteroscope in, I will move my needle up and down and left and right and I will see how the tissue moves on the inside to see how I have to reposition my needle. So I'll move it up and down and if I move it that way, that's where it will have to move my needle.

Dr. Thomas Tailly:

So I'll have to move it down a little bit and then left and right and then I'll know how to reposition my needle and you'll see that then I can come in easily. I don't need my ultrasound anymore, but I do need my flexibility ureteroscope. I could go to fluoroscopy but you don't really need it if you have your ureteroscope in there. So you see how I'm repositioning the needle and there I'm moving it past that infundibulum and it's into the collecting system.

Dr. Michelle Jo Semins:

Are you or just essentially wiggling your needle and visually getting feedback from your ureteroscope?

Dr. Thomas Tailly:

I'm getting feedback on how the kidney moves depending on which way I wiggle the needle. It's not just jiggering it around but it's up and down and then assessing if I have to go up or down and then left or right, and then you have a 3D emotion and then you knew where to go and then you repositioned the needle. And then usually it's possible to pass the wire without needing a basket. I don't necessarily need a basket to get my wire down. So come back with my flexibility ureteroscope and you'll see that the wire is, what's that?

Dr. Michelle Jo Semins:

Sorry, go ahead.

Dr. Thomas Tailly:

And you'll see that the wire is in the ureter. I used to dilate over an extra stiff wire, but recently I started the dilating over just a hydrophilic wire which goes just as nicely really. I do use an extra stiff wire from time to time. If the kidney is very mobile and then I'll have it through and through with the wire down out of the urethra and up into the kidney. And what you'll often have in females is that if you pass the wire down through the ureter, it'll just come out the urethra, you don't need to come and grab it. And you see that it was quite easy to get the flexible ureteroscope back into the ureter without needing that extra guidewire. So I have one wire in from below and one from above.

Dr. Thomas Tailly:

And what I'm doing now is I'm going to exchange that hydrophilic wire through a [inaudible 00:29:05] catheter for an extra stiff wire just to make sure that I have that extra stiff wire in there to keep the kidney taught. And usually I only use one step dilators, which work in I would say 80 to 90% of patients, but as we've seen in this patient already she has quite elastic tissue so we have a fast forward here a little bit, and I was not able to get the one step in right away. So then I pre dilate with the smaller dilators, the fascial dilators, six French and eight French and 10 French as necessary.

Dr. Thomas Tailly:

Sometimes you can just get by with using the 15, 16 French one step dilator, and then going to the 21, 22. And this patient because she has a large stone load and I want to get your completely stone free, I have decided to go for the 21, 22 French MIP set that from storage that I usually use. You'll see that I've failed to use my one step dilator here. I do use fluoroscopy for this step because I think it's still necessary to guide your one step dilator with fluoroscopy. I still have my flexible ureteroscope in there as well so I do use that as well but I do have a fluoroscopy on hand. What I'm sharing here is that I let the wire rest and I let the wire guide me. It's the guidewire so let the wire guide you. So this is the way the wire is pointing me and I will try and follow that tract with my one step dilator.

Dr. Michelle Jo Semins:

We have a question from the audience.

Dr. Thomas Tailly:

Sure.

Dr. Michelle Jo Semins:

So when we were talking about dilation of the ureter if you can't get the ureteroscope in primarily and you said you would gently dilate with serial dilators but not with balloons. Is there a reason why you wouldn't use a balloon?

Dr. Thomas Tailly:

Even if I'm treating patients with strictures and stones, I don't treat them at the same time because I've had some issues in the past with some of the stone gravel or dust or small fragments getting into that balloon dilated wound of the year if you will and that just doesn't heal nicely at all. See if you have a lot of stone fragments coming into that tissue, you may have some fat, some subcutaneous tissue, you'll have a very, very difficult part of the ureter to treat afterwards.

Dr. Michelle Jo Semins:

That makes good sense. One thing that I'm always worried about balloon dilation is, as you mentioned, she had developed new symptoms suggesting a ureteral stone and my concern is always with balloon dilation of tight ureter when I don't see above it, how do I know that there's not a stone that I'm going to balloon into the wall of the ureter, that's what makes me a little bit nervous.

Dr. Thomas Tailly:

I completely agree. Even if I'm treating strictures, I would as a rule not pass my balloon dilator if I haven't seen what's above it.

Dr. Michelle Jo Semins:

Are you draining the bladder at all right now?

Dr. Thomas Tailly:

Currently what we usually do is place a small single use bladder catheter in the bladder next to the ureteroscope, and females or in males that's quite easy to do. You just put it-

Dr. Michelle Jo Semins:

What size do you attach to that?

Dr. Thomas Tailly:

Just 10 or 12 French. Usually 12 French and that's usually enough. And my flexible ureteroscope is a Flex XC from Storz and that's an 8.5 French. So usually 12 French pass it quite easily. I'm trying to dilate here and then pushing the kidney away even with those small dilators. So I'm going from eight to 10, and then going to the smaller one that I have in that set, which is a 15, 16, and then I'll go... if I'm pre dilating with a 15, 16, what I usually try and do is not puncture the collecting system just yet, but I would try and puncture or dilate the renal capsular, because if I dilate into the collecting system, I'll have urine or irrigation fluid or contrast leak out of the kidney and just obscure my view.

Dr. Michelle Jo Semins:

And do you ever balloon dilate?

Dr. Thomas Tailly:

I do. And maybe this case would have been a good case to balloon dilate. If I don't get in with my dilators at all, I would go for a balloon. The balloons that I have in my hospital are 18 French or 24 French. What I just did there with my left hand is pushed back on the kidney to just stabilize it a little bit when I was pushing in my one step dilator.

Dr. Michelle Jo Semins:

We have a question from the audience again, can you review your markings on the skin?

Dr. Thomas Tailly:

Sure. So what I mark off is the posterior axillary line. And if you see on the video, and I'm just going to interrupt my own answer here. If you see on the video right now, you see that the tip of my dilator is into the collecting system right now. Up to this point, I've used nine seconds of fluoroscopy and I'm going to place a tract over it. So the markings on the patient are to post your accelerator line, the pelvic brim and her ribs. And I do have enough place in between the ribs and the pelvic brim to get into the kidney. As bolsters, I have inflatable bags under the hip and the shoulder and I inflate as much as I need to inflate, so I can really choose my angle as necessary. And before prepping and draping the patient, I do an ultrasound assessment of the kidney before doing anything else. And if I'm happy with my ultrasound view, I'm happy with my positioning. And if during that positioning, I see that a supine position is not possible at all, I can still switch to prune, but that happens very, very, very rarely.

Dr. Thomas Tailly:

I also do an ultrasound assessment of my patient in the outpatient clinic so I ask him to flip over to one side to simulate the Valdivia position and see if I would be able to reach the kidney. So I have my tract into the patient right now, and I go check in with my scope to see if I'm in all right. And that's just a routine because I have my flexible ureteroscope and I know that I'm in. At this point, I still have the extra stiff wire in there which may impair my movements so what I do now is I exchange that extra stiff for a soft hydrophilic wire over a flexi tip, a usual catheter takes five seconds and it really helps me with my movements in the kidney. If I'm in the kidney comfortably with my tract, I would from time to time take out the guidewire if it's impairing my movements. So I don't always keep my guidewire in if my tract isn't in nicely.

Dr. Michelle Jo Semins:

And you don't use a percutaneous safety wire outside your sheath at all?

Dr. Thomas Tailly:

No, I routinely don't or I don't routinely do that. I sometimes do if I'm thinking about maybe dislocating my tract. So if patients have not that much renal parenchyma and I'm afraid of dislocating my tract, I would place a second wire through my access sheath, take out the sheath again and go back over one wire with the one step dilator and with the sheath again so that I have one wire on the outside, but it's not routine practice for me.

Dr. Michelle Jo Semins:

Did that become that routine practice for you? Did you start out always using a safety wire and then you transitioned as you felt comfortable?

Dr. Thomas Tailly:

No. I've never really used the safety wire around the outside of the tract in the past either even during my training. So I've started doing that because I dislocated my tract once in a patient with parenchyma but it's never really been routine practice. It has been routine practice though to keep my wire in, in the beginning, but as I felt more and more comfortable with PCNL, I started taking out the wire if it was impairing my movements. The equipment that I'm using right now by the way is slender 18 French rigid nephroscope also from stores which I really like. The view is just great and I have a big working tract and to break up the stone, I'm going to use shock balls which is a dual energy probe which has a pneumatic effect and an ultrasound effect.

Dr. Michelle Jo Semins:

Is this what you've always used or have you ever used any other technology?

Dr. Thomas Tailly:

No. I used to work with an ultrasound only when I was doing fellowship and I've always felt very comfortable with the ultrasound only. I have used EHL during my fellowship. I don't have it in my practice and I don't think I would ever need it. I used to have with the glass master. It works, but to suck out larger fragments if you're having to dual action at the same time, I was not really happy with the effect that I would have of the suction so I would use the ultrasound probe alone from LithoClast Master. And then I tried the shock balls. I was really happy and I added it on to my armamentarium.

Dr. Thomas Tailly:

So I still have my LithoClast Master and I have shock balls. I have two pros of both. What I like for the shock balls is that you have a very thin probe as well if you're in there with a smaller scope. I have a 12 French scope as well and I sometimes use the smaller probe from the shock balls. What I also use for breaking up the stones is my laser. So if I have a 12 French scope, I most likely will be using my laser and then the Hoover effect to get out the stones.

Dr. Michelle Jo Semins:

Now when you're using ultrasounds to get access, do you ever switch on the Doppler mode and look at vessels?

Dr. Thomas Tailly:

I do. do that quite often actually, especially if I'm not sure that I will be puncturing nicely in line with the calyx. So if I'm coming a little bit of an angle, let's say that this is your calyx and I can get my needle nicely in line with the calyx like this, I would put on Doppler to see if there's any larger vessels there, or if I can't dilate the collecting system nicely, I would try and make sure that I'm not going to puncture a vessel instead of the collecting system. I would use that for instance in more complicated cases where I just have to put it in a nephroscopy tube.

Dr. Michelle Jo Semins:

We have another question from the audience which is great. Have you ever damaged the flexible ureteroscope with any of your percutaneous instruments?

Dr. Thomas Tailly:

Good question. Answer, unfortunately yes. I'm trying to be very, very careful nowadays after damaging once. I hope that nobody from my hospital administration is watching this but I have damaged one before, yes. To prevent that from happening, I do pull back my flexible ureteroscope as you can see on the image below the UPJ so that I don't harm it. And when I'm inspecting the collecting system with my flexible ureteroscope, I will pull back my rigid nephroscope or that's what I usually do. So there's some stone in the upper pole as you can see, and I'm trying to reach there with my nephroscope. Just going to fast forward a little bit. We have about nine minutes of video left. I don't necessarily need to fast forward. As you can see here, there's a lot of smaller fragments but I can really suck them out easily with that shock balls.

Dr. Michelle Jo Semins:

What kind of salient or what kind of fluid are you using? You always use saline?

Dr. Thomas Tailly:

I always use saline. It's heated saline. It's usually heated in incubators outside of the OR. They're at, I think 37 or 38 degrees. That's what I use. I also have an incubator that continuously heats the fluid but I don't routinely use it. I can use it for a flexible ureteroscopy.

Dr. Michelle Jo Semins:

Is that a machine that you use then?

Dr. Thomas Tailly:

Yeah, it's a machine. It's a machine where you put your irrigation bags in and it continuously heats your bags up to 40 degrees and it can also control your pressure so that your pressure is always, let's say at 40 centimeters. It works and nursing can use the machine as well. It's not that hard to use. I usually only use one bag for a flexible ureteroscopy anyway, but for a procedure that may take a long time in PCNL or a treasury floater sections, I don't use a machine because they have to switch out the bags too fast and the machine can't heat up the bags fast enough. So as you can see now, I can't reach all the calyces with my nephroscope so that's exactly when I'm wanting my fellow Ralph to come in with the ureteroscope and assess all the calyces. I'm going to pull back the nephroscope and clear out so that he has a free passage with the flexible ureteroscope so that I don't damage that scope.

Dr. Michelle Jo Semins:

[inaudible 00:43:50]?

Dr. Thomas Tailly:

What's that?

Dr. Michelle Jo Semins:

Do you consider using a single use ureteroscope ever?

Dr. Thomas Tailly:

Well actually we've just done the numbers and the data has been submitted to journal. We've looked at 750 of our flexible ureteroscopies and on average, we use our flexible ureteroscope for 23 times before needing any repair and with an average repair cost of just below 6,000 and re sterilization costs of about 60 euros. One procedure costs about 430 euros per use. So that is below any price of any single use scope. But I do believe in a hybrid system where I would use single use scopes for cases like this where there's high risk of damaging the scope. And I think a hybrid model would be ideal also for longer cases or for training your fellow in residents, especially when they're in the beginning of their training. So this is a dangerous move with the shock ball so close to the ureteroscope but I was sure not to damage it. And as you can see on the urteroscopy image on the right side, I'm trying to flesh out some fragments from that upper pole and I'm coming into to suck them out with the shock balls in the meantime.

Dr. Michelle Jo Semins:

Gravel size when you're using your flexible ureteroscope.

Dr. Thomas Tailly:

Could you repeat that please?

Dr. Michelle Jo Semins:

This is an audience question. Is there a way that you can assess the size of gravel when you're with your?

Dr. Thomas Tailly:

Of course. There's multiple ways. You can compare it to anything that's already in the kidney actually. So you compare it to the guidewire, which is about one millimeter in diameter. So if your fragment is next to the wire and it's about that size, it's about a millimeter. If you have a laser inside, my laser 272 micron, with the cladding is about 0.4 millimeters so that's another reference you can use. If you're going to use a basket, same thing. I have a 1.5 French basket which is, so that's about 0.3 millimeters, a little more, it's 0.5 millimeters. So you can have different references inside of your kidney, the guidewire, your baskets, your laser fiber.

Dr. Michelle Jo Semins:

We have another audience question, somebody wanting to know if you can use the master LithoClast and ultrasound probe together with the eight and a half French nephroscope that you have.

Dr. Thomas Tailly:

With 18 French nephroscope that I have?

Dr. Michelle Jo Semins:

Yeah.

Dr. Thomas Tailly:

Yes you can actually, because this shock post probe is not the biggest shock post probe either. It's actually I think it's a 3.5 millimeter probe and the probes that I have for my LithoClast Master are practically the same size. So I did choose my nephroscope to accommodate the equipment that I already had. So the EMS LithoClast Master probe does go through this 18 French. But there's different sizes of LithoClast Master probes as well so be sure to check the size of your probe and the size of your working channel before you buy anything. As you can see here on the image on the nephroscope image, you see that my tract is retracted a little bit and you can actually see that we're at the papilla. I'm not sure if you can appreciate that on this image.

Dr. Michelle Jo Semins:

Yes, we can.

Dr. Thomas Tailly:

Okay. I'm pretty happy with the result here. [inaudible 00:47:54] I've seen that there's nothing really left and whatever was left, oh yeah, I'm just showing how my fellow here is handling the ureteroscope and he's actually holding onto it vice versa. I call this the upside down move. So sometimes you have to put your scope upside down to look at the calyx in a different angle to be sure to look behind an infundibulum.

Dr. Michelle Jo Semins:

Now how does the suction work exactly what the shock balls? Can you control the suction?

Dr. Thomas Tailly:

So yes, there's controllable suction. There's actually a handle on top of the shock balls probe which twists up left and right, clockwise or counterclockwise. But what I usually do is I leave it all the way open and I have my finger on top. So I control it with my finger. It's always open and I just have suction when I need it, because toggling the handle is, I think my hands are too small. And I also think that if you have the suction on all the way, all the time, you really suck out the pressure from your kidney and it'll be collapsed all the time. So I leave it open all the time and I can press the small hole when necessary.

Dr. Michelle Jo Semins:

Do you ever clamp a section?

Dr. Thomas Tailly:

No, actually I don't. And what I also have, one benefit of the shock balls in comparison to the LithoClast is that the suction almost never clogs up. It almost never does. It's connected to wall suction and in the container for the wall suction, I have a sock which then contains all the fragments that I've sucked out. So I have all those fragments for analysis or to give to the patient.

Dr. Michelle Jo Semins:

Do you send it for culture?

Dr. Thomas Tailly:

It depends. If the patient has had infections in the past, I routinely do try and send a piece that I've taken out directly with a forceps or with a basket. I take it out and I put it directly into a container and I send that for analysis, for a cultural analysis. But I don't routinely do that and this patient has never had a urinary tract infection in the past. I don't necessarily send in a fragment for culture.

Dr. Michelle Jo Semins:

You look pretty stone free here.

Dr. Thomas Tailly:

Yeah, exactly.

Dr. Michelle Jo Semins:

Two questions. One is, how do you decide what you leave for drainage? Do you leave a catheter, a Foley catheter, a stent in place nephrostomy to both, neither?

Dr. Thomas Tailly:

Good question. So what we've just missed on a video. I'm not going to go back but what we've just missed on a video is I assess the ureter with my flexible ureteroscope to make sure that one, there is no stone fragment in the ureter anywhere, and two there is no damage to the ureter. So those two are very, very important. And in this patient that has a very wide ureter with no damage and no fragments left, I decided to go stentless. And the next thing that I'm going to do is it says the nephroscopy tract. I do a tractoscopy if you will. So I pull back my tract. So I have a wiring right now for sure down into the ureter and I pull back the tract while assessing the tract to make sure that I don't have any massive bleeders and to make sure that I didn't transgress any organ. And in this patient who is completely stone free has a very wide girder, no bleeders, no risk of infection or a limited risk of infection. I actually decided to do totally tubeless.

Dr. Michelle Jo Semins:

Do you leave a Foley catheter?

Dr. Thomas Tailly:

I do. I do leave it Foley catheter.

Dr. Michelle Jo Semins:

And how long do you leave that for?

Dr. Thomas Tailly:

So my routine after an ECIRS is usually just a stent and it would leave the catheter overnight.

Dr. Michelle Jo Semins:

Okay. And if you don't leave a stent on, does the catheter come out?

Dr. Thomas Tailly:

Well in this patient, I could take it out let's say four to six hours after a procedure, and this patient would be able to go home the same day.

Dr. Michelle Jo Semins:

Amazing.

Dr. Thomas Tailly:

I have not done that many day cases to be completely honest. I've done three or four, and I do cherry pick them. Very healthy patients, ASA one or two, perfect puncture, perfect procedure, no residual fragments, no bleeding from the tract. Patients like that. Yeah.

Dr. Michelle Jo Semins:

Okay. Well, with the ability to endoscopically view all of the calyces.

Dr. Thomas Tailly:

Excuse me.

Dr. Michelle Jo Semins:

Do you get postoperative in these patients?

Dr. Thomas Tailly:

Could you repeat the question please?

Dr. Michelle Jo Semins:

Sorry. What kind of imaging do you get postoperatively in these patients?

Dr. Thomas Tailly:

So in these patients who endoscopically for me is stone free, she may just come back with an ultrasound at first, but I do get CTs in all my patients at some point within three months postoperatively just to make sure that they're actually stone free. And especially in this patient that had recurring stones quite fast, I do a CT within three months.

Dr. Michelle Jo Semins:

What you do for pain management for these patients?

Dr. Thomas Tailly:

So postoperatively I usually, so that's the needle guide that I'm sharing, I usually only use paracetamol or a centimeter fan and [inaudible 00:53:40]. I'm not a fan of any morphine derivatives so they don't go home in anything like that. No coating, just paracetamol and [inaudible 00:53:52].

Dr. Michelle Jo Semins:

That's fantastic. I think we know what the opioid problem in the world, I think it's great. We have some audience questions.

Dr. Thomas Tailly:

Sure.

Dr. Michelle Jo Semins:

Have you tried the [inaudible 00:54:09] access sheaths?

Dr. Thomas Tailly:

I have not because we can't get it in Belgium yet, but really want to.

Dr. Michelle Jo Semins:

Yeah, I have not tried this either but would be looking forward to try it.

Dr. Thomas Tailly:

Yeah. I think it's very interesting technology.

Dr. Michelle Jo Semins:

Now with the shock policy, is there a max size of fragments... this is another audience question, the section can remove?

Dr. Thomas Tailly:

Honestly, I don't know because while you're suctioning you're also activating the probe. So you'll sometimes see a fragment that's just rotating on the tip of the probe. And while it's sucking the stone in, it's breaking up the stone so it'll just reduce it to a fragment that it can suck up.

Dr. Michelle Jo Semins:

And another audience question, which is great. So when you're inspecting the tract, and then I have my own questions too regarding the inspection of the tract. Number one, how would you manage excessive bleeding from the tract? And number two, if you do upper pole access and there's concern that you may have gone through the pleura, that's a possibility, would you not inspect the tract because you might get a pleura fusion more likely if you're inspecting it with active flow going?

Dr. Thomas Tailly:

So if I have massive bleeding, I've heard of people trying to coagulate that tract. I haven't tried it yet. I'm not sure how I would do that through a small tract. I don't have a very small resectoscope. I usually put in a nephrostomy tube basically the size of my tract so that it does compress. For upper poles.I do the exact same thing. If I get into pleura, which I've had in the past, you can actually put in a wire into the pleura and over that wire place a smaller tube like a gastric tube, nasal gastric tube, and drain the pleura under a PEP, positive and expiratory pressure to make sure that you drain the pleura. In that case, I would also place a stent and not in nephrostomy because if you then put in a nephrostomy tube, you're going to maintain that tract through the pleura.

Dr. Michelle Jo Semins:

Thank you so much for the fantastic information. I think we're coming very near the end. If you could just tell us some of the take home points.

Dr. Thomas Tailly:

So take home points for me would be, flexible nephroscopy is something that makes a PCNL complete. And I like to do it from below with the flexible ureteroscope. If you do an ECIRS you can really adapt to every situation you can just choose to do ureteroscopy or PCNL or both. That's how I get most patients stone free in a single session. You can assess the collecting system and you have more freedom of a calyx to choose with the flexibility reader scope in there. With ultrasound and flexible ureteroscopy you really have the choice of puncture more than with fluoroscopy alone in my hands and in my mind. I think you can reduce the number of tracts if you have a flexible ureteroscope and they're assessing any residual fragments and repositioning as necessary. And then also thing that you can reduce your tract size because you don't need to put in a flexible nephroscope from above so you don't need that 22 French tract every time.

Dr. Michelle Jo Semins:

Great. Yeah. Well, thank you so much. For me, I've learned that this is a really individualized management, the assessment retrograde and antegrade allows you to access all the calyces, presumably that would allow you to keep one access tract which increases stone free rate, decreases blood loss, decreases pain. So I think this has been a really informative, thank you.

Speaker 1:

It's both our panelists. That was really fantastic. We went right up to the amount of times, so perfectly times. Just as a reminder to all our participants still on the line that this entire webinar will be uploaded in the next couple of days to our website as well as the dictation so feel free to look back if there was anything you missed or wanted to clarify. As a reminder, the masterclass does roll on next week. We're going to be shifting gears back to BPH where we're going to have Dr. Berber and Rayburn will be discussing violation of treatment in BPH. And just some information for CME. If you're not aware, you're going to be receiving a survey from Michelle Paoli at the end of this month, and each month that you've been participating.

Speaker 1:

Just go ahead and indicate which webinars you've attended during that time and then your CME certificate will be emailed to you. And importantly, please do be sure to fill out the evaluation questionnaires as this is actually important for you securing your CME credit. And please do go ahead and look on the website at our master class tab for all our future webinars and go ahead and register for any and all that you find interesting. If you're not already a member, we do encourage you to join the endo society, tons of benefits that you can find on our website, not a which is including full text online access to all of our journals and never too early to save the date at the world congress. We'll be resuming in Hamburg, Germany in September of 2021 so be sure to mark your calendars again, thanks for all of our panelists and appreciate your attention.