Chapters Transcript Advanced Technologies in Kidney Stone Management Course: Surgical, Pharmacological, and Technological Advances in Urology Thanks, Phil. But by the end of this talk, you're all gonna be vegan. Um, OK, so we talk, discuss, uh, some new technologies, we'll talk about strictures, we'll talk about some of the virtual reality, uh, and, and augmented reality. We'll talk a little bit about burst wave or break wave lithotripsy and CVAC and Monarch, which is robotic reader scope. Um, so we all know that there are a lot of complications that you can have with kidney stone management. I've probably had most of these, um. Um, and, uh, they're associated with malpractice. Uh, malpractice for putting in a stent, for not putting in a stent, for not taking the stent out on time, for, uh, messing up the ureteroscopy, for bleeding, etc. Uh, so, you know, we don't, we don't want these to happen. Um, we are worried about complication rates. Now, complication rates tend to be pretty low for ureteroscopy, and if you look closely at the PCNL complication rates, you can see that, um, Many of them are fever and transfusion. These are sort of short-lived, uh, resolvable complications, um, but there are other significant ones, organ injury, um, urethral injury, uh, renal injury, and and and even death. So the name of the game is, you know, how do we take care of patients, how do we avoid injury, how do we avoid complications, how do we avoid lossess? Um, we know that, uh, PCNL has tends to have more complications than ureteroscopy, uh, tends to have more blood loss than ureteroscopy, but sometimes you, you need to do it, uh, because of a large stone burden, um. But ureteroscopy is not um is not totally uh benign either, and I think that as the number of ureteroscopies have gone up in this country, it's becoming the most popular procedure, uh, we are seeing more strictures and historically the stricture rates were quoted as like a 0.5%, but you know, some of the papers I've seen, stricture rates uh 1 to 2%, and so, um. So there's more strictures, uh, we're putting on access sheaths, uh, more, uh, or our scopes, first they got smaller, now they're getting larger, uh, and so strictures are, are something that we worry about and um league league uh uh could give you chapter and verse on how how to fix all these strictures. So there are many, you know, robotic ways to fix strictures, but we're we're in the end of urology session, so I'm gonna talk about endoscopic, ureteral. Um, stricture repair started in, uh, almost 120 years ago, the first balloon dilation by Nietz in 1907, um, the first double J stent in 1978, um, and Klayman used to tell stories about how, um, uh, Mr. Cook would come to the conferences and you would ask him for stents, and he would sit there with his Bunsen burner, literally twirling, twirling the stents to your to to the confirmation that you wanted before there was mass production of Double J stents. Um, 1983, uh, the first percutaneous, uh, pylolysis, uh, which uh by Laing all renamed the endopylotomy. Um, so that's a history of endoscopic repair of strictures. Um, this is just an example, this is the right UBJ stricture patient had a procedure. In 2020 and several years later developed hydronephrosis. You can see nice nice hydronephrotic ureter down to the UVJ and uh here you can see a balloon is passed across this stricture, dilated, stricture is gone, uh. Double J stent is placed. Now this balloon is probably not very different than what Neets placed in 1907, and this double J stent is probably not very different than uh what was created in 1978. Maybe the material has changed a little bit, but probably not all that much. Um, so this patient a year later, he went from Can you see my pointer? Can't can't, I don't think they can see my corner. OK, there you go. Uh, so it went from this to that, um, uh, fair amount of hydro to to no hydro, you can see there's a little bit of ureteral dilation here, um, but, uh, distally, uh, but still it's, um, uh, the hydronephrosis is gone, the stricture was cured at least a year later, and, uh, here's another example, mid-segment urethral stricture, a balloon dilated and stented, um, so. What's, what's, how do we make this better? We haven't done anything different in 120 years. Well, we can use optimum, and so if you were here for Li Zhou's talk earlier, um, optimum was originally created for urethral strictures, but it can also be used for urethral strictures. Um, it's a paclitaxel coated balloon, Paclitaxy is the same thing that is in the drug eluting uh cardiac stents that the cardiologists are are are very fond of, um, and so the idea is you. Balloon dilate your stricture, and this creates micro tears, um, and then you use a separate paclitaxel coated balloon. So the Paclitaxel coated balloon is not a dilating balloon, it's just a medication delivery balloon. So you use a separate balloon, you stick it up there, blow it up, uh, under low pressure for 5 minutes, and the the Paclitaxel, um, is absorbed into the stricture in theory, and it it it prevents fibrosis and inflammatory response, um, and then a stent is placed as as normal. Um, so if you look at the uh Uh, historical literature of stricture dilation, we can see success rates, they were between 60 and 75%. It sort of depends on the reason for the stricture, if there's radiation involved, if it's iatrogenic or primary, etc. um, but you know, the, the, the rates are reasonable. OK, um, they, they are better at 1 year and they, they tend to go down after, uh, uh, after 2 years. Optulum 1 year data was 88%, so that's, that's pretty good. Um, that's pretty good, you know, remains to be seen. I've done it in about 5 patients with varying success, um. Um, so another new technology that's coming, this is not, uh, this is not FDA approved or even been really using humans yet. Um, this is a tri layer stent where the middle layer is a biodegradable, uh, PDO monofilament. And this is coated with uh rapamycin and Paclitaxel on the internators of the stent, and it allows for cumulative release of rapamycin and paclitaxel over 30 days. So this is like, this is essentially very similar to the drug eluting cardiac stents, uh, um, but instead it's a drug luing ureteral stent, uh, and the idea is that it will it will prevent uh perforation of fibroblasts and smooth muscle cells, and this was shown in in in vitro models, um. Again, this has been done in in vitro, it's been done in some, I think rat or pig models um in vivo, but not not yet in humans, but this, this is something that may be coming down the road, um. Either in in addition to or instead of the balloon. Um, all right, so we're gonna switch shift gears a little bit to imaging. So 3D printing, uh, has multiple uses in neurology. You can see here. This is a 3D image of a of a kidney, and there's a stone in here, so you can, you could print this model and you could look at it in all different directions and figure out where you might want to put access tracks. It's important for education, uh, you can educate the patient on what they have, you can educate medicine. Students and residents, um, you could potentially manufacture various devices and instruments. You could print a stent, you could print a stent that is specially designed for a specific patient. It could be wider in one area, narrower in another area. Um, bioprinting uh is also uh going to be interesting in the future. You could bioprint a ureter theoretically, um, I think people have tried it, I don't think it's worked. Uh, but that is the future. Um, it could be helpful for surgical decision making and, uh, and surgical planning. Um, you could print, not only can you print, uh, the patient's actual kidney and show it to them, but you can help use that to plan your surgical approach. Um, so what's the next step? Uh, holographic imaging. So this is the Microsoft HoloLens and this is me, um, this is a kitty tumor, um, but the same idea applies to a stone, and you can see in this video, you get to work. Um, so you can see that on the laptop, there's an image of that kidney that I showed you before, and using hand motions and the hole lens, I'm trying to manipulate, not very well, because it takes a little bit of getting used to, but you can manipulate that, that kidney, um, flip it around, flip it up and down. Down and and try and get a better sense of it, as if you were holding the model in your hand, but you don't have to go through the cost of actually printing out that the cost and the time, which could take many hours to print out that model, you can do it, you can, uh, you know, you can have that 3D model within minutes. Um, I've never heard of Owl City, but they apparently wrote a song called The Real World, in which they say reality is a lovely place, but I wouldn't want to live there, um. So we're gonna talk about a little bit of reality. So virtual reality everyone talks about and and and for better or for worse, uh, you know, all all sort of realities are encompassed by the term virtual reality, but if you want to get down to semantics, virtual reality is a 3D model within a completely virtual environment. So like what I was showing you before, me flipping that kidney around on my laptop, that is virtual reality, um, it can be fully immersive with a headset. Um, they, uh, they make rooms that are, so we don't need a headset, but the entire room is a big screen and you can sort of feel like you're inside the kidney or or what have you. Um, mixed reality is um is a mixture between a virtual reality and a real environment where the two coexist and and interact, um, and then there's augmented reality. Where the 3D model is superimposed on a real environment. I'll show you some pictures of that. Um, and then finally extended reality is sort of a mixture of all three, and you add some AI in there um to to sweeten the deal. Um, so here is an example of a 3D reconstruction of a left kidney, uh, with a lower pole, partial staghorn. So this was a four-phase, uh, CT scan with thin cuts. It was segmented, it was 3D reconstructed, and then created into a hologram, um. So here's the stone in the lower pole, here's the sort of the 3D reconstruction. Um, and this is a holographic image, um, sort of a 3D image of the stone, and here's the, here's the stone here with the vasculature. And then you can superimpose that on the patient. And so here you can see the surgeon here, he's doing the same pinchy thing that I did. He's trying to line up, so you use, you use bony landmarks like the iliac crest and the 12th rib, and you line up, and so you mark those on the patient and then you try and line up your uh uh your 3D. Uh, your, your, your 3D, uh, virtual reality image on top of the patient, um, the patient here is in a a modified supine position. So this is, this is the patient's side. So you try and line it up and so you try and figure out, right, where's my approach gonna be. For a PCNL, um, and, and so here it is and now you can have a overlaid image. This is an endoscopic image where you're watching the needle come into the kidney. This is the actual image of you, uh, of them passing the kidney in, and here's a fluoroscopic image and you can see the needle going right into the lower pole, uh, here. Um, so this is preoperative planning. Uh, the surgeon decided that approximately a 46 degree angle into the lower hole would be the angle of approach, and then when they measured it here in actual real time, it was 45 degrees, so, so pretty good. So you can get a pretty good assessment of what you're gonna do, you can overlay the image, and then you can actually, uh, you can actually do it. Um, so this is, these are some studies of using augmented reality in interventional radiology training. This is for percutaneous, um, um, access, but this is something that urologists could also be doing. And so there's sort of two different approaches. One is wearable uh augmented reality devices, HoloLens, the one I was wearing, or the Google Glass, uh, versus uh augmented reality simulators such as the Perk Tutor. And so the, the wearable devices are providing immersive experience, they overlay the holographic data onto the visual field, um, they can improve the spatial awareness of of the operator, um. Make the procedure more precise, uh, you know, help you stay away from the liver or the spleen, um, they can enhance your needle positioning and make the procedure faster. Um, the augmented reality, uh, simulators are more for skill development. So these are, these are simulators, these are for practice, so they can make They can improve your skills, um, they can improve, uh, your, uh, the, the feedback, uh, feeling the needle, entering into the calyx, etc. um, and they can allow for any time hands-on practice. So the, the, the conclusion of this paper was basically we they should be using both, you should practice your skills, and then when you get into the actual clinical environment, use the augmented reality to make the procedure faster and safer. I mean this is just some examples of this is actually a liver biopsy, but you can see this is the This is the augment, this is the um ultrasound image, um, this is a um this is a practice model, um, this is sort of a a torso and the the the radiologist is using ultrasound um overlaid with the overlaid with augmented reality to pick out these, these red things are supposed to be tumors, and you can see the needle, um, and this is the this is the anticipated trajectory of the needle, the the the uh AI is telling the radiologist where, what trajectory to do to put the needle in to hit that, to hit that target. Um, this is, these are slides courtesy of Ahmed Ghazi at Ed Hopkins. So Ahmed, uh, is a an absolute genius in, um, creating hydrogel models. These are relatively cheap models that he can make, um, it's basically like jello, uh, he makes it basically this gel mold that hardens, and he can make anything. He can make a kidney, he can make bowel, he can make an entire abdominal cavity looks and feels real. Um, so this is a kidney, and again, you can make a generic kidney or you can make your patient's kidney, and you can practice on your patient's kidney and so this is, this is just showing the ultrasound appearance, uh, let's see if I can get that video on here. Oops. Um, Uh, I can't get the video to run, but uh. Let's try it again. Here it goes, OK, I got it. So here's, here's the ultrasound appearance, so it looks pretty good, it looks similar to an actual kidney, um, and then over here you can see the needle coming in slow, slow, slow. There's a little bit of pressure, and then it pops through, OK? So, not only does it look real, but it feels real. If you know, and you can get that feel, the needle popping into the calyx, so it's good for training. Um, OK, so we're switch gears, break wave lithotripsy, so I'm gonna be talking about uh a paper that that Ben was one of the authors on. Um, so break wave lithotripsy is the ESO killer, maybe, um, it's a narrow band, low pressure ultrasound waves, uh, and basically you use a generic, uh, you know, ultrasound probe, uh, and On top of that probe, you put this break wave with the TIPC device. So you can use any ultrasound, this thing just fits right in the middle. And um so you're doing real-time ultrasound identification of the stone, and then you're watching as the stone is comminuted. Uh, let's see if we made the video to run. All right, so this is just a cartoon schema of what's happening in the ultrasound waves are breaking the stone. Um, and then this is, this is in real time. See if we can get that. There we go. The stone just gets completely, completely destroyed uh by by the by the break wave. Um, so this study, uh, 44 patients, 5 institutions, it was a 40 minute procedure entirely. The, the, I believe the uh the the breakway was limited to 30 minutes, but the other 10 minutes were for you know, positioning, etc. etc. um, 86% had no sedation. In the beginning they started with sedation and by the end they weren't really using much sedation at all, um. Mean stone size, 6 millimeters, um, the majority of these stones were either in the UVJ or in the lower pole. Um, in the beginning they, they took a little bit of time to optimize the settings, but you can see here on the right, with optimal settings, fragmentation rate, uh, so 92% of stones fragmented. And these were all, these are all well selected patients, so this is not anyone off the street. These are patients who were deemed acceptable for shock wave lithotripsy, so the stones weren't terribly hard. They didn't have a tremendous skint distance, so I wouldn't wanna overstate these results, but, but still in carefully selected patients, 92% fragmented somewhat, um, stone free rate or stones less than 4 millimeters were 75%. Very high in the distal ureterstones, 89%. So this is, this is very promising technology that will hopefully be coming very soon. Um, ultrasound propulsion is another, uh, another, uh, sort of offshoot of this. The idea is that if you have a procedure where you've broken up stones and then there's some fragments in the lower pole or what have you, you can push those stones, painless in the clinic, takes just a few minutes, you can push them to the renal pelvis so that they will fall down by themselves. On anesthetized patients, um, this study, 84 patients, residual fragments less than equal 5 millimeters, um, 25 millisecond, uh, low pressure ultrasound pulses. Um, uh, uh, for 3 seconds, uh, procedure time took less than 5 minutes, um. And here is video. So watch the stone in the lower pole and You will see it go, boom. All right, so you push it out, the lower pole goes to the renal pelvis. Um, it did take, uh, most patients needed, um, an average of 1.35 treatments per patient. Um, but within 3 weeks of treatment, 63% of patients who underwent the treatment passed simultaneously passed on fragments versus only 5% of controls. Fewer patients Ended up having a stone. Stone event, um, if they, if they underwent the propulsion treatment, and of those who did, it was a year. Later that they actually had the stones versus the the the control group. Right, so CVAC, um, we talked a little bit about, um, previously, this is a aspiration and suction, um uh uh ureterroscope. You can see here, it's got 4 water jets in the wall of the scope. It's got about almost 7 French channels. The scope itself is 12 just under 12 French. This is the camera right here, and the laser fiber fits right through the middle, so you do your ureteroscopy as normal, you have to put up a 1214 access sheath, um. And you get, you get a passive suction of tiny little fragments, and then when you think you've gotten the stones small enough, you take out that laser bridge and you uh and you just vacuum. And so here, here this is a video, this is not me, this I got this from the website, um, but I did a case. Just like this a week ago, and if I, and I did it, but I, I didn't, I didn't put it up here yet, but if I did, you would see exactly the same thing. It works just like this, so you laser the stone. You break it up into little fragments, then you sort of popcorn and popped us those fragments. You're getting active. The reason it's it's a little cloudy is cause you're sucking up these little bits of dust and sand into your scope, so it's clouding your vision a little bit. Um, as you get this, uh, tornado effect, uh, then you take out the, you take out the laser fiber, and you get this pile of stones and you just vacuum all up and you'll, you know, you'll be 99% stone free if you um relatively quickly. So this procedure, I think it took was one, it was 1.4 cntimeter stone, took 37 minutes, and was visibly stone free, and I had, I had exactly the same thing, a 1.4 centimeter stone, took about a half hour 45 minutes. And visibly stone free afterwards. Our clear petra sheath, Ben talked about a little bit. They make sheets for percutaneous access, they make sheets for your real access, again, um. Um, uh, the sheath goes in, uh, you put a scope in with a laser, and as you are doing your procedure, uh, you're getting this. Suction of of small fragments outside of your ureterscope into the sheath. Now they have a steerable access sheet, so you can put it in pretty much any calyx, particularly the lower pole, but you could also put it in sort of a oblique mid pole calyx, and again, you do the same thing. As you're fragmenting Still getting sucked out. Uh, and finally I'll end with Monarch, which is a robotic. Access system it's a. Disposable reader scope. Aligned with a robotic arm that That creates The access for you for a mini PCML and puts in a 15 French steerable catheter. Suck out the fragments now. This was 13 patients, 33 millimeter. Uh, stone burden Only 8 patients were stone free, so not great early results, but They're working the kinks out. This is something that might be very promising. Um For the future, uh, minimal complications, no bleeding, etc. Mini perk robotically uh designed to get you a perfect track every time. All right, that's my time. And we can have answer questions. Published December 2, 2024 Created by Related Presenters James Borin, MD View full profile
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