Dr. William Finch

Breaking stones in Nepal

Mr Will Finch FRCS Urol

TUF / BAUS Endourology Clinical visit December 2013

Kathmandu, Nepal, sits in the heart of the Asian “stone belt”. Surely a must visit place for a UK stone surgeon at the beginning of his Consultant career?

The inspiration for my trip to Nepal came off the back of a conversation with Prof. Jean de la Rosette whilst visiting Amsterdam earlier in the year. He had seen a Nepalese surgeon present his experience of “Chinese miniPCNL” at a meeting in Dubai where he was performing single handedly around 800 cases per year. Amazed and intrigued by this volume of work and experience in a single place, the seed was planted for my visit to Nepal.

Nepal has a population of circa. 30 million people, of which 4 million are based in Kathmandu and the rest spread around rural Nepal. Currently the number of Urologists in Nepal totals 20, supported to an extent by general surgical colleagues. Although there is provision of Urological services within public hospitals, the treatments offered are very limited, with open stone surgery still a favoured approach by many. Private health care currently is the flourishing alternative which many therefore choose as their treatment path.

Dr Sanjay Khadgi is Nepalese, medically trained in Russia with his endourology training completed in China. It was here that he worked and trained under Professor Zeng Guo Hua, who has pioneered miniPCNL in China. He subsequently brought the technique back to Nepal where he is currently the only surgeon performing miniPCNL and has now done in the region of 4000 cases. He recently opened the Nidan Hospital PVT in Kathmandu, providing specialist endourology care in addition to other medical services as well the only transplant HLA typing laboratory in Nepal.

My clinical visit was mid December 2013. Our typical working day started at 10am with a ward round followed by outpatients from an hour. Urology theatre started at midday with small cases under topical anaesthesia followed by major cases. The volume of stone work was staggering with us performing 23 miniPCNL’s in the first 5 days. It is much amusement to the Nepalese that this is around 50% of the PCNL cases established UK stone centres will do in a year!

Dr Khadgi performs all his cases under spinal anaesthesia and achieves his own access using flouroscopy. The miniPCNL technique favours the middle calyx for ease of access to upper and lower poles as well as the potential to negotiate the upper and mid ureter. 85% of punctures by Dr Khadgi are supracostal. Stepwise dilatation of the puncture is done to 18fg to establish the tract. A semi-rigid ureteroscope is the instrument of choice to visualise the collecting system. A pneumatic ballistic lithoclast is used down the working channel of the ureteroscope to provide stone fragmentation. Irrigation fluid is provided by an intermittent pressure pump, with an average pressure of 25cmH20. Efficient stone evacuation is achieved by a combination of manipulation of the mPCNL sheath to trap fragments, the intermittent pressure pump and synchronised retrograde saline flush via the ureteric catheter on withdrawing the ureteroscope. All cases are left with a stent or a ureteric catheter overnight, but are otherwise managed tubeless.

During my visit I was exposed to a wide variety of stone cases, all treated with miniPCNL. These included mid and upper ureteric stones, renal stones both solitary and multiple, staghorn calculi and stones in horseshoe kidneys. I was given hands on training in the technique and by the end of my visit felt confidant in the technique and completed several challenging cases. The breadth of cases I saw demonstrated the flexibility of the technique and the manoeuvrability possible of a semi-rigid instrument within the kidney. Dr Khadgi describes his semi-rigid ureteroscope as his “flexible friend”. I learnt tips and tricks for securing fluoroscopic difficult access and have had a good exposure to multi-tract punctures techniques.

Does miniPCNL have a place in UK practice? I went to Nepal with my eyes wide-open but needing convincing as to why I should not be doing conventional PCNL. Over my visit I witnessed and performed the technique, achieving very high stone free rates, with no major complications and with all patients managed tubeless. I think miniPCNL certainly does challenge conventional PCNL, allowing us to achieve high stone free rates, with less dilatation / trauma to the kidney enabling us to manage patients tubeless.

Kathmandu, Nepal, sits in the heart of the Asian “stone belt”. Surely a must visit place for a UK stone surgeon at the beginning of his Consultant career?

The inspiration for my trip to Nepal came off the back of a conversation with Prof. Jean de la Rosette whilst visiting Amsterdam earlier in the year. He had seen a Nepalese surgeon present his experience of “Chinese miniPCNL” at a meeting in Dubai where he was performing single handedly around 800 cases per year. Amazed and intrigued by this volume of work and experience in a single place, the seed was planted for my visit to Nepal.

Nepal has a population of circa. 30 million people, of which 4 million are based in Kathmandu and the rest spread around rural Nepal. Currently the number of Urologists in Nepal totals 20, supported to an extent by general surgical colleagues. Although there is provision of Urological services within public hospitals, the treatments offered are very limited, with open stone surgery still a favoured approach by many. Private health care currently is the flourishing alternative which many therefore choose as their treatment path.

Dr Sanjay Khadgi is Nepalese, medically trained in Russia with his endourology training completed in China. It was here that he worked and trained under Professor Zeng Guo Hua, who has pioneered miniPCNL in China. He subsequently brought the technique back to Nepal where he is currently the only surgeon performing miniPCNL and has now done in the region of 4000 cases. He recently opened the Nidan Hospital PVT in Kathmandu, providing specialist endourology care in addition to other medical services as well the only transplant HLA typing laboratory in Nepal.

My clinical visit was mid December 2013. Our typical working day started at 10am with a ward round followed by outpatients from an hour. Urology theatre started at midday with small cases under topical anaesthesia followed by major cases. The volume of stone work was staggering with us performing 23 miniPCNL’s in the first 5 days. It is much amusement to the Nepalese that this is around 50% of the PCNL cases established UK stone centres will do in a year!

Dr Khadgi performs all his cases under spinal anaesthesia and achieves his own access using flouroscopy. The miniPCNL technique favours the middle calyx for ease of access to upper and lower poles as well as the potential to negotiate the upper and mid ureter. 85% of punctures by Dr Khadgi are supracostal. Stepwise dilatation of the puncture is done to 18fg to establish the tract. A semi-rigid ureteroscope is the instrument of choice to visualise the collecting system. A pneumatic ballistic lithoclast is used down the working channel of the ureteroscope to provide stone fragmentation. Irrigation fluid is provided by an intermittent pressure pump, with an average pressure of 25cmH20. Efficient stone evacuation is achieved by a combination of manipulation of the mPCNL sheath to trap fragments, the intermittent pressure pump and synchronised retrograde saline flush via the ureteric catheter on withdrawing the ureteroscope. All cases are left with a stent or a ureteric catheter overnight, but are otherwise managed tubeless.

During my visit I was exposed to a wide variety of stone cases, all treated with miniPCNL. These included mid and upper ureteric stones, renal stones both solitary and multiple, staghorn calculi and stones in horseshoe kidneys. I was given hands on training in the technique and by the end of my visit felt confidant in the technique and completed several challenging cases. The breadth of cases I saw demonstrated the flexibility of the technique and the manoeuvrability possible of a semi-rigid instrument within the kidney. Dr Khadgi describes his semi-rigid ureteroscope as his “flexible friend”. I learnt tips and tricks for securing fluoroscopic difficult access and have had a good exposure to multi-tract punctures techniques.

Does miniPCNL have a place in UK practice? I went to Nepal with my eyes wide-open but needing convincing as to why I should not be doing conventional PCNL. Over my visit I witnessed and performed the technique, achieving very high stone free rates, with no major complications and with all patients managed tubeless. I think miniPCNL certainly does challenge conventional PCNL, allowing us to achieve high stone free rates, with less dilatation / trauma to the kidney enabling us to manage patients tubeless. A criticism levelled at the miniaturisation of PCNL is always the efficiency of stone evacuation. With precise fragmentation, a clear understanding of where stone fragments migrate to based on the anatomy of the kidney you are operating on and confidence with the evacuation techniques described above, miniPCNL in my mind certainly competes with conventional PCNL. Overall miniPCNL I think has the potential to improve the patient experience of PCNL and reduce the length of stay for our patients whilst maintaining the very high stone clearance rates associated with conventional PCNL.

I would like to thank BAUS Endourology and TUF for providing the financial support to help with this clinical visit and Dr Sanjay Khadgi and his team at the Nidan Hospital Pvt for allowing me to visit and making my trip so rewarding.

I wouldn’t hesitate to recommend this clinical visit to another Urologist with an interest in stones disease. Nepal also has a crying need for surgical manpower within the public hospital system. Brand new, world class theatres rivalling anything in the UK, sit there fully staffed lacking surgeons to do general urology procedures – a tempting proposition for UK Urologists wanting to combine some charitable work with a trip to the Himalayas!

Miniaturisation of PCNL is always the efficiency of stone evacuation. With precise fragmentation, a clear understanding of where stone fragments migrate to based on the anatomy of the kidney you are operating on and confidence with the evacuation techniques described above, miniPCNL in my mind certainly competes with conventional PCNL. Overall miniPCNL I think has the potential to improve the patient experience of PCNL and reduce the length of stay for our patients whilst maintaining the very high stone clearance rates associated with conventional PCNL.

I would like to thank BAUS Endourology and TUF for providing the financial support to help with this clinical visit and Dr Sanjay Khadgi and his team at the Nidan Hospital Pvt for allowing me to visit and making my trip so rewarding.

I wouldn’t hesitate to recommend this clinical visit to another Urologist with an interest in stones disease. Nepal also has a crying need for surgical manpower within the public hospital system. Brand new, world class theatres rivalling anything in the UK, sit there fully staffed lacking surgeons to do general urology procedures – a tempting proposition for UK Urologists wanting to combine some charitable work with a trip to the Himalayas!

23^rd December 2013