“Maxi vs Mini” PCNL – The Southeast Asia Experience
Mr Maitrey Darrad FRCS Urol BAUS Endourology/WCE Travelling Fellowship
November 2018 – February 2019
The so called “stone belt” traverses our planet within which populations have a 10-15% prevalence of urolithiasis. Southeast Asia sits in the heart of this high-risk area. The high case volumes and expertise of surgeons in these regions in the management of urinary stone disease makes a travelling fellowship to southeast Asia a priceless commodity for a training endourologist. This certainly isn’t a path untrodden and there is now a flux of international fellows and trainees visiting these countries as a “finishing school” prior to starting independent practice.
Both Nepal and Sri Lanka are two such places and were both highly recommended to gain surgical experience by many senior endourologists from the UK. I was fortunate enough to spend 4 months between these two countries gaining invaluable hands-on experience in both conventional “maxi” and mini-PCNL.
My trip started in Colombo, Sri Lanka where I attended the Sri Lankan Association of Urological Surgeons (SLAUS) annual meeting and participated in an excellent hands-on PCNL live surgery course. Under the direct supervision of senior urology Consultants, Dr Kanchana Edirisinghe and Dr Manjula Herath I spent a total of 4 weeks over two trips in Kandy Teaching Hospital. The operating theatre turnaround and work ethic of the theatre staff was overwhelming with up to 18 open and endourology cases being performed daily in a single theatre. Some Immediately noticeable differences from UK practice were the lack of extensive paperwork and administration requirements, and the large number of auxiliary staff available enabling such impressive operative volumes. We operated 4 days a week starting at 8am and on average performed 3 or 4 PCNLs through the day. Due to the financial challenges and a lack of expertise outside of Kandy patients from almost half of the island travelled for kidney stone procedures to this teaching hospital making the elective operative waiting list approximately 3 years. This put an even greater emphasis on achieving total stone clearance in a single sitting. Due to this, the standard treatment for most stones larger than 1cm was conventional PCNL and retrograde intrarenal surgery was seldom utilised. Due to the immense pressures and the limitations of the radiology department many patients did not have a CT scan prior to PCNL, a practice we take for granted in the UK. The urologists took this in their stride and skilfully adapted their approach based on the on-table retrograde pyelogram appearance. The cases varied from solitary renal pelvic stones to complex staghorn calculi in solitary kidneys. This included both paediatric and adult populations and I was fortunate to gain PCNL experience in young children under 2 years old. Despite the time pressures, I received excellent hands-on training and was guided through both fluoroscopic and ultrasound-guided renal access. By the end of my visit I was performing some PCNLs skin-to-skin with the consultants un-scrubbed and I even managed to perform my first totally tubeless procedure.
Their standard approach was with the patient under general anaesthesia in a prone position. All punctures were infra-12th rib and tract dilatation was performed using Alken’s dilators. With the exception of the paediatric population, a 24F renal access sheath (“maxi”- PCNL) was used for the procedure and lithoclast for stone fragmentation. Only one set of triprong forceps was used for all the stone extractions with no luxury disposables like stone baskets, being available. The majority of patients were left with a nephrostomy tube overnight and discharged within 48 hours.
I performed approximately 30 PCNLs in my 4 weeks, a volume performed annually by the average endourologist in the UK. Overall, this experience is highly recommended, and Kandy boasts picturesque landscapes and a multitude of historic Buddhist temples and tourist attractions to keep you occupied during the days away from hospital.
The second leg of my fellowship was spent in Kathmandu, Nepal under the supervision of Dr Sanjay Khadgi. Having performed over 8000 minimally invasive PCNLs he is undoubtedly one of the pioneering endourologists in the art of miniaturized PCNL. Nepal has a population of 30 million, slightly bigger than Sri Lanka, with over 6 million residents below the poverty line. Patients travelled from far and wide with all their clinical notes in hand and were usually nil by mouth with the expectation of an operation on the same day. During my stay, Dr Khadgi worked in-between two private hospitals and performed up to 10 mini-PCNLs and
2 laser prostatectomies daily usually at heavily discounted prices due to the financial situation of the patients. He had a fantastic team alongside him, with his own junior doctor to look after his patients exclusively between sites and non-clinical staff for administration. One couldn’t help but notice the stark difference in waiting times between the overstretched government hospitals and the private medical care set-up where patients were being offered high quality surgery on the same day. The patient expectations were also contrasting with some wanting a guarantee of complete stone clearance and adapting a mindset that anything less would solely be secondary to surgical inadequacy.
Each morning Dr Khadgi collected me from my hotel after breakfast at around 9am and drove to work. He would religiously review all his inpatients across sites on a daily basis. There was usually a clinic of approximately 30 patients followed by surgery which would continue until all patients were successfully operated on. Despite the overwhelming volume of patients, he was incredibly methodical in his approach and scrutinized all the patient’s imaging in depth prior to surgery.
Dr Khadgi almost exclusively performed mini-PCNL for all stones at or above the level of the proximal ureter. With the exclusion of paediatric patients, all patients had their procedure under spinal anaesthesia. His team have several publications and substantial expertise in this technique which led to a remarkably accelerated post-operative recovery. His standard approach was in the prone position with fluoroscopic guided renal access. I gained invaluable hands-on experience in the art of the “gradual decent” technique for renal access and felt comfortable performing this independently by the end of my trip. The standard dilatation was up to 16-18F and a 12F mini-nephroscope was utilized which was connected to an intermittent irrigation pump to prevent sustained high intra-renal pressures. The majority of the percutaneous punctures were above the 12th rib with interpolar calyx being targeted, a technique which enabled access to almost all of the pelvi-calyceal system in a hydronephrotic kidney. The ease of manoeuvrability is a great asset of miniaturized PCNLs and is simply not possible without significant trauma using the conventional nephroscope and sheath. Lithoclast was used for stone fragmentation and the “vacuum cleaner” effect utilized to flush the stones out by trapping the fragments with the sheath and simultaneously withdrawing the nephroscope in conjunction with flushing the retrograde ureteric catheter. The technique minimizes the requirement of additional equipment like stone graspers and baskets. Most patients had an antegrade stent at the end of the procedure with no nephrostomy tube (tubeless).
Dr Khadgi visits Dhangadhi, a rural town in the most western aspect on Nepal, for 2 days a month. I was fortunate enough to join him on two separate occasions and this was, without a doubt, the highlight of my trip. We flew there with all our instruments packed in a small suitcase. This intense trip allowed us to review hundreds of patients, many of which had travelled for days from the neighbouring mountainous villages. We would operate until the early morning and start again at sunrise. This exhausting but highly rewarding experience enabled us to perform up to 25 mini-PCNLs in the short trip. Despite the significant limitations in equipment and basic resources of the hospital, where electrical power cuts were the norm, the surgical precision and professionalism of the theatre team were faultless and almost all patient were deemed completely stone-free with no significant complications during my trip. Throughout my visit, I participated in academic research in collaboration with Dr Khadgi’s team and we submitted two posters both of which were accepted for podium presentations in international conferences, including one in the annual BAUS meeting. Having experienced the benefits of mini-PCNL first hand I am undoubtedly planning to incorporate this technique in to my routine practice in the UK. The technique can be used for stones of all sizes and the significantly low, procedure-related complications makes it a very attractive first-line option.
Nepal is a beautiful country rich in its history and culture. Despite the obvious scars from the recent earthquake, the Himalayas are at your doorstep and the panoramic views are other worldly. Its people are incredibly welcoming and hospitable, traits mirrored by the hospital staff and most of all by Dr Khadgi himself. I would highly recommend visiting Nepal and Dr Khadgi for anyone with an interest in developing their skills in miniaturised PCNL. By no means am I alone in this sentiment as he regularly has international visitors and hosts a multitude of renowned leaders in the field of endourology.
I would like to thank BAUS for their generous support in this travelling fellowship. It certainly was an experience of a lifetime for me and one I hope many future enthusiastic training endourologists would follow and benefit from in years to come. I have taken a substantial amount of experience away from this trip which I plan to utilize in my future consultant practice.
Breaking stone at the edge of himalayas
Zine Abouelfadel, MD
Agadir, Morocco
meet the man who leaves no stone unbroken
Nepal is bedrock of himalaya the ceiling of the world, this country is a piece of land surrounded by two giant asian powers india and china, both a challenge and opportunity of great people of this nation I had the opportunity of visting this country this summer, beside the desire to discover the country and its people, the beauty of its landscape and ancestral traditions but the main reason of my travel to this remote land was to pay visit to an exceptional person, a man who made me discover another dimension of Nepal medical innovation, he overcame the shortage of means by the abundance of creativity and determination to attain excellence,
Dr Sanjay Khadgi a worldwide leader in minimally invasive kidney stone surgery, I first mat him in May 2016 at Paris challenges in Endourology meeting he does his surgery by mini percutaneous nephrolithotomy (NLPC ) using a small instrument called mini-nephroscope all the patients are operated under spinal anesthesia and usually feel comfortable throughout the procedure. He gets access the caliciel system using fluoroscopy, he prefers the middle calyx since according to him the whole caliciel system could be explored through this puncture even stone of upper ureter but accessing from upper and lower calices are used according the situation,
I saw him steering through the whole pelvicalcial system through a single access he blasts stone using the pneumatic device (lithoclast) and rarely uses the Laser
Dr Sanjay set up his own guidelines that deserve to be taught at the schools of endourology worldewide
Before the flight to Dhangadhi
during my stay with him this summer I saw him performing more than 35 mini PCNL procedures, both in Kathmandu Vahyoda and Venus hospitals and at Dhangahi a small in far western Nepal to which we took a flight together and i had the pleasure to a have a glimpse into the himalaya from above the clouds,
Majestic HimalayasPerforming a mini PCNL at Venus Hospital Kathmandu
Dr Khadgi is used to fly once a month to take care of stone disease patient, and I saw the kind of admiration and respect people pay to him, in addition to attending surgery we discussed the idea of setting up a training program in mini-PCNL that will emcompass both a practice on a simulator and a hands-on training on the operating theatre ; it will be a great opportunity for those who want to combine good training to the discovery of a wonderful country, This journey to Nepal was an eye opening and great discovery that people who struggle to attain excellence who works diligently to achieve it will ultimately be rewarded I myself enjoyed my stay and training Dr Kathgi and I will strongly recommend his training program to all urologists with special interest in this technique once this is up and running.
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. 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!