The morning session of the endofari festschrift for Dr. Arthur Smith was remarkably full of outstanding academic presentations as well as touching stories regaling the audience with extraordinary stories of Dr. Arthur Smith’s contributions and mentorship to individual leaders in endourology. While there was great science, there was also a bit of monkeying around.Dr. Robert Sweet opened the PM session with “The advanced modular Manikin: training the next generation of the tribe.” Dr. Sweet from the University of Washington emphasized how Dr. Smith has focused on training throughout his career, and that these efforts have been transformative to Urology, and that these efforts have influenced his current efforts in the development of training models. In his presentation Dr. Sweet presented a video which wowed the audience. Working with department of defense funding he created the advanced modular manikin, and phase one of this multiphase project has been completed. The existing manikin prototype has a modular platform which exchanges organ systems to suite the training needs. This is an open source platform which will allow each piece of the manikin to work with all the others. Individual components can work separately as well. The nature of the manikin was indeed Hollywood-like in its realistic nature. The physical manikin is correlated to a virtual model. An initial trauma model currently allows for an IV to be deployed with realistic feel, a functional pulse oximeter, realistic intubation and other interactive interventions that are connected to a physiology generator. Phase two of this project will be associated with a pelvic fracture model. Dr. Sweet emphasized that the current model crowdsources simulation development and will ultimately result in better training tools for Urologist.
Dr. Marshall Stoller from the University of California, San Francisco came to the endofari to mix it up! He clearly wanted to stir up controversy and discussion with his presentation entitled “Precursors to Randall’s plaques.” Dr. Stoller opened explaining how little we as a community know about the Randall’s plaque. In 1994 Dr. Stoller and his team evaluated cadaveric specimens and demonstrated that there were long serpiginous calcifications going deep into the papilla. This stimulated his interest in looking deeper into the anatomy both literally and figuratively. Dr. Stoller and his team utilized high definition CT imaging to characterize the Randall’s plaque as only the very distal component of a more proximal process that begins deep in the tubules. Using correlative microscopy the precise anatomy of the nephron can be better characterized and he has demonstrated that the initial insult resulting in the Randall’s plaque is a vascular process. He hypothesized that there is intra-tubular obstruction of proximal tubule which results in change in the compliance and flow to the tip of the papilla. He suggested that we should better understand the concentration gradients and the pressure gradients in the nephron to improve our understanding of stone formation. Questions regarding papillectomy arose, but earlier work done by Dr. Stuart Wolf demonstrated that the procedure does not change stone disease in the longer-term.
Dr. Gyan Pareek from the Miriam Hospital, Alpert Medical School, Brown University presented, “SWL can be saved! Fight the preditor.” Starting with the comparison of apples and oranges, Dr. Pareek compared the efficacy and costs of SWL and ureteroscopy. He emphasized the minimally invasive nature of SWL and the fact that there was no need for the dreaded ureteral stent in the majority of cases. He presented cost data on SWL and demonstrated that it is more cost effective than ureteroscopy when you are successful 66% of the time or more. He then focused on techniques to improve SWL efficacy. With regards to lower pole stones, Dr. Pareek emphasized only doing SWL on stones smaller than 1cm. He also focused on the importance of lower Hounsfield units and a short (<10cm) skin-to-tumor distance. With regards to the actual technique he focused on ramping up of the shockwave power and slower rate which improve outcomes. His Triple D concept of lower density, small stone diameter and skin-to-stone distance were emphasized.
Written by: Jaime Landman Professor of Urology and Radiology Chairman, Department of Urology University of California, Irvine