Dr. Julie Riley
Appearances
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
But in terms of actually
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
correlating that to more patient phone calls more you know need for pain medicines things like that trips to the er my data is just too much in its infancy to really say that and i think everybody's data is sort of in that in that state right now so more to come and i'm very excited to see that but i think without the real-time monitoring we'll just never know and in terms of of severe complications other than infection with increased renal pressure
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, I mean, I think some of the other very severe complications are going to be ureter injuries. You know, in terms of forniceal ruptures, I mean, we know that whenever stones are there and there's a forniceal rupture, we don't have long-term damage. So I can't really believe that that's going to be true in ureteroscopy either.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
You know, I think forniceal ruptures, that's going to lead to infections and more issues there. But long-term, I'm not sure I can say that. But I would say, you know, ureter injuries... Is there a way that, you know, by measuring some of the pressures that we know whenever we're putting a lot of force onto a ureter? I don't know. I think more to come on that too.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
But I think those are some of the severe complications that we see. And we've all seen the patient who's had ureteroscopy. and comes back later on with a stricture? You know, is that somebody else's ureteroscopy?
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I mean, I always make the joke that that wasn't mine, that was somebody else's, but I'm pretty confident knowing how many ureteroscopies I've done and the complication rate of stricture, it's happened. And is there a way that we can use pressure monitoring to know how much force we're putting on for sheaths and how much force we're really putting onto the walls of the ureter
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
We don't have that technology yet, but I certainly think that that is a huge place where we could really see what's happening in the Yerder because those are very dreaded complications.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And I mean, there are definitely studies saying, you know, we don't really have an actual force like this is too much, this is too little. Everyone's ureter is a little bit different. But really interesting studies coming out very recently about ureters change with age, right? And we know that the distal ureter is different from the proximal ureter, and we lose some of those differences as we age.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And I think for me, I definitely find that the young guys tend to have very tight ureters, and I really struggle with them. And very unfortunately, they have to have stents longer, and they do the worst with stents, right? And we've all seen kind of that little old lady, ureters wide open, you put a stent in, they never even feel it. And I do think that we're going to find that
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
everyone's ureters are a little bit different. We treat them all the same, right? I mean, we've all learned and we all do it pretty much the same, but I think we're going to find that, you know, not everybody's ureter is the same and we do have to treat them very differently.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, it's true. And it is hard because we have so many patients with so many social issues and we don't know how to do that either. Right. I mean, it's hard whenever it's the middle of the night, you get called in, you're like, I'm just trying to do my job here. And the patient throws at you a lot of things that are really important. But how do you how do you prioritize all those things?
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And I don't know. I don't have a good answer either. But I do know that the longer I go in my career, the more I realize that. All these patients are really different and there are some really hard problems for us to try to solve. So I'm hoping your younger generation, like I hope you figure out how to make the healthcare system better.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, it's a separate box and a separate monitor. So it is a little bit, I will say that the vision on it, I think is a little bit better than the original LithoView. It has a pretty big monitor. It's a little bit bigger than kind of the original LithoView monitor. But off to the side, it has a pressure monitor on it and you can see it real time.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
You can make some settings on it where it'll change colors if you're going high. I think there might even be a bell on it. I'm not sure. I turn off all the sound on it because I don't really want to hear that. But I think they told me that. But whenever you start, you pull the scope out and you have to actually calibrate it.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
So you have to set it in water and kind of swirl it around once you plug it in and it Really walks you through that, but it takes about five or 10 seconds to do that. But really similar. They do have a couple of different buttons on the front that allow you to do a little bit easier recording and taking pictures and some personalized settings on that that they've updated.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
But all in all, it handles very similar. I didn't really notice a big difference between them. I think between all of the disposable scopes, I think all of them handle pretty well. I always make the joke they kind of feel a little Fisher-Price, right? Like they feel very cheap and plasticky.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
The LithoView Elite does feel a little bit more substantial in your hand than the original one, but I still think they all kind of feel a little more plasticky than kind of your reusable scope where you really feel that bulk in your hand that feels very steady.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah. I mean, I think also with some of the disposables that far away, there's kind of that, oh gosh, there's like a halo almost. It's kind of black in the background, right? There's a little bit of the abyss look behind you. But I do think it focuses pretty well in really what you're looking at.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I still think that some of the times whenever you're using the laser, you get a little bit of feedback on those disposable ones that you don't get in the reusable ones. But I really like having the disposables, particularly for these really large stones, because I've definitely put those scopes in places in the kidney that I would never put a reusable scope because I would break it.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I'd be too afraid I'd break it. And so far, I have not broken one of the disposable scopes in the patient. So fingers crossed that that does not happen in my next cases. But the reality is, is it really has added a lot to be able to get, you know, get scopes where they really haven't been able to go before.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I am definitely a lot more cautious as I'm using my hand irrigation. I'm paying a lot more attention whenever I take the scope and my resident is using the hand irrigation or an assistant is using it as to what they're doing. And so I can really be paying a lot of attention just watching the screen, knowing what they're doing too. I'm definitely very aware that a sheath is a really good thing.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
When I haven't used a sheath with it, I've been pretty nervous as that pressure is going up. And I'm pretty careful to sort of take a break, give the kidney a little bit of a break if I'm noticing that the pressure is going up and just allow some of that fluid to drain out. maybe even pushing my sheath a little bit higher.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
But a lot more of it is I'm just being a lot more cautious than I really have been before. Not to say that I'm going crazy doing ureteroscopies or anything, but the reality is I'm definitely seeing it and I'm kind of slowing down, making sure that I keep that pressure a little bit lower. It's not adding a whole lot of time to do it. I mean, I'm not seeing huge differences in time.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
My staff is not complaining about that. But I definitely am not necessarily just putting my foot on the pedal and going pretty straight through that. I'm really kind of adjusting and making those modifications as I go.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, I am not really somebody that moves stones around very often. I usually do a lot of my lithotripsy in situ. I think moving it is fine. I just find that if I can actually get a basket around the stone and move it someplace, I'm usually like, well, it's probably time to just pull it out. So I just, I don't tend to do that.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
What I will sometimes do in the lower pole is I'll get my scope down there. And again, these disposable scopes are great because you can flex up against that sheath much more than you would with your reusable scope and use a lot more passive deflection against, you know, to get down in the lower pole.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
But if I really can't keep my sheath up, I may laser for a little bit and then I might go ahead and take my scope out, push my sheath up, irrigate some with... I'll use a five French Pollock. Now we're seeing more devices to actually do some irrigation and suction, which I think is the next thing that's going to really revolutionize ureteroscopy.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
But I just use a Pollock catheter and irrigate things out. And then I'll put my scope back in, pull a sheet back. Yes, it's a little bit inconvenient to do that, but I can get a lot of that dust to irrigate out and see a lot better. And it also gives just a second to let the cool the temperatures off if I'm really using pretty high power settings.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Also, frankly, gives my hands a little bit of a break, gives my residents a little bit of a break, right? These cases can be very long, very frustrating. And as you start getting frustrated in your ureteroscopy, you start, you know, getting a little bit more fidgety, a little bit more clumsy with it.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And I think sometimes you just have to give yourself a little bit of a break, do something a little bit different to kind of keep yourself engaged in the whole procedure.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I thought that the answer to that would be yes. And I was sort of hoping that would be true. But watching it, I am truly amazed at sometimes whenever that pressure jumps up and you're like, how did that even happen? It looks fine. And sometimes, I mean, you know, whenever... You're up there and it's getting really distended. Yeah, the pressure is up high.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
But I was actually sort of surprised sometimes whenever it was pretty hydronephrotic, pressure sometimes weren't really going up as I thought they would. So it's not as intuitive as I would have liked it to be and as I would have hoped that I could have predict. I wish I would have been a better surgeon at that one. But unfortunately, I think it really proves we have to monitor it.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, I selectively use this. My institution for sure does not want me to use this on every case. It is significantly more expensive, and I get it, and we need to be fiscally responsible. We can't pass these charges off to patients and to our hospitals. I'm typically choosing them for large stones, patients that have some sort of immunocompromised state. I operate on transplant patients, so
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Those are really high targeted patients. People that I know are at risk for having an infection, so spina bifida patients, people who have already proven that they get septic from their procedures. I certainly think that those are the patients I'm going to be using that for. But if it's a small stone, I'm not going to be putting a lot of stress on my scopes.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Wow, thank you, Jose. Every time that I hear people go over all my stuff, I'm just like, oh gosh, so much to go over. We spend so much time in school, so thank you for that introduction.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I'm going to use my reusable scope because that's exactly, you know, what that, you know, that place in the process of how to do that. But if, you know, it's somebody that I really... Need to see that pressure. It's a big deal. If they get an infection, then yes, I'm going to pull that out. I'm going to use the extra money to prevent.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Hopefully this will show up that we're preventing the infection and the admission and every all the downstream effects of that.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I think if you can't get the technology, I really think access sheaths are a good thing. Don't be afraid to use those access sheaths. Yes, you might have to put a stent in. Yes, patients aren't going to like that. But I think if you explain to patients up front, this is why I'm doing this, is to try to prevent...
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Some of these infections, some of this high pressure systems and, you know, really some of the pain that might come. Again, laying down the expectations is really going to be the biggest thing to do that. So I would say if you don't have access to that, be very careful about your irrigation. Don't set your gravity too high.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
If you're using a hand pump, make sure that the person who's using that hand pump really understands what they're doing. I would be pretty hesitant to give it to a really inexperienced scrub tech. I mean, if it's somebody you work with all the time, great. They know what's going on and you can really help them through that.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Now, whether that translates into more pain, bad outcomes for the patient in terms of infection, I don't know yet, but it does seem like those at least correlate.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
But somebody that really doesn't know, you're going to generate a lot of high pressure. So I would be very cognizant about that. So if you can't get it, that would be my suggestions.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Right. And I usually just kind of grab a hold and I'm like, you know, it's just this teeny little pump and you can see, I can see everything. That's all I really need. But I'm always surprised that sometimes I kind of turn my head and I realize all of a sudden somebody's pushing pretty hard on that hand pump. Yeah.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I think, you know, I have a luxury of having very qualified residents who are holding the scope and I'm holding the hand pump. So we have two very qualified people to do that. I think if you're at an institution where maybe you don't have a specialized team, it's going to be a lot harder.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
So you might think about switching to gravity or very low pressure bags to be able to have more control over that, make sure that it's a little bit more steady.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Gosh, I think we're going to continue to see ureteroscopy grow and grow and grow because we're going to see it's more effective than shockwave and it's less invasive than percutaneous procedures, even as we miniaturize PCNLs. I still think patients are going to see a huge value in this outpatient procedure because That doesn't require any incisions.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
even if the patient is really unhappy, the reality is you did the safe thing and you're avoiding some of this. I think we're going to find as we're measuring these pressures, that does really correlate whenever we go in without a sheath, whenever we have very narrowed ureters, I think we're going to see that that pressure goes up.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
The suction irrigators are going to really do it. I am hoping and praying that they get us cordless ureteroscopes, right? Wouldn't that be amazing that we don't have to plug in a ureteroscope? And obviously our vision is just going to get better and better and better. It would be nice, some of these robotic techniques, kind of saving our hands.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
We got to get it a lot cheaper, but I think those will be a lot more precise and really allow the surgeons to be able to save their hands and their wrists. I mean, I know all of us who do ureteroscopies, we all know that we're tired at the end of the day. Our legs hurt, our shoulders hurt, our hands hurt. And having that robotic technology, I think is going to make a big difference.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
You know, some of the stuff about moving stones around with the ultrasound guidance I think that could be a really interesting thing. I mean, it hasn't really taken off as much as I would have thought it has at this point. But I think as the technology grows, we're going to see a big difference in that. So I think that's sort of the future is we're going to have a lot more ureteroscopy.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And as residents coming out of training have done more and more and more, we're going to see that they are just really phenomenal at the techniques. And I hope that they are better than I am so that way they can move this technology forward.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Absolutely, which is sad because I really do like PCNLs, but I appreciate that patients aren't really as interested in doing those PCNLs and definitely seeing a lot more interest in ureteroscopy. So I want to do more PCNLs, but fair enough, that's not what the patients want.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
You're right. And I still am telling my patients that. I think one of the things that has really changed and one of the things I see in my practice is there is a huge use of blood thinners, right? I don't know about you, but I have definitely seen that there is more and more and more and patients have to be on these. It's harder and harder to get them off of them.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And ureteroscopy, I do them on blood thinners. So I don't need to stop that. Whereas in a PCNL or shockwave, I need to stop those. And so I think that that's another big thing. It's a little less stressful than doing a PCNL. There's a lot more fluid shifts in PCNLs. There's a lot more to consider in PCNLs in terms of risks and lung injury, bleeding risk.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah. So the nice thing about ureteroscopy is that just about anybody can have a ureteroscopy as long as they are a surgical candidate. So as long as we can have anesthesia clear them, you can probably put a ureteroscope where you need to go to take out the stone.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, those are small, but they're very unique to that procedure. And I'm seeing a lot more sick patients walk in my door that their lungs are not that good. They really can't handle the risk of bleeding. And so that pushes me more into ureteroscopy And so I'm pushing the limits of what it can do because sometimes my patients are sort of pushing what I have to do to get that stone out.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
It never ceases to amaze me whenever you're like, oh gosh, I didn't really realize that somebody as frail as you could manage to get a stone that just has to get treated because it's obstructing and it's getting you sick. And it's just amazing how many more sick patients are coming in like that.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I treat them the same and I have not noticed any difference with that. They certainly do have a little bit more bleeding risk, but really nothing that's been significant change in terms of the way that their management afterwards are needing to come in more or something like that. So I treat them the same.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And it's true, right? There's that patient that you're like, I had no idea that you could possibly need to get this ureteroscopy. Awesome. I'm so excited I get to do it.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
No, I think that we covered a lot in this, Jose. I think this was really good.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, I appreciate it.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
A few caveats to that, of course, are that, you know, lower pole stones, very large stones are going to take significantly more time, significantly more time. you know, effect on the scopes, putting more pressure on them. But truthfully, just about any stone can be managed that way, and that is one of the very large appeals of ureteroscopy.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, I mean, I'm much like you that some of the biggest things I'm going to talk about is that stent discomfort and the need for the stent and what that's all about. I think really laying down the expectations for patients goes a really long way to help them get through that stent pain.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
But some of the more severe complications, I do talk about infections and I will highlight that some of these patients can get quite sick, particularly these very large stones, patients that have complex anatomy infections. These are a lot of the patients that I'm seeing that are referred to me. And so I do really highlight this infection risk and that that is not a minuscule thing.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
The other thing I do talk about is the chance of either not being able to get the scope into the kidney, either, you know, a tight ureter, something like that, that that's a possibility. And then also strictures and scarring in the future. and that we do need to continue to monitor them afterwards.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And I think the other thing that we really, I wish that we did better, and I try to do this as well, is to really talk about this is a long-term disease and that they're going to need follow-up after that ureteroscopy. So it's not even just the complication of the surgery, but this is a disease process that needs managed.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I think the biggest thing is prevention. So making sure that you've actually worked up the patient beforehand. I get routinely a urine culture on all of my patients. I'm going to treat them with antibiotics if that is positive for at least five to seven days beforehand. I give very strong antibiotics perioperatively to make sure that we avoid any of those infections.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And if I see any signs of infection during the case, so if they're having purulence, maybe in the PACU that they're not exactly behaving as well as they should, I'm going to certainly have a low threshold to put those patients onto antibiotics for a period of time afterwards.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
The vast majority of my patients, however, they're getting a one time dose perioperatively because the vast majority of patients, that's truly what they need. But these patients that come in with infections already, they were already stented for their pyelonephritis. I'm going to be much more liberal with the use of antibiotics and making sure that I'm very directed based upon cultures.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, I typically give ampicillin and gentamicin for my perioperative period. If I truly believe that they had an infection, but we missed the culture, right, because they got the dose of antibiotics in the ER before we ever even saw them. That's a very common scenario. Then I'm usually going to give something like, you know, sulfamethazole or, you know, some sort of cephalosporin beforehand.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
if I truly believe that they have something that, you know, is really at risk. And that's going to be how I manage them preoperatively. Postoperatively, I really try to get them off of their antibiotics as much as possible because once they're stone free, really most of those risks should be gone.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
You know, I actually don't really notice that there's a big difference whether it's in the ureter or it's in the kidney in terms of the infection risk. I think if they needed a stent beforehand, that risk exists because we've instrumented the stent is in. In terms of the location of the stone, not as much. The size of the stone I do think matters though.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
So if it's up in the kidney and it's a two, three centimeter stone, I'm going to be there a long time. I think they do have a much higher risk of getting an infection from that.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, I use access sheaths very liberally. I like them. I also train residents. So I think that it's really very nice tool to have while you're training residents. It's just a lot less chance of pulling scopes in and out and losing access. But these really large stones, I worry a lot about the pressures that are building up within the kidney.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And I think that the access sheath allows the kidney to decompress a lot and not have as much of that pressure going on and also just flushes some of the pieces out while I'm dusting. I think also we generate a lot of temperature issues with our high power lasers so that sheath allows a lot more irrigation to go in with, again, these safer pressures.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
So I do believe that those sheaths are really making a big difference.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, I think, I mean, gosh, every one of these smaller scopes, every one of these high power lasers, these are helping us to do more and more stones, giving less complications. But I think the big game changer that's come out that I'm really excited to start using and have had experience with is this new Lithovue Elite to be able to measure the pressures.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And obviously, this is one product from Boston Scientific. I certainly think that all the other companies are going to jump on board, which I certainly recommend. I highly am excited about the competition to see where some of these prices can go. But the reality is, is right now we have the Lithovue Elite to measure these pressures with the scope.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
And that has been, I think, very interesting to see as I've used this how much pressure we actually generate in a very quick fashion. I mean, if there's not a sheath in, it's amazing how fast the pressure goes up. If we irrigate too hard, it is for sure I can see that pressure go up.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Even as we are lasering up against the wall or into a calyx or we're sitting in an infant nibulum, definitely can see the pressure go up. I actually had a patient that had a narrowed UPJ
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
that we were working on and it required me to actually incise the upj to get the sheath in but before we actually did that i put the scope in to measure the pressures there was no question that pressure was higher just sitting with that kidney alone so i believe that this is going to be a big change for us and that having real-time monitoring of these pressures
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
is going to translate into better outcomes for patients. There's no question having more information is going to be good.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah. So in terms of what is normal, so an intrarenal pressure should be sitting, the measurements have shown it's around six of just a resting kidney, no instrumentation. When we put instruments in, we can easily see that go up without a whole lot of, you it's going to go up around 15, 20 millimeters of mercury.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
The danger zone is above 40, more or less, because that's where we start to see maybe some pylovenous backflow, and that might be where we're starting to get some of the infection risk. The problem that we have right now is for how long? Is that like a one-time burst? Is that a big deal? Or is it over a long period of time? So
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
The question is, if you give one shot and it goes up to 100, but for a half a second, quarter of a second, is that worse than if you maintained at 50 for five minutes? And none of us know the answer to that at this point. But there's no question if we don't measure it, we'll never know the answer to that.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I personally use a hand irrigation, so I do know that those certainly can generate a lot of pressure, but it gives me a lot of control with the instruments. And again, I'm training residents, so I'm usually with the hand pump, and I can manipulate the stones a little bit to help the residents be a little bit more successful with that and kind of keep some of that control of where the stone is.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I don't think that that is... written in stone that you have to do hand irrigation versus pressure irrigation versus gravity. I think all of those things serve their purpose. And if you're successful at any one of those things, do that. But I personally use hand irrigation.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
Yeah, I think that there's a lot of discussion about this. And actually, this was some discussion that we had at the recent AUA. But I think stenting and coming back is obviously the safest thing to do. And I think you have to take into account a lot of patient factors in that. You may not have that much time to bring the patient back into the operating room.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
They may have to wait quite a significant amount of time. So you may be more forced to push that a little bit more, particularly if you understand that the patient doesn't like stents, doesn't like the whole experience of stones, and you need to just get it done.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
If it's a short, narrowed area, so less than two centimeters, I have no problem using a balloon to dilate up and then put the sheath in to allow access in that way to save an extra trip to the operating room. I think if it's a long, narrowed ureter, you are going to be kind of obligated to either put the flexible scope in, accept that you're going to have some higher pressures.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
This is a great time to make sure that you get in, get out, be very efficient with your lasering, and really don't spend a lot of extra time looking around, doing things like that. Be very efficient with that. But if all else fails, stent and come back, even if the patient is really unhappy, the reality is you did the safe thing and you're avoiding some of this.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I think we're going to find as we're measuring these pressures, that does really correlate whenever we go in without a sheath, whenever we have very narrowed ureters. I think we're going to see that that pressure goes up. Now, whether that translates into more pain, bad outcomes for the patient in terms of infection, I don't know yet, but it does seem like those at least correlate.
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I would leave the stent for at least two weeks, but I would argue if I have a narrowed ureter, probably leaving a stent for two weeks anyway. So, you know, they're not sure that I'm really trading a whole lot there. And I think all those patients require follow-up anyway. So I'm going to be getting ultrasounds. I'm going to be watching for those obstructions. So...
BackTable Urology
Ep. 194 IRP Monitoring: Enhancing Patient Outcomes in Urology with Dr. Julie Riley
I would say that my data is just simply too small to really make that assessment just yet. I have certainly seen patients that have a little bit more pressures in their kidneys have had more pain. Now, what I have not been able to correlate yet is how long does that pain last for? I certainly have had that experience like you're talking about in the PACU. They're definitely having more pain.