Update from Arthur Smith’s South African Endofari - AM Session

Kapula Game Reserve, South Africa - After closing the 34th World Congress of Endourology and SWL in Cape Town South Africa, over a hundred of the world’s most distinguished Endourologists came together today to celebrate the Festschrift for Dr. Arthur Smith. A festschrift is a rare academic celebration of a distinguished academic career.
The festschrift is remarkable as it not only requires a distinguished and productive career, but is typically engendered by trainees who wish to celebrate their professor and contribute a manuscript to an issue of a major journal in his honor. Indeed, Dr. Smith has in every way earned this celebration having literally defined the field of endourology, and has trained and/or inspired many of todays’ contemporary leaders.

Dubbed the “Endofari” the two day meeting kicked off today at the Kapula game reserve, a pristine savanna of 150,000 square kilometers. After a three hour morning safari, the participants joined together to celebrate Dr. Smith with endourology presentations.

Hosted by Drs. Louis Kavoussi and David Hoenig from the Smith Institute of Urology, Hofstra Northwell School of Medicine, the morning session included twenty presentations on endourology related topics with safari related titles. Several morning presentations engendered lively discussion.

Dr. Clayman opened with “Let the tribe decide – assessing manipulative skills of residency applicants.” Dr. Clayman from the University of California, Irvine reported on the UC Irvine experience evaluating urology residency applicants. These medical students were videotaped performing a variety of technical surgical drills as part of their residency interview process. The videos were assessed using crowd sourcing and by expert reviewers. Four experts required twenty two days to review the videos, and over 3,000 crowd source workers evaluated the videos in less than four hours. Data clearly demonstrated that the expert and crowdsourced reviews were remarkably similar. Lively discussion included comments that training too many qualified surgeons could result in limited case distribution per surgeon. Other comments included possible pre-judging students who may excel in other aspects of urologic practice including cognitive function and creativity. Positive remarks included comments regarding how urology remains both cognitive and technical function and how this sort of assessment may become an important part of selecting residents in surgical fields in the future.

Dr. Evangelos Liatsikos from University of Patras, Greece challenged the commonly taught statement that access for percutaneous nephroloithotomy should be gained via a papilla. In this study entitled “PCNL: Challenging the myth of the papilla puncture Dr. Liatsikos evaluated the blood supply around papilla using CT scans and suggested that there would be no difference in bleeding complications. Comments included Dr. Arthur Smith who stated that he was not certain if there was a difference, and Dr. Mahesh Desai stated that access was inferior when not gained in the traditional manner. Heated discussion made it clear that more data are needed.

In her presentation “Ureteroscopic stone management: are we charmed by the snake,” Dr. Margaret Pearl from the University of Texas, Southwestern noted that ureteroscopy is the most utilized modality for the management of upper tract stones. She reviewed contemporary ureteroscopy series and noted that stone-free outcomes are relatively poor when strict CT criteria are used. She and her team prospectively evaluated their ureteroscopy experience with complete fragment removal. Using CT criteria she treated 3.3 stones per patient with most stones being in the kidney. The average number of ureteroscope passes to remove stone fragments was 44, and despite these heroic efforts, the stone free rate was only 55%. She concluded that ureteroscopy results are disappointing, and that better stone management strategies are required. She also presented data from Northwestern showing that approximately 20% of patients with residual fragments in this setting require another intervention within 18 months. Additionally, she showed data that fragments greater than 2mm in size were most likely to place patients at risk for recurrence.

Dr. Stephen Nakada, Chairman and Service Chief of the Department of Urology at the University of Wisconsin, Madison presented, “Quality of life studies in cystine stone formers.” Dr. Nakada spoke on the importance of quality of life, particularly as it related to minimally invasive approaches, and how it has been an underutilized metric. Using the Wisconsin QOL survey he presented results from a prospective 2000 patient registry. Thirty five cystine stone patients from Dr. Nakada’s practice were matched with non-cystine stone formers. Cystine stone formers had inferior QOL results in the majority of domains. He suggested that we need to develop better techniques to address the needs of cystine stone formers, especially given their young age of disease onset and the chronicity of this condition.

Written By: Jaime Landman Professor of Urology and Radiology Chairman, Department of Urology University of California, Irvine