Stephen Y. Nakada, MD, a Urology Times editorial consultant, is professor and chairman of urology at the University of Wisconsin, Madison.

Stephen Y. Nakada, MD

Urology is cited as an attractive specialty due to its mix of office-based and surgical treatments, but beyond this clinical mix lies another opportunity for urologists: the role of physician executive. In this interview, 

outlines his multiple professional roles, explains how he divides his time between clinical and administrative responsibilities, and offers advice to young urologists seeking a career in leadership. Dr. Winters is vice chancellor for clinical affairs, CEO, and professor and chair of urology at Louisiana State University HealthCare Network, New Orleans.

the Uehling Professor and founding chairman of urology at the University of Wisconsin, Madison.

Please discuss your current roles at Louisiana State.

I was appointed to the position of vice chancellor about 3 years ago. I am responsible for coordinating the clinical activities of all the schools and the Health Sciences Center, so I work with the schools of Allied Health Professions, Dentistry, Graduate Studies, Medicine, Nursing, and Public Health. The School of Medicine is about 80% of my focus, but I facilitate the clinical care activities of all those schools.

During that time, the CEO of the LSU HealthCare Network retired and I became the interim CEO. Eventually, I merged the vice chancellor and CEO positions because of their synergy. So I'm now the CEO of the network, in addition to vice chancellor of clinical affairs. This allows me to not only manage the physician line, but also the operational line as well. I've been in this dual role now for about 2-1/2 years.

Please discuss what you do during an average week.

I'm still practicing urology about 40% of the time. I have a clinic day and an OR day, and the rest of the week is balanced with administrative duties. I don't really have dedicated chair time; I incorporate that in my administrative time, like probably all of us do. I meet with the executive team, and then I have a meeting with the leadership team of the system. Following that, my time is based on the strategies of the system and various clinical needs. I spend most of my time with the operative managers of each clinical site and the senior vice presidents of the system. I also spend time with chairs and section heads of the clinical departments, trying to optimize clinical functions.

What are the key skills or attributes that have made you suitable for this position?

Listening and remembering are the two biggest things. I find that the only way to be able to communicate in the most meaningful way is to communicate with all stakeholders by listening to them with the goal of learning something new. That way, you develop an understanding of their needs and requests. From there, it becomes a lot easier to communicate (even negatively), as you can express things in a way that’s most relevant to them. Also, I find that people become more engaged and collaborative with you when you remember and follow up. Either you can facilitate their requests or provide an alternative that works which achieves their goals.

Do you think a lot of your skill set comes from your activities as a clinician or more as a department head?

I find it to be a matter of both. I think most communication skills are innate in all of us in one way or the other. However, through either being a clinician or a chairman, we refine those skills. As urologists, we have very sensitive conversations with our patients on a daily basis, and that does help you prepare for many of the interactions encountered in leadership roles. I will say, though, that the administrative tasks of chairing the department helped me stay organized as my role expanded.

How have you changed as a department chair since you've been in this role?

I like to think I’m a better department chair, but I guess you’ll need to ask my faculty! First, I spend more time overseeing the department, because I have more dedicated time which I never really had before. More importantly, my executive roles have allowed me to view all of our departmental activities in a much more integral way with the rest of the Health Sciences community, in my case, not just within the School of Medicine, but in all aspects of the Health Sciences Center community. I've been able to integrate my department into multiple disciplines within oncology, where we're probably one of the more integrated units in the entire system. Being exposed to other components of the Health Sciences Center benefits my department, because I have more familiarity with processes that may have been more foreign to me just as a department head.

A number of urologists hold a role similar to yours. Do you think there is a reason for this?

Urologists are very personable people. People remember most how they're treated, and I think urologists tend to be easy to get along with. Also, urology is an interesting profession because we have a high-volume patient turnover in both the office and outpatient setting, so we are exposed to a diverse spectrum of health care. This makes urologists pretty well versed to do to assume leadership roles across health systems.

Do you feel that remaining in clinical practice is critical to success in your administrative role, or is that something that's just worked out?

Unequivocally, no question it is. It makes me a better leader. All physicians deal with the frustrations of the EMR, phone systems, and things like that. Because I'm still in practice, I understand (and experience) these frustrations as viscerally as they do, which is helpful in trying to fix these problems. It also helps me relate to the physicians on a different level. When they open up the schedule, they see me on there, seeing patients as well. I’m convinced it does help.

How would you compare how an academic institution has to perform compared to a private group practice?

That's an interesting question. Academic institutions are largely becoming like private institutions; many of them have basically separated out some of their clinical components to an entity that functions more like a private practice. I think we are under similar private practice-type pressures to a significant degree in academic medicine.

But academic medicine has its own challenges. How can we get protected time to do research? How can we get the resources to teach our students and train our residents? How can we expand simulation efforts? I find the biggest challenge in academic centers is that the clinical resources that we're getting are being increasingly used to subsidize the academic mission of our institution. That makes productivity-based incentives harder sometimes as there may be less expendable resources.

On the other hand, private group practices also have pressures of their own: How can they expand, provide the same level of service consistently, and stay competitive in this era of acquisition and consolidation? I see all practice models as having many challenges that will likely change as our marketplaces continue to evolve. Every type of practice needs to remain engaged so they can prospectively meet these demands.

Do you think you need to be a department chair before you take on a leadership role in a health care system?

I don't think so. Although being a department chair facilitates development of the innate qualities that you need to lead, it also encompasses a lot of tasks you have to perform to manage that unit. At the executive level, it's more about setting goals; it's about setting a vision, and empowering others to achieve. What is needed is to have experience with managing people at a pretty substantive level, whether it's a section head, center head, committee, board chair, or other administrative pursuits that allow you to develop organizational and leadership skills.

You've been extremely successful in both roles. How would you counsel a young person starting in practice on how best to prepare themselves to be a department chair or potentially a leader in health care administration?

First, get a good mentor, somebody who can answer your questions and who will allow you to learn by doing. Second, seize the opportunities available to you where you are. There are a lot of opportunities in every organization to get involved in the administrative architecture and "rise up," which is what happened to me.

I'm not going to comment specifically on formal training; do you need to get an MBA or an MPH? That's a topic of debate in our area. I don't have either. Certainly, whatever you can do to educate yourself, whether it's a professional development course or another method, is very helpful, because there are some aspects of reporting and data that we see on the leadership level that you don't learn in medical school or residency. I do not think it’s a necessity for all, but advanced training is clearly valuable and will also open more windows of opportunity.

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In this interview, physician executive J. Christian Winters, MD, outlines his multiple professional roles, explains how he divides his time between clinical and administrative responsibilities, and offers advice to young urologists seeking a career in leadership.

The physician executive: How one urologist balances MD, CEO roles

With society’s increased focus on wellness and disease prevention, management of stone recurrence presents an opportunity for clinicians to help prevent stone patients from suffering additional attacks. In this interview, 

 discusses how he follows patients once they are stone free, how he utilizes dietary/lifestyle modification and medical management, and his advice for young urologists looking to become experts in stone recurrence. 

is medical director of the Kidney Stones Clinic at Cleveland Clinic. He was interviewed by 

 the Uehling Professor and founding chairman of urology at the University of Wisconsin, Madison.

The way I look at it, and the way I talk to patients, residents, and fellows about it, is that stone disease is a chronic disease. It doesn’t go away. Kidney stones used to be seen as something that occurred as an isolated case and maybe happened once in a blue moon afterwards. Nowadays, we know that’s not the case. It’s a disease that can come back. If a patient has an initial kidney stone attack, they may actually have another stone forming, depending on the type of stone and the conditions of the patient, they may have recurrence of stone disease within a couple of years. Sometimes the stone-free period lasts longer.

Stone recurrence: Advice for young urologists

On average, around 30% to 50% of patients, depending on the studies you look at, may have recurrence or another stone attack within 3 to 5 years. There are actually reports dating back more than 30-40 years suggesting that the recurrence of stone disease is 100%. I tell patients that in around 30% to 50% of the cases, they have a high chance of having recurrence 2-5 years after the initial stone.

How important is obtaining stone composition?

I give a lot of importance and weight to stone composition because sometimes we may tailor our recommendations to patients in terms of diet and stone preventive medications based on stone composition. There are some basic recommendations that apply to all patients, but composition is still very important because sometimes we may discover rare kidney stone types. There are some genetic abnormalities that can influence the formation of stones or there may be associated genetic abnormalities that are potentially treatable. 

Now, if you’re a betting person, you know that more than 70%-80% of stones are going to be calcium based, and of those, more than 70%-80% are probably going to be calcium oxalate. So although most kidney stones you analyze are going to be calcium oxalate, it’s still important to determine their composition.

Let’s say someone has a stone, they pass it, and they are stone free. What’s your follow-up plan to seek recurrence? At what interval do you obtain studies, and what studies do you get, if any?

It’s very dependent on each case. I put a little more emphasis on those patients who start forming stones at a very early age. If it’s their first stone and they haven’t had any other complications or any other major comorbid conditions, sometimes just general recommendations will do. It’s also age dependent. If the patient is a middle-aged man or woman and they have had only one stone in their lifetime and they have some risk factors that I think we can handle with diet or lifestyle, we may not even need to do a comprehensive panel of a 24-hour urine collection or something along those lines. As a nephrologist, I always check their kidney function, and for almost all patients, I also check on their electrolytes just to make sure there is no major abnormality that we’re missing. Now, if patients have had kidney stones in the past or have any other condition-those who have undergone kidney transplant, patients with a single kidney, and so on-those are patients I will place more of an emphasis on.

Who do you think needs medical management once they’ve had a stone?

In general, who do you think needs medical management once they’ve had a stone?

Mainly, I use medical management for patients who have had either recurrence of stone disease, have bilateral stones, or who may have any major genetic or anatomic abnormalities that predispose them to have greater recurrence risk. I also usually recommend medical management in patients for whom we have done the full metabolic workup and found very abnormal risk factors that could be treated with medications.

Does diet play a significant role in your practice?

Yes, definitely. I discuss goals for urinary output with every patient. I tell them that any patient who has formed a kidney stone should be aiming for at least two and a half to three liters of urine coming out per day. Obviously, this depends on their size, gender, and whether they have any other medical conditions or surgical conditions. Considering the amount of salt in food today, I very strongly recommend that they try to limit their salt consumption. Again, as a nephrologist, I think about the hypertension and renal disease sides as well. I also make recommendations regarding protein intake and perhaps oxalate intake depending on the type of stone and type of patient.

Looking at dietary modifications versus medication, what do you think patients want more?

Unfortunately, patients are very inclined to want medication because it’s much easier to take a pill than make the effort and the conscious change in dietary habits. It is usually time consuming when I see patients because I’m trying to change lifestyles more than anything else, and it’s very difficult. Even foods that are regarded as healthy may actually be harmful in terms of kidney stones. The epidemiology of stone disease has changed so much in our country, and it’s probably because of many changes in our dietary habits.

Who should be managing the follow-up for recurrent stone patients?

I think these patients should be managed with a multidisciplinary approach. A dietitian or nutritionist could be involved with them. The nephrologist and primary care physician could play a big role as well in the prevention of kidney stone disease. And ultimately, there is the urologist. You guys see these patients much more commonly than any of us. For the most part, urologists have very good knowledge of how to handle stone attacks and can play a very important role in the management of stone prevention. In terms of work force, there are more urologists than nephrologists in the community, and urologists could probably manage those patients in the long term, making a lot of emphasis on the changes mentioned above and management of medications as well. But in an ideal world, it would be a combination of providers managing these patients.

What’s your advice for a young urologist who wants to become an expert in stone prevention and minimizing stone recurrence?

I would tell them to think of it as more of a chronic disease than the way that we used to think about it. I would advise them to insist more to patients in terms of dietary and lifestyle modifications. Most of the medications haven’t changed in a long time, so it’s very easy to get a handle on those. I would also recommend that they not forget about kidney function, because even though a kidney stone is not the biggest risk factor for chronic kidney disease or end-stage renal disease, it could affect these conditions, and it definitely affects the quality of life of those patients.

In this interview, Juan Calle, MD, discusses how he follows patients once they are stone free and how he utilizes dietary/lifestyle modification and medical management.

Managing stone recurrence:  What practitioners should know

One of the key elements of successful percutaneous nephrolithotomy (PCNL) surgery is obtaining percutaneous access. In this interview, 

 outlines his step-by-process for obtaining access, discusses the ways he reduces radiation exposure during PCNL, and gives his thoughts on how clinicians can gain proficiency with percutaneous access. Dr. Knudsen is an endourologist, the Henry A. Wise II Endowed Chair in Urology, and Director of the OSU Comprehensive Kidney Stone Program at The Ohio State University Wexner Medical Center, Columbus. Dr. Knudsen was interviewed by 

Please discuss the principles of percutaneous access.

At The Ohio State University, we do a lot of PCNL procedures and have gone through a series of evolutions over the years. The basic principle is to have precise, clean access into the kidney that permits easy access to the stone(s) and minimizes bleeding. The goal is to enable the clinician to do the case safely and effectively.

When we approach any stone patient, we always study the stone, the kidney, and the anatomy, and create a plan-usually heavily based on the CT scan-of where we’re going to go into the kidney and how we envision that operation going.

In the past, it was pretty straightforward; we did all our access antegrade prone with split-leg spreader bars. Over the years, that has evolved. Our access was always 30F in the past and now, with new options for tract sizes, we rarely utilize 30F PCNL tracts but rather favor smaller tract sizes. It is important to limit the number of punctures into the kidney to reduce the risk of bleeding and other complications, so we always try to make the first puncture as accurately as possible. If you can get it on the first shot that’s generally going to be your best opportunity. Once you have the puncture in the right spot then it is a matter of simply dilating the tract and removing the stone. With a good puncture, usually the rest of the case is fairly straightforward.

Take us step by step through obtaining percutaneous access on a procedure, beginning with looking at the CT scan.

When we see a patient and make the decision to proceed with a PCNL, we’ll look at the imaging. Is the stone in the upper pole? Is it in the lower pole? Is it in the pelvis? Are there multiple stones?

Holmium, thulium lasers show similar ablative effect on stones

Some surgeons prefer to go in a certain location for all cases, such as the upper pole. This is not our approach. Our approach is to pick the best calyx to get to the target. If lower pole is going to give us the best shot for a lower pole stone, that’s where we’ll go. If upper pole is better, then that is where we will go provided the CT does not show any other anatomic problems with an upper pole approach.

You have to look at the pleura and you have to look at the spleen and liver and make sure that they’re not going to be in a problem with your choice of tract location. That’s where getting the CT scan is very valuable.

Once we pick the location of the tract, the other thing we think about is the size of the tract. That is really a function of the stone. If it’s a smaller stone-1.5 to 2 cm in size-we’re probably going to do a mini on that patient. If it’s a single stone, we’re going to lean toward a mini, even if it’s a little bit bigger. If there are multiple stones scattered through the kidney or if it’s a very large stone or branching stone, then we’re probably going to do a larger tract. But for us now, a large tract is 24F rather than 30F.

"There are a lot of simple things that can be done to reduce the amount of radiation"

Please discuss radiation exposure with regard to PCNL.

That’s something we’ve been very concerned about, not only for our patients but also for the surgeon and the staff in the operating room who are there every day doing multiple cases. We actually recently published a paper on reducing radiation during PCNL by looking at certain steps of the procedure and the ways we can reduce it 

Emergent setting linked to lost follow-up for stents

There are a lot of simple things that can be done to reduce the amount of radiation. Number one is just being aware of radiation: alerting the staff, alerting your residents, having a discussion with your x-ray technologist in the room. All of these are important. There are other simple steps to take: using a low dose mode on the C-arm, using pulse modes, coning-down and collimating the C-arm image, use last image hold, using spot rather than continuous imaging, and employing a foot pedal will all reduce the amount of radiation exposure. We have been able to reduce fluoroscopy use to under a minute in many cases by employing these simple steps.

There’s no question that incorporating ultrasound can bring down your radiation as well. There are some barriers to learning ultrasound; it depends on your comfort level with it and also on your patient population as obesity can increase the challenge of ultrasound. However, it is now something that we are currently employing during all our PCNL procedures. We will visualize the kidney and determine if we are comfortable proceeding with an ultrasound guided puncture. We still have the C-arm on hand and often use it to check things if we are not certain with ultrasound alone. This “hybrid” approach is a great way to become more comfortable with ultrasound.

What are the pitfalls and complications of percutaneous access?

Surgeons do worry about complications from PCNL, and when you look at some of the most devastating complications, bleeding is right at the top of the list. The more sticks you have into the kidney with a needle, the more opportunity there is for bleeding. By being competent at gaining access effectively, you can reduce that risk. Remember to always try and make the first puncture as accurately as possible.

How would you counsel the patient on their risks before a given procedure?

I walk every patient through the surgery. I explain that we are going to create the tract at the time of the operation and that I need to get up into the kidney through a tract to do the operation. I would say we are 99% successful at getting access.

I don’t spend a lot of time telling them that I don’t expect to be successful unless there is some complicating factor such as an altered anatomy, but in a normal, routine patient, access usually isn’t the problem. I quote them about a 1% risk of major bleeding requiring transfusion and possible embolization, and that’s been our consistent experience over many years at our center. I tell them we are not planning to transfuse them; we are not going to group and match them for blood. We don’t do that routinely. I do counsel them on the risks of delayed bleeding when they go home and that if they do have bleeding, they need to come back and alert me.

What type of drainage do you use post-stone removal?

It depends, but we have moved away from nephrostomy tubes for the most part. We will only use nephrostomy tubes if we believe we need to go back in percutaneously, such as for a planned second-look nephroscopy or a staged procedure, on that patient. If the patient absolutely does not want a stent under any circumstances, then we might also leave a nephrostomy tube after the procedure.

How to bill when a stone changes location during procedure

We’ll leave stents in the majority of patients, but we’ll often leave them on a string exiting via the urethra and take them out the next morning. A lot of times, we’re stenting just overnight and monitoring for bleeding and/or fevers. If the patient is stable in the morning, the stent comes out before discharge. If there are issues, then we simply leave the stent in longer. With mini-PCNL procedures, and occasionally 24F procedures, we will do them totally tubeless with no stent at times, usually when there is very little bleeding and no edema around the ureteropelvic junction.

Do you put the stent in in the prone split-leg position?

You certainly can, both antegrade or retrograde. We did this for many years. However, we have now moved to doing about 80% of our PCNLs in the supine position. Supine also facilitates both antegrade or retrograde stent placement. When we place them retrograde, we watch the coil in the kidney deploy with the nephroscope, thereby reducing the use of fluoroscopy.

"You need that critical volume of cases once you start"

As you know, a minority of urologists do percutaneous stone removal. Do you think you need a fellowship to do this?

You don’t need a fellowship, but there are a couple of important things that need to happen. One is you must get the training in your residency if you’re not going to do it in a fellowship. There are a lot of residencies where the residents come out quite competent to do their access. At Ohio State, our residents graduate being able to do access and this is certainly the case for other programs as well.

Age a predictor of filling opiate prescriptions post-URS

Then, you need that critical volume of cases once you start. That’s been a little bit of a barrier for some individuals where they didn’t have the volume when they started their practices. In this situation, you can lose your skills and/or confidence pretty quickly and then give up doing the procedure altogether. I suspect this happens a lot.

How many cases do you think you need to do to be trained, and then how many cases per year do you need to do to keep up?

There have been a few studies that have looked at learning curves, but I would say 20 to 30 cases in a 1-year period to be trained. You’re going to need probably about 20 cases a year to maintain skills in the future. That being said, learning is a lifelong endeavor; even today after more than a thousand procedures, I feel there is always something new to learn, to optimize, and to make the procedure better. This is why performing PCNLs is such a rewarding experience.

Do you believe that urologists should do all access?

There are different models that work. The key is, if you aren’t doing the access yourself, then working with someone who understands the surgery and the goals of the operation is very important. If you and your radiologist work together and plan the tract together, that’s a perfectly fine and very reasonable approach. Certainly, the model of having a radiologist that you work with closely can be very successful and may help you through that learning curve too.

The challenge is if somebody has a nephrostomy tube put in by a radiologist whose only concern is getting a tract in somewhere and is not focused on the best location for the stone, then it can lead to problems later. We will also often see patients who had nephrostomy tubes placed urgently, such as when they present with sepsis from an obstructing stone. After the initial infection is treated and the patient is stabilized, then we will take them to the operating room for the PCNL. Our experience is that the location of the tracts from the urgent nephrostomy tube placement are rarely adequate for the procedure. However, the tracts facilitates performing an antegrade nephrostogram and then permitting us to choose a location for a new tract in the OR.

You mentioned you’ve made the transition to supine. How do you keep current in the field?

You have to be open to new ideas. For any surgeon, it’s important to not get too comfortable with what you’re doing, even if it’s going well. You need to keep an open mind and think about how you can make things even better than what you’re doing. Meetings and training courses-those from the AUA are a great example-are great places to pick up new ideas and learn. Just getting together with your colleagues and discussing your approach is a very valuable way to understand why you might want to think about doing things differently. While I felt perfectly comfortable doing procedures prone, I decided to try supine based on feedback from others. I also had experience doing retrograde PCNLs as a resident, and the supine position was not that much different. As I embarked on supine, I felt it facilitated the mini-PCNL approach since the tract was more dependent and the stones washed out easier with the Venturia effect. Unsurprisingly, our use of mini-PCNL continues to grow. Having more tools in the tool chest is always valuable.

How would you recommend that someone learn PCNL access and PCNL if they’re already done with their training?

There are some good training courses now. The AUA sponsors a pretty robust training course on percutaneous access that’s run multiple times a year. There are centers that do a lot of PCNLs where you can gain that expertise from a visit. We are always open to having visitors at OSU to see procedures. For residents who are interested in endourology, there are many very good fellowship programs including our program at OSU. Once in practice, having a surgeon with you in the OR who is an expert in access look over your shoulder for a few cases may also be beneficial. You can also partner with somebody at your own institution if you have a colleague who has some expertise with this.

In this interview, Bodo Knudsen, MD, outlines his step-by-process for obtaining percutaneous access, discusses the ways he reduces radiation exposure during percutaneous nephrolithotomy, and gives his thoughts on how clinicians can gain proficiency with access.

Percutaneous access: Principles and best practices

Ureteral access sheaths confer several advantages to the urologist treating a stone patient ureteroscopically. In this interview, 

 discusses his experience with sheaths and describes an algorithm for their selection and use. Dr. Portis is chair of HealthEast Kidney Stone Institute, St. Paul, MN. He is a consultant and investigator for Boston Scientific.

Please tell us what a ureteral access sheath is and when you would typically use one.

A ureteral access sheath is basically a means of getting up and down the ureter multiple times while avoiding the need for reintroduction of guidewires to do so. Sheaths range between 10F and 16F in outer diameter.

PCNL tips and tricks: Access is everything

I use an access sheath on any stone case where I think I’m going to have to make multiple trips up and down the ureter. For urologists like me who prefer to fragment and extract stones, that would include any stone over 4 or 5 mm. It is important to consider stone volume for estimating fragment load rather than just linear dimension.

When did you start using an access sheath?

I started using an access sheath during my fellowship with Dr. Ralph Clayman around 1999-2000. That’s when Applied Medical Resources was coming up with the first really functional access sheath, and Dr. Clayman was involved in the development of that product.

What did you perceive as the real tangible benefit aside from the ability to make multiple passes? Were there other advantages you were seeing?

The advantages included time efficiency, reliability, and the ability to be systematic and standardized in how I did the procedures.

Since they vary in size, can you give us a tip or two as to what you do if an access sheath cannot be passed easily over a wire?

I’ve created an algorithm that can be viewed online 

 The algorithm begins with placing a guidewire into the kidney. I traditionally use a Benson wire first. Occasionally, I’ll find, particularly in men, that the access sheath won’t track well over that. I always place the obturator of the sheath before placing the whole sheath. The obturator will usually track up but sometimes when you add the actual sheath component to it, you’ll get a troublesome step change in durometer (stiffness) and you may have a challenge getting around a prostate.

At that point, I’d swap out to a super-stiff wire and then I find the assembled access sheath usually tracks up well. But obviously if, according to our algorithm, you’re meeting significant resistance, the solution is just to stop. It’s a matter of recognizing resistance versus kinking.

How do you know the difference between resistance and kinking?

Kinking is easy because you’ll see the tip deflect in the region of the ureteric orifice on fluoroscopy. For monitoring resistance, I like to keep fingertip pressure on the access sheath as I’m inserting. I get a lot of information regarding the caliber of the ureter initially from using an 8/10 dilator system, so I’ll pass the 8F inner element. If the 8 goes easily, I’ll pass the 10F coaxial sheath over that. If I find resistance with that, unless I’m very confident that I’m going to go after a small stone that can be quickly cleared without a sheath, I stop.

Update on PCNL technique: Tips to optimize outcomes

If I have absolutely no resistance with that, I start thinking about using a 12/14F access sheath system. If it just absolutely falls in, which would commonly be the case if a patient is pre-stented, then I might go to a 13/15F sheath system.

If you can’t get the access sheath inserted, you said you stop. What do you do then?

I place a stent and wait 2 weeks for passive ureteral dilation.

What do you tell your patients as part of informed consent with regards to that possible outcome?

We track this. We know that we have a 5% failure rate but it can be difficult to predict. Generally, people who are younger, female, or first-time stone patient would be the ones who might be more challenging. Then you need to differentiate an impacted stone versus a tight ureter. An impacted stone can still allow some careful options to potentially clear. There are very limited second-line strategies to deal with an extremely tight ureter.

What are some of the risks of using a sheath regularly?

The biggest risk that has been brought to our attention is the risk of ureteral trauma, and I think if you follow a stepped approach like we’ve adopted, it’s unusual to see any kind of significant injury. We see a fair number of mucosal splitting cases, and we haven’t seen any clinical sequelae from that. But placing a sheath blindly or forcefully is asking for trouble.

If a urologist were to just use sheaths intermittently, what would be the best case for using one?

The best case is one in which you need to maximize the trips up and down the ureter. Specifically, this would be for a larger stone (1 cm or greater) with intent to clear. Again, our group is fragmenting stones and clearing, so we’re doing multiple trips almost all the time, but if you’re more of the dusting persuasion, then this may not be as important. Without the access sheath, you have to be very cognizant of increased intrarenal pressure and pyelovenous backflow.

What’s the maximum you would do ureteroscopically?

The typical top end, for a patient who didn’t have a contraindication for percutaneous nephrolithotomy, would generally be about 2 cm.

Does stone composition or density play a role in your calculation?

If somebody has a really dense stone, where the Hounsfield units are about 1,500, we’d probably start dialing back on what we want to do for extraction because we’re concerned about traumatizing the ureter when removing sharp fragments. By “dialing back,” I mean that I might be very cautious when stone size approaches 1.5 cm.

Do you have any uses for a sheath other than ureteroscopy? Any other endoscopic procedures?

I occasionally use an access sheath through percutaneous access for patients with challenging retrograde access who have ureteral stones. For example, a patient with cystectomy and conduit; you’re working on a ureteral stone with them and you’re going to use a flexible ureteroscope. In that case, it can be handy to place an access sheath in an antegrade fashion.

How do you select the different lengths and sizes of access sheaths in a given scenario?

As far as length, I’ve followed the advice of Dr. Glenn Preminger, who published years ago that if you can get the sheath above the iliac vessels, the pressure issues seem to abate 

 For the most part, I use a 36-cm access sheath on both men and women. I occasionally use the shorter one (20 cm or 28 cm) more in patients, particularly men, with an impacted mid-ureteric stone, just proximal to the iliacs, that require flexible ureteroscopsy. 

I stay away from using the very long ones because I find that places the sheath tip into the proximal ureter, which I think is the most fragile area of the ureter. I don’t want to get the sheath all the way into the kidney because then I find everything collapses down; I don’t have any working space.

Challenging case: Persistent ureteral stone in a 76-year-old male

For diameter, 12/14F has been our standard. I use a 13/15F access sheath if I know I have to clear a lot of stone and I’m confident I can get it in, typically if the patient is pre-stented. In general, it’s best to use the smallest sheath which will allow you to efficiently clear stone and we are increasingly using 11/13F for smaller stones. Since transitioning to digital ureteroscopes, the 10/12F has really become the bottom end which will accommodate our current scopes.

We are a referral target for complex stones so we stock them all in every length. We turn over the midrange sheaths frequently, and the extremes sit.

Have you ever regretted putting in a sheath?

Sure. There’s a particular sensation of a ureter “unzipping” which is best avoided and you never want to experience twice.

Everything seemed favorable and the obturator went up fine. Then as I advanced the sheath, it just felt like Velcro. Our algorithm generally keeps us out of trouble but ultimately sometimes you just have to make decisions based on your instincts. Sometimes those instincts betray you but you don’t know until after the fact.

No. I haven’t had an avulsion but I’ve had a transmural perforation or two. These were managed by prolonged stenting and careful follow-up. So far, we haven’t had any patients who required reconstructions that were attributable to a sheath. We find chronically impacted stones to be much more troublesome for ureteral injury than the access sheaths.

What do you think the future is for access sheaths?

I think we’re well served by the current sheath. I don’t see a need to change that. As we continue to pay attention to getting patients stone-free, the ability to actively clear stones will remain. I’m optimistic we’ll have better ways to actually remove stone fragments, but ultimately the business we’re in is to render a patient stone-free and if we can do so efficiently and safely, that’s a bonus.

Do you think the introduction of larger access sheaths will expand the stone sizes that can be tackled ureteroscopically?

If you can insert a bigger sheath, you’ll be more efficient. There has been some research recently on tamsulosin potentially having an effect in the ureter in allowing insertion of larger sheaths 

 In some of the studies of the use of sheaths with tamsulosin, they’re using a force gauge that actually gives you a real number as opposed to subjective observations. I look forward to those results; that could be a big step forward.

Do you use tamsulosin typically in all of your cases before inserting the access sheath?

We don’t have a firm position on tamsulosin yet. I tell patients it’s the “might” drug. It is certainly controversial whether tamsulosin actually helps stones pass. We presented research at the 2018 AUA annual meeting that showed that careful attention to symptom control was more important than tamsulosin 

 Still, we can’t rule out that tamsulosin “might” be beneficial in some circumstances. It “might” make it easier to place an access sheath but we are still waiting on larger randomized trials. It “might” decrease postoperative symptoms from a stent, although there was also a nice 2018 AUA paper saying that that didn’t pan out but the sample size was limited 

It may be difficult to evaluate whether tamsulosin makes a difference on placing access sheath in clinical practice. Our primary access failure rate is only 5%, so it would have to be a very marked effect to make a noticeable improvement. If we move from 5% to 4%, we’re really not going to perceive a difference. The change that we might perceive is being able to get to larger sheaths.

In this interview, Andrew Portis, MD, discusses his experience with ureteral access sheaths and describes an algorithm for their selection and use. 

Stephen Y. Nakada, MD

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