Dr. Roger Sur

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102 appearances 1 recordings 1 series first heard Oct 2024 last heard Oct 2024

Dr. Roger Sur’s voice in public audio — every appearance, attributed to the second.

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BackTable Urology · Ep. 197 Suction Devices in Urology: Improving Stone Removal with Dr. Roger Sur · 29 Oct 2024 podcast

So what they did was they basically took two stopcocks and they attached them side by side and attached it onto the working port. And that's what they have is direct in-scope suction. Through one stopcock, they're irrigating and through the other stopcock, you can aspirate. But one of the limitations here, the working channel is still 3.6 French. You haven't changed anything.

Unlike, you know, fans where it's maybe 10 French inner diameter or 12 French, depending on your axis sheath, or a CVAC where it's 7 French, you're still using your standard ureter scope. So the working channel is only 3.6, so you really have to make dust if you want to use discs. And it's not continuous, unlike CVAC, which has constant irrigation. This is you have to either aspirate or irrigate.

You can't do both at the same time. But it seems to be an economical solution, but limited by the fact that you still have a tiny channel that you're working through.

So you basically have the camera, you have a separate irrigating channel, and then the third thing that exists is that seven French suction channel that you're aspirating. And through that seven French, you can put a laser through or remove the laser. And when you remove the laser, With the laser there, you're getting parts coming through, but the laser is kind of there.

So it's, you know, you don't have the full seven French volume or size. So if you want the full seven French, you have to remove the laser fiber. And now you've got a full seven French size aspiration channel. So what I'll do is I'll start the case and I'll have the laser in there. I'll break everything up into what I think is about one to two millimeters, remove the laser fiber.

Now, a lot of the pieces actually have already gone. While I'm just dusting, they're all just sucking into the little, I can see it going to the canister, the tiny pieces, but there's still some one to two millimeter fragments that are left behind. So I'll remove the laser device

then aspirate or irrigate full force and then engage the uh the lever and i get full uh very high volume aspiration all the larger pieces and come flying through the seven front channel i wish i had a picture for you here but i hope that makes sense no i intentionally didn't look it up so i could try to explain it without having or you know talk about it without having preconceptions

Yeah. So the overall is a 12 French or 11. It's a little under 12 French. It's 11.9. It's not tiny. And this, I would say, is one of the disadvantages of the CVAC is it requires a 1214 French access sheet. And not every patient is going to accommodate a 1214 French, right? I'm sure you put up a 1214 like it's not going to go. Well, in that case, you can't put the CVAC through.

Now they do have a get around for that. If the 1214 doesn't work, they have a, you can just use the scope by itself. It has an obturator kind of like its own access sheet. It has an obturator that goes through the seven fringe working channel and you literally pass over a wire, the entire CVAC with the obturator over a wire into the kidney.

But again, if you have a really tight ureter, it's not going to work. You have to pre-stent the patient or just do standard ureoscopy with your normal ureoscope. But an 11-13 wouldn't work. Oh, 11-13 would not work with the CVAC, yeah. And you could say that's an advantage of the fans is that you don't need a 12-14. They have 10-12. They have different sizes. You can use your own ureter scope.

I will say with fans, one of the disadvantages potentially is think about the wear and tear on the tip of that ureter scope. You're going back and forth, back and forth. You can imagine, you know, a lot of these reusable scopes, they last, what, 10, 12, 14, 20 times, and then they break down, and you send them off for repair.

So you might want to consider using a single-use scope if you're going to use the fans to avoid the wear and tear on your standard reusable scope.

Yeah, these are all the different... As far as cost goes, I think what you're alluding to is what's the price and what am I getting for it, right? And each of the devices has its advantages and potential disadvantages. CVAC, you're not using your scope. It's a single-use scope, so you're not using your...

standard wolf or your olympus or carl stortz flexible ureterscope it's its own single use scope it's one and done um so there's no wear and tear on your scope and then with fans you could use a reusable scope but you probably want to consider using a single use scope so you're not wearing tearing on that and then this you've got to use your reusable scope with their attachment

So across the board, one thing has been clear, and this came out in a systematic review, that the use of suction devices, just broadly speaking, achieves two things. Number one, higher stone-free rates, and number two, lower infection rates. So irregardless of what you're going to use, Adidia, you're going to achieve potentially an advantage there. So I think that's nice.

We've moved the needle forward that, look, we're getting better stone-free rates and lower complications. Now the question is, well, which of these devices is better, right? Which one achieves better stone-free rates? Which one has less, reduces morbidity more? And the problem is we don't have comparative trials. I will say the CVAC, we do have that. We have a multi-institutional Aspire trial.

It was made up of 11 institutions. And their 30-day results demonstrated benefit of a higher stone-free rate for the CVAC over ureteroscopy. It was a comparison of just standard ureteroscopy basketing versus CVAC. And the CVAC appeared to be better. This is the 1.0, not the newer one that we have out there. But we don't have a CVAC versus FANS versus DIS study to date yet.

I will make one other comment here. What was very interesting with that ASPIRE trial that I'm talking about was we just published, or we're about to publish, we presented at the World Congress, the one-year data of this. And what they demonstrated was that by using the CVAC 1.0 device, they significantly reduced post-operative events.

ER visits, readmissions, need for another surgery, stone growth. So again, this kind of gets back to this thing is if we can reduce more stones, will we have a benefit? And sure enough, we did demonstrate this because in the CVEC arm, there were the volume of stones left behind, which was much lower than standard reteroscopy.

Which actually, if I can kind of pontificate a little bit more on the whole stone free rate thing, which I actually recently wrote an editorial or a response to an editorial in the European Urology. Olivier Traxair, who was one of our thought leaders from Europe in ureteroscopy, he is definitely considered a key opinion leader in our space.

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