Comparing Surgical Options for Benign Prostatic Hyperplasia

it I’d also like to thank the doctor shulem in the urology department for allowing me to come do a summer internship here I’ve really enjoyed my time working with all the faculty in the resident is that I look forward to the next two weeks as well so my topic today is going to be comparing the surgical approaches for a benign prostatic hyperplasia the reason I kind of came across this topic was in my institution we do a lot of green light laser for bph and when I came here we were doing some turps and I just sort of asked the clinical question is there an advantage to one procedure over the other and I wanted to kind of look at the primary literature to see what the answer to that question was that’s sort of why I pick the topic to start off I have no financial disclosures or conflicts of interest with any of the manufacturers of any commercial products discussing this presentation so kind of an outline we’re going to discuss the surgical interventions and how they work and what they are then I’m going to examine the kauai trial which is a study that evaluated the greenlight laser versus Terp in the head fashion and then after that I’m going to dress shortcomings of the study and also other questions generated by looking at other primary literature to answer that question so obviously bph is a common problem facing older men in 2010 DNA estimated that 1.4 million meds are excuse me 14 million men in the u.s. suffered from lower lower urinary tract symptoms suggestive of bph and obviously bph is something that dramatically increases with age being that our the average age of our population is shifting right towards an older population this is actually going to become even more of a common problem so when considering treatment for dph obviously the first step should be lifestyle modifications and changes to medications so things like Matt drinking water at night you know changing diuretics to the morning as opposed to evening things like that then after that medical management which was the alpha 1 blockers 5-alpha reductase inhibitors things like that from there you could consider minimally invasive therapy for example like the new euro lift would be an example of a minimally invasive therapy that could be considered but beyond that from there the next option would be surgical therapy so obviously you know transurethral resection of the prostate has been the mainstay of treatment for bph for decades it’s an effective procedure it’s going to run a long time there’s actually a 150,000 terr performed in the u.s. each year alone so it’s a very common procedure that’s been well characterized recently however the photo selective vaporization of the prostate with the greenland lasers came onto the scene the first procedure was done in 1997 and since then there’s been over 500,000 worldwide performed a key point to note for the entire talk actually with the green laser since 1997 they’ve actually came up with several different products originally they were you know there was one laser then there was the 60 watt and 80 watt 120 watt which is a lot of places used if we use 120 watt here and then the newest version is actually 180 watt which is what was studied in the study i’m going to talk about so I wanted to kind of address some of the perceived pros and cons to the greenlight laser before I looked at the literature this was sort of thought that I gathered from you know talking to different attendings and reading different articles and things like that and one of them is that the greenlight laser is supposed to be better have decreased bleeding short of recovery times and then also have the option of performing the procedure under anticoagulation however a lot of people complain that it’s a longer procedure there’s a higher incidence of the irritative symptoms and then there’s also no acquisition of tissue at the end it could be analyzed so those are some of the gist initial perceived pros and cons so when I was you know starting the to look at the literature some of the important considerations I you know I mentioned was obviously that you know because there’s been so many different green light lasers a lot of the studies that have looked at this versus turf I’ve been using older lasers so I tried to focus on the newer studies with the newest products because the older layers lasers have been shown to be inferior to the new ones and I wanted to look at the most current data you know additionally I wanted to figure out what I thought was going to be meaningful outcomes in this study you know there’s both objective and subjective measures you know things like the aua score max flow rate post void residual those are kind of some of the things that would be important as well as adverse effects such as in continents irritative symptoms bleeding need for an adventure and then lastly I wanted to think about what was the durability of these results with respect to long-term treatment I wanted to avoid you know focusing only on that you know there was success three or six months I wanted to try and look at longer-term outcomes deal which obviously with me unless need for intervention so the glass study was came out in 2014 by Alexander Bachmann and I was a study in Europe I consisted of hospitals from nine different countries and it was a prospective randomized control trial to evaluate the non inferiority of 180 watt greenlight laser versus the Terp the primary outcome they measured in this study was the International prostate symptom score and then the secretary outcomes they looked

at where the max flow rate it among other things and then also complications one thing I wanted to point out some of the key things that they ensure were with randomization we’re equal was that the prostate volume PSA TBR the number of people on 5-alpha reductase inhibitors an IPS esic you max were all not significantly different in the study population so that was important to note that’s obviously there so now taking a look at the primary and secondary outcomes so this is looking at at six months we’re looking at the greenlight laser versus the Terp and it’s looking at the International prostate symptoms for the Q max and then the complication free period during 180 days and I think for the numeracy sizes are going to explain what they mean by complication free they mean that a complication is divine designed as an adverse effect relating to treatment so basically people that needed some kind of reinvention or additional or prolonged hospitalization an adverse event as far as application free is not including short-term things like a catheter for three or four days it’s only for either intervention or longer-term things so the key point with this slide is that of these three categories all three were not significantly different at six months between the the greenlight laser and the terps so this is sort of showing it six months the efficacy calm is not significantly different so looking at the data a little more closely the ipss we can see here that at three weeks there was actually an improvement for terp is the orange red line but then at three and six months it did actually watch out to the fact that there was no difference and then same thing with quality of life score there was a significant difference in three three weeks but then it three months in six months there was no significant difference between the two treatment modalities additionally looking at Q max and PVR there’s the same trend they both were successful without any significant difference in the data lastly looking at the prostate volume and the PSA both studies were able to show a decrease in both prostate volume and PSA so they were significant compared to baseline for post treatments however compared to each other there was no significant difference in the at six months and prostate volume or PSA so this is I think an important slide that the study really highlighted looking at operative parameters and patterns of recovery so the operative primer is here what we can see his procedure time the greenlight laser the average procedure time was 49 minutes whereas the Terp was 39 minutes now a lot of people I talked to you know like this was a common thing that this procedure takes a lot longer this study showed that it was only a 10-minute difference however the big thing to take away with this is that this is what the newest slaves of 180 watt laser I’m actually going to show some data later in the presentation comparing the 120 which is currently used here to the 180 but that’s a big advantage of the 180 that is much faster so there was a gravely difference but it was only ten minutes difference now looking at the recovery time we can see they look this and got a length of catheterization was about 19 hours shorter with a green light laser time to hate with stable health status which they defined as once you have a successful avoiding trial or discharge that was about 26 hours shorter and then length of hospital stay was about 31 hours shorter now this data it does seem higher 65 hours for the green light and 69 hours for the Terp it’s important to recognize one that that’s including people that have to stay longer for complications for example the longest day you know for these are 500 24 hours and 30 57 hours so that’s the max but it’s so that’s one thing and then the other thing is this is in European countries so their standard of care might be a little different but I do have another slide looking another study showing this the same time trend as well the overall point with it is that the Greenland laser is about a day shorter in a hospital so complications I mean this is an important aspect this is looking at people at complications at six months and we’re looking at several different things you’re bleeding urinary tract infections irritated systems and so forth some of the key things I wanted to point out is the majority that were not significantly different in the p-values including things like bleeding was not sickly different but the one that did stick out was urinary incontinence there is actually significantly more urinary incontinence in the greenlight laser group as opposed to chirp to kind of examine that a little further they we have a table here kind of talking about what the urinary incontinence was for the majority of them of the 16 pages 12 of them were mild and the greenlight laser and then nine of the 12 did recover did fully recovered by the six months only four were moderate urinary retention and three of the four did recover however the turkey you can see that very very few people had yer a incontinence as opposed to the greenlight laser group also looking at complications the study looked at need for intervention so adverse events requiring you know invasive or surgical intervention they broke it down into

early and delayed so in the first 30 days the turf group actually had significantly more me for reinvention most of that was either urinary retention or bleeding but there was a significant difference there favoring the greenlight laser however at six months there was no difference in the need for intervention between the two treatment modalities so that was the first paper that came out with a six-month data then after that they came out with a 12 month update basically the same study the same patients and they just kind of updated the data for how people were doing it 12 months looking at the same values here prostate score the quality of life q-max etc without looking at every individual data point itself the thing I wanted to highlight is that the p-value for all six of these categories between the two groups compared to each other 12 months was not significantly different so whether this data sort of tells us is that at 12 months that you know the efficacy pretended to two treatments is similar additionally they looked at other things in this twelve-month update where they looked at functional and quality of life questionnaires we use the standard form 36 question physical and mental health surveys as well as the international index of erectile function and the key thing here is that again the p-values were not significantly different between the two groups adjusting the overall people feel happy with the treatment and the erectile function is good this is an important slide this is looking more specifically the irritative symptoms like I mentioned the beginning this is a perceived weakness of the greenlight laser and what this shows us is this is looking at the overactive bladder questionnaire and also an incontinence questionnaire and what we can see here is for the three six and 12 months it’s groups the greenlight laser is significantly higher scores meaning more overactive symptoms compared to the terp so that sort of does you know explain the perception that there is more irritated symptoms with the green laser that was also the same term with the quality of life and then also foreign comments there was a significant difference with the memo having higher scores meaning more in comments now what the paper are the authors of the paper argues that even though there is a significant difference in that the greenlight laser is inferior to turpin this aspect what they point out is that the baseline for these patients was around 44 44 44 and by 12 months day at a score of 16.8 so they’re still dramatically improved from the baseline and what they also argue is that on a scale that’s 70 questions 78 points rather going from 16 to 12 it’s only a four point difference they argue that that degree of difference is not actually that significant even though the data the numbers are significant how clinically significant is that they argues that it’s not really that different additionally they also ask patients at six and 12 months if they would do the therapy again and if they would recommend the therapy and overwhelmingly both groups recommended the therapy again at both timeframes and there was no significant difference between the two groups so the last slide here for the glass study is kind of looking at complications and they using the klavian dindo grading system and again without looking at every single point individually the main things I want to highlight is that for grey one to 3a and 3b and then also overall there’s no significant difference in these adverse events requiring some type of medical or surgical intervention so the conclusions from the Goliath study is that you know the efficacy and clinical outcomes comparable at six and 12 months with 180 watt greenlight laser versus the turf now the efficacy is good but the complication profile does vary the green laser does have more irritated symptoms and also in continents however the turf does have more complications requiring intervention within 30 days and like I said the paper argues that the significance of the degree variance of these symptoms was questionable the other thing that the paper really pointed out was that post-operative recovery is superior with the greenlight laser with shorter catheterization times decreased lengths of hospital stay and decreased time to add stable health status so after going through the glass study I just this brought up other questions that I wanted to kind of look at one of them was what is the longer-term outcomes I mean yes they came out with six months and then a 12-month update but you know I was more interested in is there any papers that go you know two years five years ten years the next thing I thought about is you know I mentioned all these other different laser versions in the fact you know there’s a 120 and 180 I wanted to see if there was a study looking at the differences in outcomes and operative perioperative parameters additionally I wanted to see how significant is it that the green little asia doesn’t provide any tissue that could be analyzed for diagnosis of prostate cancer and lastly what is the cost difference cost is obviously an important thing in healthcare so i wanted to see if that’s been looked at so one study i found looked at using the greenlight laser for bph patients with and without urinary retention the goal of this study was to see if the Greenland laser is a viable option for people in urinary retention I just sort of wanted to use this study because it did go a little further than the book alive study however

unfortunately did use the 80 watt laser however I do think that even though there is no study that with a 180 watt going longer than one year I think we can sort of tell at least a trend from the data with this study so what they basically show is the green is the the excuse me the blue is patients in non urinary retention and the raddest people in urinary retention and what I want to highlight is this point to this point so 12 months and then 6 24 months and all three groups which is Q max residual volume ipss quality of life and I PSS all three groups is actually has a positive trend meaning from 12 to 24 months it shows that the efficacy is still positive so again it’s not the same laser exactly but it’s you know I’m hoping to sort of just infer point that there is some data showing that at least the two years the the outcomes are still good road with chirp obviously church been around a lot longer you know so there’s a lot more data a lot more studies with it this study was a looked at 10-year efficacy and the study itself compared chirp to two other treatments contact laser prostatectomy an electric vaporization of prostate main things I just wanted to highlight was the turf data not so much the other two data but they did look at up to ten years and they did get over half their patients to follow up at ten years and what they were able to show is that at ten years IPSS quality of life q-max and PSA were all significantly different from baseline so that does show there is some durability of results with the turf even at ten years however you can sort of see a trend where the score the numbers are actually trimming from like two to six here for ipss qmx is getting a little slower and PSA begins to rise a little bit so I ten years the parameters are increasing are getting clinically negative but they’re still say clearly different from baseline so the next question I had was about the different lasers this study looked at 80 patients that underwent phone of vaporization with 120 watt laser and 120 patients that had 180 watt laser in this study was performed by a single surgeon that had prior to the study over 500 cases of the green laser so he was an experienced surgeon and it’s similar types of things that looked at ipss quality life q-max PVR and PSI and they looked at patients at three at baseline three and six months and then they also analyzed the operative parameters so looking at the efficacy data what we can see here is that we have the HPS is the 121 the XPS is the 181 and what we can see is that in ipss quality of life and PBR and Q max there was no significant difference in the data so what this is telling us is that the 180 watt compared to the one to analyze as far as efficacy goes is as good or better because PSA was improved with the 180 watt and then for most of these the trend is actually in the pot in the pie in the direction that the green light the new 180 watt is better but the key thing with this data that i wanted to point out is that the perioperative and adverse effects is are a little different the mean operating room time for the 181 a 120 watt is 79 minutes which i think is a lot a lot of people in this room are probably more familiar with the green laser taking an hour and a half hour 20 minutes whereas the 180 watt laser which 43 minutes so 36 minutes shorter for the procedure which i think adds a huge advantage from the previous version because that was you know one of the things that deterred a lot of people from using it and then otherwise the majority of the applications were actually not securely different however there was less retention with the new laser so what this sort of tells us between the efficacy data and the prayer of order parameters is that 180 watt laser is as good as far as efficacy and side effects but it’s better as far as speed compared to the 120 watt so the next thing I wanted to look at was the incidental diagnosis of prostate cancer with chirp this was just sort of a question I had because I know that obviously with the turbulent for analysis now part of the PSA era 27-percent prostate cancers were detected at the time of term and the odo group hypothesized that incidental diagnosis diagnosis of clinically significant prostate cancer was no longer of significance with the modern PSA are so what they did is they did a retrospective review and looked at 793 patients that have a Terp over a five-year period and they excluded anybody that had a preoperative diagnosis of prostate cancer and what they found is that of the 771 patients included only eleven were diagnosed with prostate cancer so only one point four percent 10 of those were clinically insignificant Gleason 6 is that they ended up just doing active surveillance as opposed to operator and only one person had at least a clinically sequent significant place 27 that they did an operation on so what this data sort of tells us is that you know it’s not getting tissue you know at the time of a Terp is not important you know one we’re finding a very few amount of prostate

cancer is this way and two we don’t want to be we don’t want to find you know clinically insignificant cancers you know so what this is telling us is that if somebody has you know elevated PSA you know clinical symptoms physical damn we you know we’ll we’ll find prostate cancer with a biopsy the Terp isn’t giving us anything that we can’t get outside of that and then the last point I wanted to kind of talk about was the cost so this group sort of compared this is a bailar prepared the did a retrospective perioperative cost analysis for all patients that underwent a terp during its turf war the greenlight laser during a 12-month period they included both direct and indirect costs and they analyzed 252 paintings with 220 ponen vaporization patients and what they showed is that first the first thing I want to point out is that the payer profile was not squeakquel a different so you know Medicare versus prior insurance that would have influenced the study not significantly different just out of here is showing the mean days of hospital stay so this sort of reflects the noted that i showed you can apply study a little bit the numbers are a little different with the trend is the same brunette then the green laser with 1.7 3 days again this is Jessica people that will stay longer for complications and then mature plus 2.5 nine days against an adjustment but the key point is again it’s about a day difference so that that influences cost looking at the cost of cells overall costs the difference we’ve got eight hundred dollars for 42 66 250 97 and that was significantly different so what’s that showing this is because of the shorter recovery times agreement later daisy is having a prosecutor so final conclusions the quiet study did them successfully demonstrated the non-literal repolarization when the parsley perspective efficacy cricket chirps they both six or 12 months irritated simply connect on and continue to be the biggest drawback the dream of laser patients protective antigen opposition perspective however however all technologies continue to improve their most closely ever get a new lasers the respondent ligne droite these relays are all still demonstrating without put out comes with krassimir over x cos its new message over there in your area is to study versus terrific because they came from reality lasers concern for gays having over 1200 studies at the University of Alaska lacks any doin see you live your five-year point privately probably a million new laser student at all it’s only so maybe ye wat the support of the water sometime study there a barrier because these generalities but also it is showing showing it group a playa de la crosse so what’s new what’s next lots of other person is going to mention all these last thing last thing we have our July powerful science studies visualization thousands of dollars renovated hundreds we firmly at our data the bleep serious relationship Russian Harbor Airport so with that without any questions in the interview during it is what it is like a poster paper um yeah the most the time a time they talk to a lot of the one of your distances live in [ __ ] styles but the exam just messing with been disrupting the strangers most likely hope for in that case so the class study the trial was funded by Amos but the operation oscillation because I’ve been involved in several occasions you just as an observer and Kelvin medication the conference is very good agreement they don’t attend conferences as soon as I get one drop their throw bottles towards women you know the exact color a lot more that’s all my wife’s cousin all criminal on

location but this is a significant issue of my mind a honey consultation we’re sitting there and on your cell Giles’s you will proceed you are you going to say there is a data out there that shows you know even at 12 months or might be struck what would you say so but then a second I’m just going to put comment which was a great talk I just want to give you two a history buff dr. Foster was going to mention the study of each you’re silly of eph by the NIH has followed an interesting path inaudible different letter acronyms be busy the first grade study was attending hops that ignorant losing my prosthetic circles forearm study qualified they wanted to look at NIST to never rec’d miss Sampson only face of surgical trials we want to do analyze the present Goliath feet you know and i think they drop that sort of idea and then they went into alternative and complementary medicine to page for assault on discovery channel so i find that me and I just interest in this area this was there Harris was PIR m+ and so what do you think about consent well I think it’s anything obviously it’s important to mention but you know one of the things in the data i pointed out was that looking at both the irritated symptoms and overactive bladder incontinence the study still showed at 12 months there’s still much better than baseline so it’s not like it got worse you know or you know significantly different as far as a negative standpoint it still got much better just not as good as the Terp but I definitely still think it’s you know clinical responsibilities to you know mention that one it’s discussing surgical options the first presentation that are very like Don that was a just a superficial reporting alert unlike the waves what I thought about the clinically relevant questions and really try to get all my stats I appreciate that I did a great job a couple things just in terms when you’re looking at the literature one of the things when you mentioned that there was a difference it might be statistically significant but not clinically significant I think that’s important a lot of the patient reported outcomes or subjective outcomes there’s more focused on a bit away important difference I guess a synthetic fist died at the SS so that’s something just when you’re presenting to mention that especially if you know the difference is as the attend point difference differently a three-point difference so that can be important another thing is when you’re looking at long-term data there are changes that are and I totally agree like 12 months is okay two years is better and you have to same sort of perception and a female literature one thing to remember what the lower urinary tract or if there are changes that occur with aging you can also affect you know like the troops are under activating or increasing so again just just something to include when you’re presenting or thinking about it and I totally agree with that their same comment about you do need to see who’s answering feeds and even though it would be hard to hold you know you look at their primary outcomes everything was carefully done rigorously done it’s still people tend there’s always some of your highest it’s only joints or to have a nun in his troop supported study those are hard to do these days so sometimes industry you can still clean important information from that but but I so I heard that statement and also was moving forward with non industry supported studies the best you do and there were 10 the one thing I thought was missing from that study they did have a patient satisfaction because the female literature new-onset irritated symptoms or persistent in a major driver of satisfaction I thought it was curious there wasn’t more of a sad it’s actually different specially what Kobe said incontinence thing plus the irritated think would make me you turned if I was counseling like a family member about which one’s dead so the satisfaction literature even sometimes capture all that right like improvement plus de novo symptoms so there are some other measures that are local impression like patient global impression of improvement or satisfaction and something like that overall how is your bladder condition compared so that would have been a nice addition to that study and my ipad is it moving forward or studying full believe that but overall and I thought it was really nice I wasn’t asked about the mechanism for the irritated comments that sorry thank you thank you alright next we have a chignon chen who was born in china before immigrating to the UK and finally settling in canada it obtained his bachelor’s degree in immunology from the University of British Columbia it’s currently studying

medicine at Brown in addition to to obtaining his mph at Harvard some of his extracurricular activities include the sub internship with the director general at the wh 0 dr. Margaret Chan and serving as a medic in a UN refugee camp in the West Bank some of his research interests of included prosthetic artery embolization for the treatment of bph and he’s currently working with dr Joseph renzulli on building the MRI fusion biopsy program of brown she nan Chi nouns other interests include playing the alto and soprano saxophone traveling golf and as a self-described movie CNN was initially set up for a formal sub I with us for an entire month however due to an upcoming plans surgical procedure he was unfortunately only able to do a one-week observership nonetheless she has volunteered to give us a quick talk that he had prepared prepared for another sub I and we’re very grateful Thank You ma thank you very much for the introduction dr. sherlyn dr. foster exactly a resident good morning today I would like to talk about a very interesting idea I learned a few years ago at a national meeting rsna in Chicago and I’ve been following doctors dollars from UC s SS publications recently in 2015 he published his paper describing this idea so first of all I still make sure that I have no financial accounting complex let’s start with the cakes so miss mr is 46 year old female presenting with one day history of flank pain nausea and brush and materia her past medical history include hypertension and kidney stone she’s currently taking 25 milligram the hydrochlorothiazide and has no drug allergy in the ED her vital signs are stable she appeared to be in distress and in pain pregnant pause allowed to include elderly cranium 2.1 and your analysis showed three bus blood then contrast CT showed 11 millimeter proximal red ureteral stone and ultrasound showed great through hydronephrosis of red kidney so what are the treatment options for Miss mr prior to nineteen eighty treatment for stone was major intra-abdominal surgery and is really hardly used nowadays with aquarius a few exceptions since nineteen eighty many minimally invasive treatments have become available including s ball pcnl and ureter oscar p um in order to understand how microbubble works we need to understand the physics behind as well so here’s demonstration of how s will work with this very big bulky machine it generates the shock wave and interns to fragments though this was first develop in 1980s in germany an a use focus electro-hydraulic or electromagnetic energy from outside the body to can refocus shockwave and the chocolate interns and induce formation of cavitation bubbles in vivo so what those bubbles do is when they collapse they release a tremendous amount of energy to fragment still and interns allow passage of a small fragment however there are limitations of this idea including an anatomy of patient location of the stone and the distance complications from shockwave includes gross hematuria hematoma aki and damage to surrounding tissue so in recent years shockwave have become less frequently used in treating kidney stones one reason is that newer generation machine has smaller foucault’s own and become less effective and another reason is the availability of the minimal invasive procedures here is a very important question we actually apply the principles of microbubble cavitation using endoscopic approach without this really big bulky machine if it is possible it will further mix don’t treatment more minimally invasive so what are micro bubbles they are made of inert gas core stabilized in the shell and they’re designed to be point 1 to 10 micrometers in diameter and they’re also engineered to target very specific target and they’re usually short live about 15 to 20 minutes here is a picture of a micro bevel as you can see there’s a core surrounded by a shell and you can engineer anything I like with antibody and to target anything in the body there are two major fda-approved brands in the United States one is called definity

once called up descent in recent years microbubble has become a very very hot taught research topic in the world of biomedical engineering it has growing and significant role in medical therapeutics and diagnostics in the United States is only fda-approved as a contrast agent to identify party after an anomaly hearing echocardiogram are we outside the United States has been widely used other fuels including cancer treatment coagulation Rimbaud lysis and most recently I read a paper about regulating kidney a rejection after kidney transplant so the next question is does it work and it is safe dr. APIs team from Rush University in Chicago demonstrated that using micro bubbles as a contrast agent reduces observer variability in echocardiogram they also showed it has great potential in decreasing imaging cause mortality and radiation exposure another team of scientists from Minnesota investigated the safety of microbubbles uses ultrasound contrast so in 418 consecutive patients with known right-to-left shouts no neurologic orem bolic average events were found only one patient reported transient back pain as a secondary complication so by conjugating antibodies to microbubbles it allows its accumulation renal vasculature dr. duma’s team took interest in finding out the effect on micro bubbles on renal physiology in their study they found that kappa rupture occurred in rats when after some energy set as highest index however such as such things were not observed in larger animals such as pigs or rabbits so what about kidney stone here’s a proposed approach of how it works after preparation of microbubbles we can inject it into the kidney and then use ultrasound energy to activate micro bubbles in turn and then to Franklin stone so how do we target kidney stone and micro bevel can be engineered ex vivo with this phosphate phosphonate group specifically targeting hydroxyapatite and as we know that mostly stone are composed of have a significant portion of hydroxyapatite and also we learned from treating osteoporosis is this supposed to Nate has high affinity to hydroxyapatite so how can we deliver the kidney stone I mean the microbubbles so the microbubbles can be delivered with why you interrupt your reader scope or also I can be delivered percutaneously a nexus bubble can be washed away energy source wise we can use low frequency electromagnetic radiation or standard address on unit to activate the micro bevel and this forms energy propagate very well through t-shirt without strong interaction other than using standard ultrasound machine energy can be delivered endoscopically and their fluoroscopy which allows real-time visualization so in this way we’re able to replicate the mechanism of microbubble cavitation general in vivo bike shop later here’s a picture from dr. stallers recent publication it shows ex vivo cavitation by micro bubbles and below are the images of stone fragmentation captured by high-speed camera so let’s come back to the case so so how we treated miss miss mr we treated her with urine rasca p was laser and then afterwards with stent placement so hypothetically if we treated her with microbubble it’s possible it is a less invasive procedure and has less radiation exposure and when compared to shock wave as well it may have less adverse effect here it is a significant energy delivering the doctor scholars team believed that micro bubbles have great potential to be the next frontier in kidney stone treatment and could further contribute to stone fragmentation and diagnosis and their team also made a very very good YouTube video which is available online laughs for salvage well I think the

entire idea behind this it’s say they’re trying to think of ways to first off to reduce complication and also to make it more minimally invasive it’s really just it’s kind of like they’re proposing an alternative treatment plan I don’t think this actually intentionally used as like a supplement 12 to use after a failed as well and also another important thing is just it really does allow real-time visualization receipts don’t fragmentation I mean all this information is all in preclinical stage so there’s no real kinetic data comparing to other methods this is all hypothetical right now do they talk about the affinity of the microbubbles to that finish Raghavan there I don’t know there’s many measurement but the dawn is very strong it’s like basically they follow that the idea of treating osteoporosis which is like really rich content about this yes for the group I think for this to have any traction they would have to make a major difference don’t very short right yeah but you’ve done this with this changed a non-invasive procedure into an invasive you’ve changed your procedure that ninety percent of the time does not need to be done with general anesthesia that probably is that’s true that trade-off kind of be a completely different yeah I make a comment about actually the 2d cuts are very interesting pissed like to hear someone actually give a talk about application of technology in the well you know I’ve seen talks about early adopters versus later doctors I know this is unavailable biggest out was about music lasers which is available for ology the question is what what is the balance when you buy new technology to something we do every day in clinical medicine because you know the purported it’s always it’s always better to use new technology but is it really better and it is a difficult question I’m doing this sort of a generic kind of prime the common link between the two because eventually this new technology wants to look for a place in clinical medicine sort following a doctor single hot message but I sometimes I think technology you know it’s a trade-off it so we don’t technology goes back to that we know how to get this and some people mr. well because if something really does work the late adopters completely miss about because the people who are everything will obviously try to outcomes that don’t work so it would be interesting to know all the different ways of thinking of how to dock you know new technology within clinical medicine and maybe dr. she won’t has comment is deeply the cover the pot coffee kind of canonical com what’s the best will desert us whether it is an ethical considerations Gatorade but you know I’m always challenge because it’s okay I got this great new devices hunt with Boeing Travis it works great now I really and you know your colony wait what kind of data you need and what’s it incremental bet you know

there’s a lot of costs I mean with respectfully I think the other patient comes in the door asking some of these things that advertising pays to hear it from their friend resistor that and doing a fair amount of dph of the earth there’s not a significant number of guide to come in and basically saying I want the laser notwithstanding you know the paucity of long-term theater you have been a that’s a real time issuing that you have to deal with face-to-face actually got the militia and then if you know the same thing happened with all these generations of swings that we’ve done over the years many of which have fallen overboard thank you very much thank you