Medical Education Programmes
Endourology Travelling Fellowship Programme in Paris
by Azi Samsudin Lead clinician stone management, Whiston and St Helen’s Hospital, Manchester.
I am very grateful to The Urology Foundation who awarded the Travelling Fellowship in collaboration with the BAUS Section of Endourology and hence bestowed upon me this golden opportunity to visit Professor Olivier Traxer, one of the world’s leading endourologists.
I had a thoroughly enjoyable week in Paris. I was given the chance to have hands-on training with with Professor Traxer and his team, and during the week I picked up lots of tips and techniques to improve my personal practice which will benefit my patients in the UK. Professor Traxer ensured that I was made to feel part of his team and I am grateful to him and all of his colleagues who made every effort to speak English to me. I would also like to thank all those people who make donations to The Urology Foundation as it is your generosity which makes it possible for The Foundation to set up specialised clinical visit programmes such as this one in endourology.
Day 1
I turned up at 08:00 and walked into the Urology Dept in Hôpital Tenon. The hospital is one of the many large
Public Teaching Hospitals in Paris, and serves the 20th arrondissement. It is named after Jacques-René Tenon
who was a famous French surgeon. The Assistance Publique - Hôpitaux de Paris (AP-HP) is the public hospital
system (établissement public de santé) of the city of Paris and its suburbs. The AP-HP employs more than 90,000
people (practitioners and administratives) in 44 hospitals.
Tenon is renowned for its Urology department which has one of the best reputations in Paris. It is also famed for being the birthplace of the legendary French songstress Edith Piaf, whose greatest warble was "Non, Je Ne Regrette Rien".
Professor Traxer performs >300 flexible ureteroscopies and around 12-20 percutaneous nephrolithotomies (PCNLs) per year. He treats stones up to 3cm ureteroscopically and usually needs only 2 sessions for the larger stones. He also has an on-site Lithotripter. He treats all aspects of stone disease including performing full metabolic scrutiny on recurrent stone formers. He sees Parisian patients as well as tertiary referrals from all over France.
Monday’s list included 7 URS and laser lithotripsy cases, one of which was bilateral. Professor Traxer has the largest collection of flexible ureteroscopes at his disposal that I have ever seen! There are 7 Olympus and Storz scopes in the general use of the department, but the Professor also has another 7 personal ureteroscopes kept in his office. He also has the latest Olympus video ureteroscope with “chip on the tip” technology. The department is also blessed with 5 different Holmium laser machines ranging from AMS to Storz machines.
After observing 3 flexible URS procedures that morning, I was invited to scrub with Professor Traxer. He has a set technique when it comes to performing flexible uretero-renoscopy. There is no scrub nurse at the table during ureteroscopy – instead, there is always an Intern (trainee) assisting him. The Intern would get the table ready and lined up with the scope and guide wire to ensure that there is minimal risk of wires falling out during the procedure. This is especially important as he only uses Terumo Ultraglide hydrophillic guide wires which are prone to falling out. Meticulous attention is given to wetting the individual parts of the introducer sheaths and guide wires to minimise friction.
The assistant’s table is always positioned such that it is continuous with the patient’s left buttock, below their left thigh. The wheels are then locked in place. This ensures that the various guide wires or baskets exiting the scope would rest on the table in a straight line and not be prone to displacement.
Professor Traxer then scrubs up and puts the cystoscope in. He inserts it with the Albarran bridge already connected and proceeds to pass the guide wire and ureteric catheter into the ureteric orifice. He does not routinely perform a retrograde study but instead prefers to “feel” his way up with the guide wire. He also has full control of the image intensifier and there is no requirement for a Radiographer in theatre. He always uses an access sheath to instrument the pelvicalyceal system and has a safety wire when instrumenting the upper urinary tract.
Having found the Urology Ward, I then had to enquire about how I could find the Professor. After embarrassing myself with my feeble attempts at speaking French, I managed to get one of the nurses to show me to main theatre where I met Professor Traxer. I had previously met him in Amsterdam when I attended a PCNL and URS Masterclass and he seemed to remember me from then.
The Urology Department has 14 Consultants who sub-specialise in all aspects of Urology and Renal Transplant Surgery. Professor Traxer is a renowned Endourologist and specialised in ureteroscopy. That week, he had a packed schedule consisting of 3 full days of main theatre operating lists and one half day in the day surgery department. The rest of the working week consisted of outpatient work. I was briefed that apart from flexible ureteroscopy, there would also be the opportunity to observe some Bladder Outlet Obstruction surgery in the form of Green light PVP and the insertion of Artificial Sphincters by other surgeons in the unit.
There is no blanket rule of requiring laser goggles with any Holmium laser work, as is the case in a lot of centres in the UK. There is no need for a laser officer during these procedures. After successful instrumentation and fragmentation, he always looks closely at the ureteric mucosa whilst going down the ureter. He assesses it for any mucosal tears or lesions and records the evidence on DVD. He has a low threshold for leaving a double J stent whenever he does anything more than diagnostic uretero-renoscopy, and tends to use the Coloplast 7F 28cm silicone stent on everyone.
On occasion, he will leave a ureteric catheter in for 24 hours instead of a stent. This stent has a lockable introducer and is very easy to insert and manoeuvre. Most stents are removed after one week.
His technique seemed very efficient and there were no issues with wires falling out. Use of the laser was performed safely and meticulously throughout. There was particular emphasis on measures to reduce the operative time by employing various tips and tricks. I was most impressed by his skill in performing flexible uretero-renoscopy; it was certainly enlightening to watch. He also prefers standing up to sitting down when operating with the flexible ureteroscope as he finds that this way he has more control. Later that morning, I spent some time chatting with the scrub nurses.
I enquired about their on-site decontamination process and found that they used an enzyme based system. The turnaround time for scopes was very impressive, being in the order of 30 minutes.
At lunchtime, I was taken by one of the Interns to their equivalent of the Junior Doctors Mess. This was a most interesting experience! La Salle de Garde was a French tradition that goes back many years. Lunchtime is considered sacred in French hospitals and the Interns are provided with a wholesome four course spread complete with red wine and beer! It appears that this tradition is funded by the hospital, and intriguingly there are rules which must be strictly adhered to and some of which are listed below:
- White coats must be worn with the collars turned up and nametags concealed.
- No other language but French should be spoken and any mention of work matters is strictly forbidden.
- Upon entry into the room, one has to touch already seated members on the back of the shoulder as a sign of greeting. This seemed quite strange at first!
- One must then sit on the next available seat and cannot choose a different seat on another table until each table is full.
- All matters of hierarchy should be left outside the room.
- One must not use a spoon as an eating implement; yoghurts were a real challenge!
At the end of the meal, all interns would then be expected to go back to their respective duties. The typical working day would end around 19:00 hours every day – nobody seemed to know what I was talking about when I mentioned the European Working Time Directive (EWTD)! Needless to say, I was not forewarned about these traditions (the interns thought it would be funny) and ended up breaking several of the rules that first day.
Back in the Operating Theatre, the day only ended after a further 3 flexible URS procedures, during which I was gradually allowed to handle different flexible ureteroscopes but frustratingly was not allowed to use the laser or baskets. Two of the cases were upper tract TCC and I got to see the Professor Traxer use the Holmium laser to good effect. He used an Olympus Narrow Band Imaging camera stack and I was very impressed with the results on imaging TCC of the renal pelvis. That evening, I crawled back to my hotel room, ate my baguette and went to bed dreaming of the perfect wish list of endourology equipment that I was going to get my Trust to purchase once I got home.
Day 2
Tuesday’s list started at 08:30 sharp. I had the chance to observe another surgeon (Professor Lukacs) perform Green
Light PVP on a patient on clopidrogel who had a large gland. After a good discussion regarding the virtues of various
modalities of treatment for bladder outlet obstruction, I was shown a modification of the Saline TURP loop which
was his prototype for use in performing Saline Enucleation of the prostate. It consisted of a bipolar resection loop
with an additional loop at the distal end which was not electrified and was used to elevate the adenoma whilst
performing the procedure. Professor Lukacs would then use the “Mushroom technique” to complete resection of
the adenoma, thus obviating the need for morcellation. To my surprise, the lack of laser safety goggle usage extended
to Green Light PVP as well and I therefore had the dubious honour of watching a PVP without any safety goggles,
as my prior request for them was met with a vacant stare followed by a Gallic shrug...
Professor Traxer then demonstrated his technique on a patient with calyceal diverticulum stones. He used a mixture of Indigo Carmine and Contrast media to locate the neck of the diverticulum (which was exceedingly small) and then carefully incised it with the Holmium laser. He then set about fragmenting the stones. He was meticulous in ensuring that every single fragment was removed before completing the procedure. Throughout this, it was also obvious that he had tremendous knowledge of the technical specifications of all the equipment involved, and I could never imagine an instance when he would have had to ring up a rep to address an equipment issue. I therefore used every opportunity to gather various tips on scope technique and general endourology practice from him.
The day ended after another 4 flexible ureteroscopy procedures. By this stage I had racked up enough “top tips” and techniques to decide that I was going to change my practice when I got back home! I also managed to quiz the Interns about their daily routines after lunch that day. There appear to be no SHO/FY1/FY2 equivalent grades in French hospitals, so the day starts with menial chores on the ward at 08:00 hours. Luckily, French medical students are paid around 200 Euros per month to help out on the wards every day until 14:00 hours after which they then attend the Medical School for lectures.
After that, the Interns have to pop up to the ward in between cases to deal with any ward work until they finally clock off at around 19:30 hours. On the plus side, they do appear to get quite a lot of operating experience throughout their 5 year training program in Urology. There is then competitive entry for the position of Chef du Clinique (similar to Senior Registrar) which lasts for 2 years, after which they are then eligible to apply for Associate Urologist positions.
Day 3
There was a quick demonstration of the ESWL facility and I was given the day off to explore Paris.
Day 4
Wednesday was the Day Surgery morning session for the Professor. We started with an easy stone in a lower pole
calyx which was dealt with in no time at all. I then had the opportunity to be the primary surgeon in the next case,
involving the extraction of several hundred (not joking!) fragments of calculi in a patient who had undergone laser
lithotripsy 2 weeks previously. On that initial occasion, the procedure had to be abandoned due to excessive bleeding.
After a quick evaluation, we decided to remove the stones using a basket and 2.5 hours and 200+ ureteroscopic
passes later we managed to completely clear the patients system of stones. I was most impressed with the durability
of the basket as it managed to last almost right up to the end of the marathon procedure. The Professor said that
he had never had a case whereby there were that many fragments removed
in a single sitting. I felt especially pleased with myself when he commended
me on my technique and shook my hand at the end of the procedure.
Day 5
This was my last day in Hôpital Tenon. How sad! By now I had made lots of new friends and was just getting used
to Professor Traxer’s routine in theatre. I actually felt like I was part of his team. After a quick salvo of espressos
in his office, we started with a few cases of lower pole stones. These were dispatched in no time at all. Next was
a most interesting case of a transplanted kidney with a retained stent within it. The stent had become calcified
and incorporated into the staghorn calculus in the kidney after being left in for 18 months. A previous attempt at
removal had resulted in the stent fracturing, and the whole thing looked a right mess on the CT images.
We started by gently inserting the scope and then used the laser to carefully fragment the calcification on the stent. The stent was removed and we then set about fragmenting the stone. The technique of positioning the laser fibre in the middle of the calyx and using high frequency blasts (aka “Popcorn Effect”) came in very handy this time. The whole process took 3 hours after which there were still a load of fragments left in the PCS, so a nephrostomy stent was inserted and a repeat procedure was planned for the coming week.
I then watched a few substitution urethroplasty cases performed by the reconstructive specialist before calling it a day. I duly said my goodbyes to Professor Traxer and thanked him for such an enlightening week. As a leaving present, I was then given a few manuals on ureteroscopy edited by him. That evening, I finally managed to spend a night out on the town, accompanied by some of the Interns. What a great night! I finally had enough and called it a day at 3 o’clock in the morning.
I managed to get back to the hotel somehow and collapsed into bed! One top tip for anyone who finds themselves in the same position - get the last Metro train home as Parisian taxi drivers only seem to pick up female passengers at that time in the morning! It was a great end to my “French Experience” and the next day, with a heavy heart and a sore head I set off to Gare du Nord to catch my Eurostar train home.
