No fluoro, no lead. That was one of the themes for the morning as attendees imagined one day doing a percutaneous nephrolithotomy without x-rays. It was also a phrase that was heard several times from attendees during the 2023 hands-on course, 106HO: Interventional Ultrasonography: A New Urology Paradigm Using Renal Ultrasound to Guide Percutaneous Access and Biopsies. For this AUA hands-on course, over 45 urologists from around the world gathered to learn US-guided renal access, tract dilation, nephrostomy and suprapubic tube placement, and biopsy (Figure 1). With 13 expert faculty from the United States, Canada, Argentina, and Belgium, the course began with didactic lectures, breaking down topics into US knobology, imaging the kidney and perirenal structures, access and dilation, and finally renal biopsy and cyst aspiration. Attendees learned that obtaining a steady optimal view of the kidney is a critical skill to support US-guided interventions. Factors such as patient anatomy, respirations, rib shadowing, and using only 1 hand to hold the probe introduce unique skills to master.

After didactics, attendees rolled up their sleeves and rotated through 4 unique US stations using different simulation models. At one station, volunteer human medical models joined learners to practice renal imaging. Course participants learned to obtain images of the kidney from different intercostal spaces, with dominant and then nondominant hands, in prone and supine positions. Human volunteers lent realism to the imaging experience for attendees. At a second station, learners obtained needle and wire access under US guidance into hydrodistended pig kidneys placed inside large chuck roasts to mimic human tissue. Course instructors challenged attendees to place a needle with their dominant and then nondominant hand, with and without a needle guide, and then with both longitudinal and transverse approaches relative to the US probe. Learners who placed their needles accurately into the collecting system were rewarded with fluid dripping from their needle stylet, colloquially known as the “champagne” sign. A third station utilized 3D-printed kidney/flank models from Dr Ahmed Ghazi’s group (Department of Urology, Johns Hopkins University) to teach US-guided coaxial and balloon tract dilation, as well as nephrostomy and suprapubic tube placement (Figure 2). Here participants learned how to watch the echogenic wire disappear on the US image as it is covered by the nonechogenic plastic dilator or balloon. A final, fourth station utilized a gelatin mold with artificial kidney, olives, and water-filled balloons placed inside for attendees to learn renal biopsy and cyst aspiration skills. Learners who hit their target accurately with the biopsy needle were rewarded with a fine slice of green kalamata olive. Participants remarked that they were impressed with the high visual and tactile quality and the diversity of kidney models. With only 3-4 attendees in each rotation group, the high faculty-to-learner ratio ensured everyone received quality hands-on time and instruction.

A major take-home from the hands-on course was that there are numerous patient care benefits to US access: an easier learning curve for urologists to obtain their own renal access for US compared to fluoroscopy, reduced or no ionizing radiation for the surgeon, patients, and staff, as well as the ability to obtain detailed visualization of renal and perirenal structures number among them.¹ Perirenal structures such as pleura, bowel, spleen, and liver that would not be seen on fluoroscopy can be readily identified and avoided. This allows urologists to more safely obtain percutaneous renal access in higher-risk locations such as supracostal or upper pole locations. Radiolucent stones can be visualized on US to confirm stone clearance that would not show up on fluoroscopy. Urologists obtaining their own access for percutaneous nephrolithotomy have better outcomes and lower complication rates compared to cases where interventional radiology obtains access.² Urologists who obtain their own renal biopsies can expedite safe and effective patient care for renal tumor management. US is a tool that urologists should be applying to many aspects of day-to-day care that will enhance their ability to optimize patient outcomes.

We’d like to formally thank the AUA and course staff Sarah Hardy and Beeta Nazemian, industry sponsors, and faculty for another successful year. The logistics to organize and run such a course are extensive to say the least. We received tremendous positive feedback from attendees and look forward to bringing back even better future iterations. Participants left the course with new skills in their tool belt to implement in their clinical practice right away. For course attendees, we know the AUA hands-on course is the beginning of a transition toward more US usage. As more urologists become comfortable with it, “less fluoro, less lead!” can definitely become a reality.