Endoscopic Combined IntraRenal Surgery for complex stones - The Turin technique

Abstract

Objective: The study aim of this video is to present our stepwise technique of Endoscopic Combined IntraRenal Surgery (ECIRS) for the treatment of large and/or complex urolithiasis. Patients and surgical procedure: Patients under general anesthesia are put in the Galdakao-modified supine Valdivia position. The operating room is preliminarily organized optimizing the working areas; reference lines are drawn, and a unique sterile draping is applied. Preliminary semirigid ureteroscopy followed by flexible ureteroscopy evaluates the dynamic anatomy of the urinary tract and the urolithiasis, inserting a guidewire and performing urine culture followed by retrograde pyelography. An ultrasound-assisted, fluoroscopy-guided, Endovision-checked renal puncture is performed, usually through an inferior-posterior calyx, a through-and-through guidewire applied, the percutaneous tract dilated and stabilized under endoscopic vision when possible. Rigid nephroscopy is used to perform ballistic and/or ultrasonic lithotripsy, progressively evacuating stone fragments. The flexible nephroscope completes stone clearance, moving residual fragments in front of the Amplatz sheath or treating them in situ with laser lithotripsy. Flexible retrograde ureteroscopy has an active role in case of ureteral stones or strictures, stones in calyces parallel to the percutaneous tract or with tight infundibula. Final antegrade and retrograde exploration of the collecting system is performed, a double J with the string inserted and a closed small-bore pyelostomy applied performing final antegrade pyelography. Results: ECIRS includes tips and tricks enhancing its safety and efficacy: preliminary diagnostic retrograde flexible ureteroscopy, Endovision control of the percutaneous access, application of a through-and-through guidewire, bilateral irrigation with optimal vision and fragments’ drainage, retrograde cooperation in stone preparation, clearance and treatment. Conclusions: ECIRS is a comprehensive and versatile approach for the one-step treatment of urolithiasis, where the contribution of retrograde flexible ureteroscopy ensures high stone-free rates with low complication rates, tailoring the procedure on the patient, the urolithiasis and the anatomy of the collecting system.

Keywords

• ECIRS
• Endoscopic combined intrarenal surgery
• Flexible ureteroscopy
• Percutaneous nephrolithotomy
• Urolithiasis