Urology Video Journal (Dec 2020)
Micro endoscopic combined intrarenal surgery (microECIRS): A step-by-step guide
Abstract
Background: Renal stones are conventionally treated with percutaneous lithotomy (PCNL), with miniPCNL and endoscopic combined intrarenal surgery (ECIRS) as preferred choices to reduce morbidity associated with bigger tracts. MicroPCNL is not recommended for larger stones as fragments obscure intraoperative vision and high intrarenal pressure with prolonged operative time increases the risk of sepsis. MicroECIRS overcomes these disadvantages with simultaneous antegrade and retrograde lithotripsy and drainage. Objectives: To provide a step-by-step illustration on how to perform microECIRS. Materials and methods: 1. Patient in supine Barts flank-free with French split leg or Galdakao-modified supine Valdivia (GMSV) position. 2. MicroPCNL with 4.8Fr “All Seeing Optical Needle” (Polydiagnost, Germany). 3. Placement of access sheath with/without suction. 4. Retrograde intrarenal surgery (RIRS) with Boston Scientific Lithovue or Olympus URF-V ureteroscope. 5. Lithotripsy using Lumenis 120-watt high-power 200-micron laser with/without Moses fibre. Results: MicroECIRS has multiple advantages. Direct ureteroscope-guided puncture, antegrade visualisation of the tract via the ''all seeing needle'', and miniaturization, ensures safe and accurate percutaneous access even in challenging renal anatomy, hence reducing the risk of bleeding and need for post-operative nephrostomy. Low intrarenal pressure with good active and passive drainage bidirectionally prevents pyelovenous reflux and sepsis, and maintains clear vision to allow precision laser lithotripsy. MicroECIRS is also ergonomic for both antegrade and retrograde surgeons as they can remain seated throughout the operation, avoiding muscle fatigue. Additionally, as the camera head of the microPCNL set is mounted on a separate rod, weight is taken off the handheld part such that the surgeon only maneuvers the lightweight needle. Conclusion: MicroECIRS is a safe, easy, and ergonomic option for larger stone volumes. Achieving single-stage stone clearance with no morbidity translates into shorter hospital stays and a faster return to daily activities, hence making this economically viable.
