Retrograde ureteroscopic intrarenal surgery (RIRS) in patients with renal and upper ureteric stone until 4.3 cm : is a good and effective treatment?
Flexible ureteroscopes allows a variety of procedures like treatment of kidney stones, renal pelvic tumors and calyceal diverticulum's. It’s possible with many accesories instruments like, tipless nitinol baskets, wire, thinner hydrophilic coated kink resistant access sheath, Holmium laser with thinner fibers (200 micron) to access lower calyx without affecting the deflection of the flexible scope.
The percutaneous nephrostolithotripsy (PCNL) is a gold standard procedure for large kidney stones , and also has certain limitations in patients with bleeding diathesis, obesity and malrotated kidneys.
Retrograde ureteroscopic intrarenal surgery (RIRS) is a less morbid procedure than PCNL, less hospitalization’time and better compliance for the patients
So, we have evaluated the feasibility of RIRS as a viable alternate to PCNL in treating patients with renal and upper ureteric calculus of 2 cm to 4.3 cm stone burden, the cases which are usually taken up for PCNL otherwise.
Methods and results
From 2011 to genuary 2014, a total of 36 cases of upper ureteric and renal stone of 2 cm to 4.3 cm stone burden for which PCNL would be done otherwise were treated by RIRS.
We do not routinely pre stent the patient. The largest fragment was basketed out to assess the size.
Several techniques can be applied to improve the fragmentation minimize the need for re-look surgery. The major time consuming maneuver in RIRS is trying to fragment the stone in lower or middle calyx. This can be overcome by repositioning the stone in a favorable upper calyx. This will help the flexible scope to be straight during fragmentation process and avoids strain on the deflection mechanism and the risk of laser fiber damaging the scope.
This study was not done in a randomized way and did not have a control group. The follow-up for residual fragments was done with ultrasound and X-ray KUB.
The stone free rate in RIRS is 82.6% in first sitting, 97.2% % and 100% in thirth sitting.
PCNL was the only option to treat large upper ureteric/renal stones before the introduction of RIRS. RIRS is superior in terms of less complication, less morbidity and good stone free rate and has an advantage of one day of hospital stay and resuming duties after two days. RIRS is, for us, a viable alternate for PCNL for upper tract stones up to 4.3 cm.