Nonpapillary prone endoscopic combined intrarenal surgery: effectiveness, safety and tips, and tricks

Abstract

Purpose To evaluate the effectiveness and safety of nonpapillary prone endoscopic combined intrarenal surgery (ECIRS) and provide practical tips and tricks for the successful accomplishment of the procedure respecting the anatomical particularities. Material and methods This study is an analysis of a prospectively collected database including all cases of ECIRS performed between January 2019 and December 2021 in a high-volume tertiary center. All patients underwent the procedure in prone-split leg position. A nonpapillary renal puncture was performed. The used access sheaths were 22Fr or 30Fr. Lithotripsy was performed anterogradely with a dual-energy lithotripter with incorporated suction and retrogradely with holmium Yttrium–Aluminum–Garnet laser. Results A total of 33 patients were included. The initial stone-free rate (SFR) was 84.8% and the final SFR was 90.9%. The median stone size was 35 mm and 60% of patients had staghorn calculi. The prevalence of renal abnormalities was 21.3%, including 3 cases of horseshoe kidney, 2 cases of malrotation and 2 cases with complete duplicated systems. The median operative time was 47 min. The median hospital stay was 3 days and median hemoglobin loss was 1.2 gr/dL. Overall, the complication rate was 9.1%, all being Grade II complications (n = 2 fever and n = 1 transient bleeding). Conclusions Nonpapillary prone ECIRS is an effective and safe procedure. Standardization of the procedure is critical to achieve good outcomes. Patients who benefit the most are probably the ones where additional punctures can be avoided using this technique, namely patients with renal abnormalities, incrusted ureteral stents and staghorn stones.

Evolution and current applications of endoscopic combined intrarenal surgery: a scoping review from back to the future

“…Otsuka et al [19 ▪ ] compared a lateral decubitus position with GMSV in 226 patients and reported that both operative time (92 vs. 189 s; P < 0.001) and fluoroscopic time was significantly shorter in the lateral decubitus position. Kallidonis et al [2 ▪ ] studied outcomes in 33 patients who had in purely prone position a nonpapillary prone ECIRS. By virtue of in-situ visualization of the puncture, it was reported as effective and well tolerated procedure.…”

“…The remaining 162 full-text articles were further evaluated for appropriateness and 127 articles were excluded. Finally, 35 articles were considered eligible and included [1,2 ▪ ,6–13,14 ▪ ,15–17,18 ▪▪ ,19 ▪ ,20–22,23 ▪▪ ,24,25 ▪▪ ,26–36,37 ▪ ,38]. Figure 1 shows the flow diagram of the literature search.…”

“…There were 22 retrospective [6–13,14 ▪ ,17,19 ▪ ,20,24,25 ▪▪ ,26,28,31–34,36,38] and 7 prospective studies [1,2 ▪ ,18 ▪▪ ,21,23 ▪▪ ,27,29], and only one among the latter was randomized [29]. There were 16 single-arm studies [1,2 ▪ ,6,7,9–11,13,17,20,21,25 ▪▪ ,28,31,33,36], whilst 7 studies compared ECIRS with other procedures [8,12,14 ▪ ,18 ▪▪ ,24,26,34]. Yet, four studies compared ECIRS in different patient positions [19 ▪ ,27,32,38].…”

“…Yet, four studies compared ECIRS in different patient positions [19 ▪ ,27,32,38]. Regarding percutaneous size tract, there were 19 studies using a standard PCNL [1,2 ▪ ,6,7,9,11–13,17,19 ▪ ,20,21,27–29,31–33,38] tract and 9 a mini-PCNL tract [8,10,14 ▪ ,18 ▪▪ ,23 ▪▪ ,24,25 ▪▪ ,34,36]. Only one study compared standard vs. mini-ECIRS [26].…”

“…ECIRS, the acronym for Endoscopic Combined Intrarenal Surgery first reported in 2008, is a technique that combines a simultaneous anteroretrograde approach to the renal cavities for the resolution of large and/or complex urolithiasis [1]. Reportedly, this achieved higher stone-free rate (SFR), lower complications and avoided additional punctures, especially in complex stone situations [2 ▪ ]. Historically, the prone position has been the approach used to perform percutaneous access.…”