Ultrasound guided endoscopic combined Intrarenal surgery – 10 steps for the success

ABSTRACT

Background:

Endoscopic combined intrarenal surgery (ECIRS) has been used to treat complex kidney stones (¹). The combined use of ultrasound (US) has the potential to improve safety and reduce radiation exposure, however, it is still underutilized (²).

Objectives:

Our objective is to describe, in a step-by-step manner, the ultrasound-guided ECIRS (USG ECIRS) technique, in order to facilitate learning by urologists.

Materials and Methods:

We describe the 10 standardized steps that we recommend to achieve a good outcome, based on our previous experience on a high-volume kidney stone center. We recorded a case of a 37-year-old female patient with complex bilateral kidney stones that underwent a left simultaneous combined retrograde and antegrade approach. The 10 described steps are: 1 - case evaluation with CT scan (³); 2 - preoperative care with antibiotics and tranexamic acid; 3 - warm-up and training with phantoms; 4 - patient positioning in Barts flank free position; 5 - retrograde nephroscopy with flexible ureteroscope; 6 - US and endoscopic guided puncture; 7 - tract dilation under endoscopic view; 8 - stone fragmentation; 9 - status free checking and 10, kidney drainage. Images were captured by external and internal cameras, promoting a complete understanding of the procedure. The patient has signed a written informed consent form.

Results:

Puncture was achieved under US guidance with one attempt. Another puncture was necessary in the lower pole, parallel to the initial puncture, due to a large fragment. Surgical time was 140 min. Stone-free status was verified by retrograde and antegrade view. Kidney drainage was done with ureteral stent on string, removed after 7 days. Hb drop was 1.1 Hb/dL. The first postoperative day CT scan showed no residual stones and no complications. The patient was discharged after the CT and urethral catheter removal.

Conclusion:

The USG ECIRS seems to be a very efficient and reproducible technique for the treatment of complex kidney stones. Its use should be widespread.

• Available at: http://www.intbrazjurol.com.br/video-section/20220029_Vicentini_et_al

REFERENCES

• ¹
  Scoffone CM, Cracco CM, Cossu M, Grande S, Poggio M, Scarpa RM. Endoscopic combined intrarenal surgery in Galdakao-modified supine Valdivia position: a new standard for percutaneous nephrolithotomy? Eur Urol. 2008;54:1393-403.
• ²
  Tzou DT, Metzler IS, Usawachintachit M, Stoller ML, Chi T. Ultrasound-guided Access and Dilation for Percutaneous Nephrolithotomy in the Supine Position: A Step-by-Step Approach. Urology. 2019;133:245-6.
• ³
  de Souza Melo PA, Vicentini FC, Beraldi AA, Hisano M, Murta CB, de Almeida Claro JF. Outcomes of more than 1 000 percutaneous nephrolithotomies and validation of Guy’s stone score. BJU Int. 2018;121:640-6.

Publication Dates

• Publication in this collection
  26 Aug 2022
• Date of issue
  Sep-Oct 2022

History

• Received
  17 Jan 2022
• Accepted
  08 Mar 2022
• Published
  10 Apr 2022