A 33-year-old female visited a local hospital and she was diagnosed as acute pyelonephritis with a right-sided large renal stone. The size was 53x24x63mm. She was recommended to visit my hospital and undergo ECIRS (Endoscopic Combined IntraRenal Surgery: PCNL + flexible nephro/ureteroscopic surgery).

KUB: radiopaque, a large staghorn stone with long caliceal necks in the upper and lower calices

CT: RK renal pelvis/RK upper M/RK lower M/RKUPost/RKMAnt /RKMPost/RKLAnt/ RKLPost (53x24x63 mm), HU 800

<What are your choices?>

Position: prone vs supine

Puncture: upper pole vs lower pole

Puncture by a radiologist or a urologist

Size of balloon sheath: 30Fr vs 24Fr vs 18 or smaller

Ancillary procedure: Flexible nephroscope vs multiple tracts

Energy: Laser vs ultrasonic vs others (combined?)

I chose supine position, lower pole puncture by myself, 24Fr balloon sheath, ancillary flexible nephroscopic and ureterorenoscopic removal and Holmium laser.

[Puncture]

First I removed all the stones in the lower pole, renal pelvis through the 24Fr balloon sheath. And then, a large upper pole stone was removed by a flexible nephroscope. However, a large stone in the midpole could not be removed by the flexible nephroscope. What is your next choice? Another puncture vs RIRS? I chose the latter.

2017-02-10 ECIRS 01. calyceal navigation

You can see the navigation of a flexible ureteroscope through a 24Fr mini-PCNL sheath (Rt side video). I put the flexible ureteroscope to remove a remnant midpole stone after all the stones in the upper pole, lower pole, and renal pelvis were removed through the 24Fr mini-PCNL (Lt side video).

2017-02-10 ECIRS 02. calyceal escape of fragmented stones

You can see the escape of fragmented stones by the flexible ureteroscope (Rt side video) through the 24Fr mini-PCNL sheath (Lt side video). You should manipulate the irrigation system efficiently to perform the techniques such as pop-corn, pop-dusting or dusting.

2017-02-10 ECIRS 03 stone removal by fURS into sheath

You can see that I am removing the fragmented stones into the 24Fr mini-PCNL sheath (Rt side video) by the flexible ureteroscope (Lt side video). The fragmented stones usually go out through the mini-PCNL sheath spontaneously, because the flexible ureteroscope obstructs the ureter and the channels into other calices become edematous during the ECIRS surgery. The pressure usually becomes lowest inside the mini-PCNL sheath.

Finally, all the stones were completely removed.