Gerhard J. Fuchs, M.D., Dr. med., F.A.C.S.
Professor of Urology, UCLA School of Medicine
Vice Chair, Cedars Sinai Department of Surgery
Medallion Chair in Minimally Invasive Urology
Cedars-Sinai Medical Center
Los Angeles, USA
Retrograde Intrarenal Ureteroscopic Surgery (RIRS)
1. Retrograde Intrarenal Ureteroscopic Surgery (RIRS): a Step by Step Introduction Gerhard J. Fuchs, M.D., Dr. med., F.A.C.S. Professor of Urology, UCLA School of Medicine Vice Chair, Cedars Sinai Department of Surgery Medallion Chair in Minimally Invasive Urology Cedars-Sinai Medical Center Los Angeles, USA
2.
3.
4.
5.
6.
7.
8.
9.
10. RIRS Techniques Upper tract Access: “ Optical” dilation with 9.5 Fr. rigid ureteroscope allowing one-stage procedure Simultaneous use of RIRS and SWL Simultaneous bilateral RIRS RIRS under local anesthesia in office setting
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. Fragility of flexible scopes and high repair costs: How to overcome this obstacle to RIRS?
21. Most common causes of damage: Cleaning and Sterilization = Operator induced Operator induced: Laser fiber burn or puncture 60% Working instrument puncture 20% Deflection failure – too much torque 10%
22.
23.
24. RIRS-Access Left hand: Straighten urethra Advance scope and direct tip Right hand: Keep wire under slight tension Up/down flection
25. RIRS-Access Right Hand Actions: Keep wire under slight tension Up/down flection after removal of guide-wire
52. RIRS for “the hidden LC stone” 46 yr old male with left lower caliceal stone s/p E-SWL x 3; no stone passage presently asymptomatic airline pilot (grounded for 5 months)
125. PCN -fulguration PCN perirenal if no access to RCS PCN in RCS + perirenal PCN or doubleJ, if access to RCS
126.
127.
128. Caliceal Diverticulum RIRS is the choice for the majority of caliceal diverticula (upper pole, mid renal, anterior/posterior w/o large dependant portion,) PCNL is the choice for large posterior diverticula in the lower pole or RIRS failures (posterior location) Laparoscopy is the choice for large anterior diverticula with large stone burden or when partial nephrectomy is needed
132. RIRS : The next Step Combination with Simultaneous SWL (RIRS-SWL)
133.
134.
135.
136. Advances in Endourology: RIRS assisted SWL 1. Complete vaporization and fragmentation 2. Active removal of gravel No / Minimal residual Minimally invasive
140. RIRS assisted SWL Staghorn Stone RIRS – Holmium debulking of renal pelvis upper pole Simultaneous SWL of lower calyceal group mid calyceal group 1000 800 400
141.
142. Pt with ileum conduit s/p E-SWL for 2.5 cm pelvic stone + ureteral stent PN, right now drained with PCN What to do next?
143.
144.
145.
146. Stones in the Reconstructed Urinary Tract Single kidney & Ileal conduit: An easy case Lateral view fluoro identifies anastomosis
147.
148. Stones in the Reconstructed Urinary Tract Bladder augmentation with septic complication Large filling defect in bladder Large filling defect in obstructed left solitary kidney PCN drainage placed Large fungus ball removed from bladder (perc. suprapubic)
149. Stones in the Reconstructed Urinary Tract PCN access and PCN renal surgery performed Removal of large amount of matrix material with rigid/flex instrumentation
150. Stones in the Reconstructed Urinary Tract Kock pouch with large stone in aff.limb URS stone removal Laparoscope for Marlex
151. Stones in the Reconstructed Urinary Tract Girl with bladder extrophy Large pouch stones, Kidney stones, Blt.
152. Stones in the Reconstructed Urinary Tract Anatomy precluded safe PCN access (lung/liver/spleen) RIRS performed blt with removal of all stones
153.
154.
155.
156.
157.
158. Advanced Endourology RIRS assisted SWL 1. Complete vaporization and fragmentation 2. Active removal of gravel No / Minimal residual Minimally invasive
159.
160.
161.
162.
163. RIRS assisted SWL Staghorn Stone RIRS – Holmium debulking of renal pelvis upper pole Simultaneous SWL of lower calyceal group mid calyceal group 1000 800 400 RIRS
164.
165.
166.
167. RIRS and Upper Tract TCC The role of Organ Preserving Treatment
168. Upper Tract TCC Treatment Alternatives Single Kidney: Organ preserving treatment N’ux = Anephric ------ Dialysis, Txp Two Kidneys: Nephroureterectomy (laparoscopic/open) Organ preserving treatment for select pts.
181. RIRS in the Out-Patient Clinic under Local Anesthesia Gerhard J. Fuchs, MD., FACS Cedars-Sinai Medical Center Los Angeles
182. Retrograde Intrarenal Surgery (RIRS) RIRS- Routine Procedure: Renal Stones (with or w/o simultaneous SWL) UPJ repair, intrarenal stenosis (tic) repair Organ preserving upper tract TCC
183. RIRS under Local Anesthesia Background: 17 yrs. experience with RIRS (> 1.500 pts) 12 yrs. experience with upper tract flexible endoscopy as diagnostic procedure under local anesthesia (> 200 proc.)
184. RIRS under Local Anesthesia UUT Flex. Endo Experience: 12 yrs. UUT eval under local anesth. for F/U of TCC > 200 procedures, mostly (> 95 %) well tolerated Un-stented Out-patient, (urol. clinic/office)
185. RIRS under Local Anesthesia Results (diagnostic eval N=150) Outcomes/morbidity: targets successfully evaluated under local Minimal discomfort Minimal pain meds (intraop or post) No f/U complications (no stents, no hospitalization)
186. RIRS under Local Anesthesia Objective: Evaluate outcomes and patient acceptance Small renal stones UPJ, intrarenal strictures (w/o stone) Small TCC recurrence (at time of F/U)
187. RIRS under Local Anesthesia Set-up Out-patient clinic (office) Sterile urine, po Cipro 500, (Pyridium 100 po) Lithotomy position (supine, male) Topical anesthesia (2% Xylocain jelly) No fluoro needed
194. RIRS under Local Anesthesia Results (initial 25 pts.) 15 female, 10 male age: 38 - 62 yrs. (48.4) Stone 12 (4 mm. - 1.5 mm., ave 8 mm.) TCC 9 (.5mm., 2x.5 mm., 10 mm.) Stricture 4 (UPJ 1, 3x intrarenal)
195. RIRS under Local Anesthesia Procedure Tumor cytol washings (protocol) basketing of exophytic portion for cytospin Ho resection/ablation of base (Nd:YAG for larger exophytic portion (> .5 cm.)) +/- stent (depends on tumor burden = 2 nd look)
196. RIRS under Local Anesthesia Procedure Stones a. w prev. stent: basketing of frags < 4 mm. b. w/o stent: Ho frag/vaporization (10-3 W) +/- stent (US localization)
197. RIRS under Local Anesthesia Procedure Strictures a. UPJ (w prev. stent): 10 W Ho incision (9.5 Fr. semirigid, female) (7.5 Fr. flex. male) stent b. Intrarenal: 10 W Ho incision, no stent
198. RIRS under Local Anesthesia Results (initial 25 pts.) Outcomes: Stone 12 SF 12/11 92.5 % TCC 9 (+1had 2nd session) 89 (100) % Stricture 4 patent 4/4 100 %
199. RIRS under Local Anesthesia Results (initial 25 pts.) Outcomes/morbidity: 23/25 targets successfully treated under local (1 TCC not fully reached, 2 nd session 1 pt not completely stone free) Minimal discomfort Minimal pain meds (intraop or post) No f/U complications (no stenting required)
200. RIRS under Local Anesthesia CONCLUSIONS 1. Diagnostic upper tract endoscopic evaluation and RIRS under topical anesthesia (urethra only) are well tolerated for selected patients 2. Ho and Nd:YAG energy in the kidney is well tolerated w/o anesthesia to the UUT 3. Treatment targets can be accomplished with minimal discomfort for small stones, TCC, and stricture patients 4. More experience and randomized trials (stone) needed to identify ultimate role
201. Simultaneous retrograde intrarenal surgery: a new solution for complicated renal stones Gerhard J. Fuchs, MD Christopher S. Ng, MD Steve Chung, MD