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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
RIRS - Definition ,[object Object],[object Object],[object Object],[object Object],[object Object]
Retrograde Intrarenal Surgery (RIRS) ,[object Object],[object Object],[object Object],[object Object]
Retrograde Intrarenal Surgery (RIRS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Retrograde Intrarenal Surgery (RIRS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS - 21 Years Review  ,[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS – Indications Stones ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS - INDICATIONS   STONES (Special Indications) ,[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS - INDICATIONS   Non-Stone ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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
RIRS  Improvements ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS  Improvements ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PATIENT PREPARATION  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
FLEXIBLE URETERORENOSCOPY WITH RIRS: Protocol ,[object Object],[object Object],[object Object],[object Object]
Access to the Upper Urinary Tract Technique (URS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Access to the Upper Urinary Tract Technique (URS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS:  Access to the Upper Urinary Tract  ,[object Object],[object Object]
 
 
Fragility of flexible scopes and high  repair costs: How to overcome this obstacle to RIRS?
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%
Passage of the Flexible Ureterorenoscope over Guidewire ,[object Object],[object Object]
RIRS-Access ,[object Object],[object Object]
RIRS-Access Left hand: Straighten urethra Advance scope and direct tip Right hand:   Keep wire under slight tension Up/down flection
RIRS-Access Right Hand Actions: Keep wire under slight tension Up/down flection after removal of guide-wire
RIRS: Points of Technique ,[object Object],[object Object],Suction Irrigation (gravity 60 cm) RIRS: Points of Technique
Retrograde Intrarenal Surgery  Equipment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Universal Urology  Energy Source: Holmium Laser
Retrograde Intrarenal Surgery  Equipment ,[object Object],[object Object]
RIRS Exemplary Cases ,[object Object],[object Object],[object Object],[object Object],[object Object]
LC Stone Residual after ESWL ,[object Object],[object Object]
RIRS-Holmium Laser ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS- Holmium lithotripsy Shockwave   Lithotripsy Simultaneous
2 Lower Pole Stones 8 mm and 11mm; 46 yr. old male ESWL RIRS RIRS-SWL PCNL
RIRS for Lower Pole Stones
RIRS for Lower Pole Stones What to do when the ureteroscope  won’t get you good exposure?
Lower Calyx Repositioning Technique
Lower Calyx Repositioning Technique
Lower Calyx Repositioning Technique
RIRS – SWL for Lower Pole Stones
RIRS - RESULTS STONES ,[object Object],[object Object],[object Object],[object Object],[object Object]
Complications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Retrograde Intrarenal Surgery  Conclusions ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
RIRS Exemplary Cases ,[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS-Holmium Laser ,[object Object],[object Object],[object Object]
RIRS-Holmium Laser Holmium Vaporization: Stone “debulking”
RIRS-Holmium Laser ,[object Object],[object Object]
RIRS-Holmium Laser Lower calyx residual: 200 micron fiber (10-5 W) + basketing of gravel
RIRS Exemplary Cases ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
RIRS Exemplary Cases ,[object Object],[object Object],[object Object],[object Object],[object Object]
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)
Retained Stones after ESWL (Arthur Smith’ theory)
RIRS for “the hidden stone”
RIRS for “the hidden stone”
RIRS for “the hidden stone”
Multimodality Treatment for Complex Renal Stones ,[object Object],[object Object],[object Object]
An endourological Challenge ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case  Presentation ,[object Object],[object Object]
Case  Presentation CT
Case  Presentation KUB
PATIENT PREPARATION   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS:  Access to the Upper Urinary Tract   ,[object Object],[object Object]
 
RIRS: Points of Technique ,[object Object],[object Object],Suction Irrigation (gravity 60 cm) RIRS: Points of Technique
Surgical  Technique Bilateral Simultaneous RIRS
Surgical  Technique Bilateral Simultaneous RIRS
Surgical  Technique Bilateral Simultaneous RIRS
Surgical  Technique Bilateral Simultaneous RIRS
Surgical  Technique Bilateral Simultaneous RIRS
Simultaneous Bilateral RIRS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Simultaneous Bilateral RIRS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Stones in Caliceal Diverticuli Facts ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS - The Future ,[object Object],[object Object]
RIRS -  Outlook ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
Case  Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case  Presentation CT
Case  Presentation CT
Case  Presentation KUB
Case  Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
Case  Presentation CT
Case  Presentation KUB
Case  Presentation ,[object Object],[object Object],[object Object],[object Object]
Case  Presentation Retrograde  Pyelogram
Case  Presentation Retrograde  Pyelogram
Case  Presentation ,[object Object],[object Object],[object Object],[object Object]
Case  Presentation ,[object Object],[object Object]
Case  Presentation CT  Urogram
Case  Presentation CT  Urogram
Case  Presentation CT  Urogram  -  Delayed  Images
Case  Presentation CT  Urogram
Case  Presentation ,[object Object],[object Object]
Case  Presentation Nephrostogram
Case  Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case  Presentation Nephrostogram
Case  Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Retrograde  Intrarenal  Surgery  (RIRS)
Case  Presentation Video
Case  Presentation ,[object Object],[object Object],[object Object],[object Object]
Case  Presentation ,[object Object],[object Object],[object Object]
Case  Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],Retrograde  Intrarenal  Surgery  (RIRS)
RIRS for Caliceal Diverticuli Material and Methods ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Stones in the Caliceal Diverticulum ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],RIRS – the initial experience
RIRS Patient Preparation  ,[object Object],[object Object],[object Object]
RIRS for Intrarenal Strictures Technique ,[object Object],[object Object],[object Object]
RIRS for Intrarenal Strictures Technique ,[object Object],[object Object]
RIRS for Intrarenal Strictures Technique ,[object Object]
RIRS for Intrarenal Strictures Technique ,[object Object],[object Object]
RIRS for Intrarenal Strictures Technique ,[object Object]
RIRS for Caliceal Diverticulum
RIRS for Intrarenal Strictures Current Options for Stone Removal ,[object Object],[object Object],[object Object]
Caliceal Diverticulum RIRS assisted SWL 1. Complete vaporization and fragmentation 2. Active removal of gravel No / Minimal residual Minimally invasive
RIRS for Intrarenal Strictures After Care ,[object Object],[object Object],[object Object],[object Object]
RIRS for Caliceal Diverticuli RESULTS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS for Caliceal Diverticuli RESULTS ,[object Object],[object Object],[object Object],[object Object]
RIRS for Caliceal Diverticuli Stone retrieval: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS for Intrarenal Strictures  Conclusions ,[object Object]
RIRS for Intrarenal Strictures  Conclusions ,[object Object],[object Object]
RIRS for Intrarenal Strictures  Conclusions ,[object Object],[object Object],[object Object]
Caliceal Diverticulum The Percutaneous Approach Direct PCN access Indirect PCN access
PCN – fulguration of  Lower Pole Diverticulum
PCN -fulguration PCN perirenal if no access to RCS PCN in RCS + perirenal PCN or  doubleJ, if access to RCS
 
Caliceal Diverticulum Role of Laparoscopy ,[object Object],[object Object]
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
 
Peripelvic Cyst, Hydronephrosis, and Caliceal Stone 58 yr old male Left flank pain
Removal of Peripelvic Cyst and Pyelolithotomy
RIRS :  The next Step Combination with  Simultaneous SWL (RIRS-SWL)
RIRS assisted SWL  Procedure ,[object Object],[object Object],[object Object],[object Object]
RIRS assisted SWL  Equipment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS assisted SWL INDICATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Advances in Endourology: RIRS assisted SWL 1. Complete vaporization and fragmentation 2. Active removal of gravel No / Minimal residual Minimally invasive
RIRS-Holmium Laser ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS- Holmium lithotripsy Shockwave   Lithotripsy Simultaneous
RIRS assisted SWL INDICATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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
Retrograde Intrarenal Surgery  Equipment ,[object Object],[object Object]
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?
Stones in the  Reconstructed Urinary Tract ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Stones in the  Reconstructed Urinary Tract ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Stones in the  Reconstructed Urinary Tract ,[object Object],[object Object],[object Object],[object Object]
Stones in the  Reconstructed Urinary Tract Single kidney & Ileal conduit: An easy case Lateral view fluoro  identifies anastomosis
Stones in the  Reconstructed Urinary Tract ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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)
Stones in the  Reconstructed Urinary Tract PCN access and PCN renal surgery performed Removal of large amount of matrix material with rigid/flex instrumentation
Stones in the  Reconstructed Urinary Tract Kock pouch with large stone in aff.limb URS stone removal Laparoscope for Marlex
Stones in the  Reconstructed Urinary Tract Girl with bladder extrophy Large pouch stones, Kidney stones, Blt.
Stones in the  Reconstructed Urinary Tract Anatomy precluded safe PCN access (lung/liver/spleen) RIRS performed blt with removal of all stones
RIRS - RESULTS STONES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Complications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS - RESULTS OTHER INDICATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS - RESULTS:  OTHER  INDICATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS - RESULTS:  OTHER  INDICATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Advanced Endourology RIRS assisted SWL 1. Complete vaporization and fragmentation 2. Active removal of gravel No / Minimal residual Minimally invasive
RIRS assisted SWL  Rationale ,[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS assisted SWL  Procedure ,[object Object],[object Object],[object Object]
RIRS assisted SWL INDICATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS assisted SWL INDICATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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
RIRS assisted SWL  Equipment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS assisted SWL RESULTS ,[object Object],[object Object],[object Object]
RIRS assisted SWL (MFL 5000) RESULTS (1995-1996) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS and Upper Tract TCC The role of  Organ Preserving Treatment
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.
Issues in Upper Tract TCC: Diagnostic Accuracy
Upper Tract TCC “Staging” and Treatment Planning ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Upper Tract TCC Diagnostic Accuracy
Upper Tract TCC Technique of RIRS Identify : Selective visualization of entire RCS Remove : Nd/YAG:Ho Laser, Ho Laser, RF-ESU Reduce Rec :Low pressure RIRS, diuretic, careful “resection”   MMC instillation Recognize :  Endoscopic re-evaluation of entire RCS at 6 wks. then 3, 6, 12 mos. (office, topical anesthesia)
 
Renal Pelvis TCC
TCC Renal Pelvis Nd:YAG for the base
Ureteroscopy for UUT-TCC Ureteral TCC
How to Follow UUT TCC “Asymptomatic” ,[object Object],[object Object],[object Object]
Retrograde Intrarenal Surgery  Conclusions ,[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS - The Future ,[object Object],[object Object]
RIRS -  Outlook ,[object Object],[object Object],[object Object],[object Object],[object Object]
RIRS in the Out-Patient Clinic  under  Local Anesthesia Gerhard J. Fuchs, MD., FACS Cedars-Sinai Medical Center Los Angeles
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
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.)
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)
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)
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)
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
How to Follow UUT TCC “Asymptomatic” ,[object Object],[object Object],[object Object]
RIRS under Local Anesthesia Instruments 15 Fr. flexible cystoscope  (Storz, ACMI, Olympus) 5 Fr. angiocath 0.038 Bentson guide-wire 7.5 Fr. flex. ureterorenoscope  (Storz, ACMI) Nitinol (tipless) basket  (Cook) Holmium Laser  (Nd:YAG-Ho Coherent, Ho Trimedyne)
RIRS under Local Anesthesia Procedure 1. flexible cysto  2. 7.5 Fr. flex. scope access to UUT w or w/o guide-wire 3. identify pathology and treat
RIRS: Points of Technique ,[object Object],[object Object],Suction Irrigation (gravity 60 cm) RIRS: Points of Technique
RIRS – Treatment in the Office Setting ,[object Object],[object Object]
Pt. MS 1994 Pt. MS 2003
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)
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)
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)
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
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 %
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)
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
Simultaneous retrograde intrarenal surgery: a new solution for complicated renal stones Gerhard J. Fuchs, MD Christopher S. Ng, MD Steve Chung, MD
Simultaneous Bilateral RIRS ,[object Object],[object Object],[object Object]
RIRS –Endourology Info [email_address] Fax: 310 423 4711 Ph: 310 423 4700

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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
  • 26.
  • 27.
  • 28.
  • 29.
  • 30.
  • 31.
  • 32. RIRS- Holmium lithotripsy Shockwave Lithotripsy Simultaneous
  • 33. 2 Lower Pole Stones 8 mm and 11mm; 46 yr. old male ESWL RIRS RIRS-SWL PCNL
  • 34. RIRS for Lower Pole Stones
  • 35. RIRS for Lower Pole Stones What to do when the ureteroscope won’t get you good exposure?
  • 39. RIRS – SWL for Lower Pole Stones
  • 40.
  • 41.
  • 42.
  • 43.  
  • 44.
  • 45.
  • 46. RIRS-Holmium Laser Holmium Vaporization: Stone “debulking”
  • 47.
  • 48. RIRS-Holmium Laser Lower calyx residual: 200 micron fiber (10-5 W) + basketing of gravel
  • 49.
  • 50.  
  • 51.
  • 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)
  • 53. Retained Stones after ESWL (Arthur Smith’ theory)
  • 54. RIRS for “the hidden stone”
  • 55. RIRS for “the hidden stone”
  • 56. RIRS for “the hidden stone”
  • 57.
  • 58.
  • 59.
  • 62.
  • 63.
  • 64.  
  • 65.
  • 66. Surgical Technique Bilateral Simultaneous RIRS
  • 67. Surgical Technique Bilateral Simultaneous RIRS
  • 68. Surgical Technique Bilateral Simultaneous RIRS
  • 69. Surgical Technique Bilateral Simultaneous RIRS
  • 70. Surgical Technique Bilateral Simultaneous RIRS
  • 71.
  • 72.
  • 73.  
  • 74.
  • 75.
  • 76.
  • 77.  
  • 78.
  • 82.
  • 83.  
  • 86.
  • 87. Case Presentation Retrograde Pyelogram
  • 88. Case Presentation Retrograde Pyelogram
  • 89.
  • 90.
  • 91. Case Presentation CT Urogram
  • 92. Case Presentation CT Urogram
  • 93. Case Presentation CT Urogram - Delayed Images
  • 94. Case Presentation CT Urogram
  • 95.
  • 96. Case Presentation Nephrostogram
  • 97.
  • 98. Case Presentation Nephrostogram
  • 99.
  • 101.
  • 102.
  • 103.
  • 104.
  • 105.
  • 106.
  • 107.
  • 108.
  • 109.
  • 110.
  • 111.
  • 112.
  • 113. RIRS for Caliceal Diverticulum
  • 114.
  • 115. Caliceal Diverticulum RIRS assisted SWL 1. Complete vaporization and fragmentation 2. Active removal of gravel No / Minimal residual Minimally invasive
  • 116.
  • 117.
  • 118.
  • 119.
  • 120.
  • 121.
  • 122.
  • 123. Caliceal Diverticulum The Percutaneous Approach Direct PCN access Indirect PCN access
  • 124. PCN – fulguration of Lower Pole Diverticulum
  • 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
  • 129.  
  • 130. Peripelvic Cyst, Hydronephrosis, and Caliceal Stone 58 yr old male Left flank pain
  • 131. Removal of Peripelvic Cyst and Pyelolithotomy
  • 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
  • 137.
  • 138. RIRS- Holmium lithotripsy Shockwave Lithotripsy Simultaneous
  • 139.
  • 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.
  • 169. Issues in Upper Tract TCC: Diagnostic Accuracy
  • 170.
  • 171. Upper Tract TCC Diagnostic Accuracy
  • 172. Upper Tract TCC Technique of RIRS Identify : Selective visualization of entire RCS Remove : Nd/YAG:Ho Laser, Ho Laser, RF-ESU Reduce Rec :Low pressure RIRS, diuretic, careful “resection” MMC instillation Recognize : Endoscopic re-evaluation of entire RCS at 6 wks. then 3, 6, 12 mos. (office, topical anesthesia)
  • 173.  
  • 175. TCC Renal Pelvis Nd:YAG for the base
  • 176. Ureteroscopy for UUT-TCC Ureteral TCC
  • 177.
  • 178.
  • 179.
  • 180.
  • 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
  • 188.
  • 189. RIRS under Local Anesthesia Instruments 15 Fr. flexible cystoscope (Storz, ACMI, Olympus) 5 Fr. angiocath 0.038 Bentson guide-wire 7.5 Fr. flex. ureterorenoscope (Storz, ACMI) Nitinol (tipless) basket (Cook) Holmium Laser (Nd:YAG-Ho Coherent, Ho Trimedyne)
  • 190. RIRS under Local Anesthesia Procedure 1. flexible cysto 2. 7.5 Fr. flex. scope access to UUT w or w/o guide-wire 3. identify pathology and treat
  • 191.
  • 192.
  • 193. Pt. MS 1994 Pt. MS 2003
  • 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
  • 202.
  • 203. RIRS –Endourology Info [email_address] Fax: 310 423 4711 Ph: 310 423 4700