The document outlines a comprehensive overview of retrograde intrarenal ureteroscopic surgery (RIRS), detailing its definitions, contraindications, indications for use, techniques, and outcomes. It discusses advancements in equipment and instrumentation, patient preparation, and clinical case examples illustrating RIRS in various scenarios including stone management and tumor treatment. The future outlook for RIRS reveals its growing role in the minimally invasive treatment for urological conditions, increasingly replacing traditional methods like SWL and PCNL.

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. RIRS - Definition RIRS = Retrograde Intrarenal Surgery i.e.. endoscopic surgery for management of pathology within the renal collecting system using a retrograde closed approach

3. Retrograde Intrarenal Surgery (RIRS) Contraindications Overview of Current Indications Equipment, Techniques (covered during the live surgery) Examples of Clinical Cases

4. Retrograde Intrarenal Surgery (RIRS) Contraindications: ( infection and coagulopathy): Absolute: Untreated urinary tract infection (UTI) Treat according to C&S with antibiotics for 10 d If obstruction – start antibiotic and manage obstruction with ureteral stent or PCN tube Caution: Infection stone or History of UTIs Pretreat with broad spectrum Abx for 10 d even if culture negative

5. Retrograde Intrarenal Surgery (RIRS) Contraindications: (infection and coagulopathy ): Relative : Preferred management to correct coagulopathy if medically safe Relative: Untreated coagulopathy Cautious treatment with direct contact laser (Holmium, Thullium) Use access sheath to reduce bleeding (prostate, frequent passage up/down ureter)

6. RIRS - 21 Years Review Range of Present Indications Development of Indications (equipment, techniques) Results Outlook to Future Role

7. RIRS – Indications Stones Residual after failure of ESWL (not fragmented > not passed) Residual after PCNL (not passed > no access) DeNovo stones (primary RIRS) Stones up to 1.5 cm (known COMH) Lower calyx location Stricture below stone (diverticulum, nephrocalcinosis) Stone can not be positioned for ESWL (habitus, obesity, ileum conduit, radiolucent) Source of relapsing UTI Anticoagulated patient

8. RIRS - INDICATIONS STONES (Special Indications) RIRS assisted ESWL (stones up to 2.5 cm.) Staghorn stones (RIRS-SWL) using Holmium “debulking” Staghorn stones ( when ESWL and PCNL not be technically or medically feasible )

9. RIRS - INDICATIONS Non-Stone Evaluation of hematuria Evaluation of positive upper tract cytology TCC tumor treatment (Holmium, Nd:YAG Laser, electrofulguration) Treatment of UPJ or intrarenal stenosis Removal of migrated foreign bodies (stents, staples, broken ureteral stents)

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. RIRS Improvements Instrumentation/energy sources : 7.5 Fr. ureterorenoscope (Storz, ACMI): one-stage procedure access to entire renal collecting system Holmium Laser (Coherent, Trimedyne, Microvasive, Dornier): fragments all stones, + vaporization, incision of strictures, tumor coagulation/ablation, coagulation of bleeders (AVM)

12. RIRS Improvements Instruments/equipment: Zero-tip baskets: - atraumatic, reach into all calyces Access sheaths: - easier access for larger stones - easier access with enlarged prostate - less bleeding risk in anticoagulated patient

13. PATIENT PREPARATION Patient Selection (see indications) Sterile urine (neg. C&S) IV hydration IV peri-operative antibiotics (e.g. Ampicillin + Gentamycin) KUB (for stones), general anesthesia (IV sedation, local)

14. FLEXIBLE URETERORENOSCOPY WITH RIRS: Protocol Pre- and intraoperative forced diuresis (fluids + diuretic) as renoprotective measure against pyelo-parenchymal reflux Cystoscopy , retrograde pyelogram, and placement of 0.038 guidewire Removal of previously placed double J stent

15. Access to the Upper Urinary Tract Technique (URS) Access to the Ureter: To Dilate or Not to Dilate ? Myth: Most ureteral orifices need to be dilated Fact : Less than 3 % need dilation (9.5 Fr.scope) No advantage of smaller "mini"scopes in this regard Dilation only needed if : S/p pelvic or ureteral surgery or radiation with extrinsic ureteral compression (tumor/fibrosis)

16. Access to the Upper Urinary Tract Technique (URS) Advancement of Ureteroscope to Pathology Advance alongside safety wire (works in most cases) Advance over working guide wire (edema, narrowing, difficult to see) Advance through introductory sheath

17. RIRS: Access to the Upper Urinary Tract Dilation of ureteral orifice or higher ureteral segments rarely necessary when “optical dilation” with 9.5 Fr. rigid ureteroscope used

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. Passage of the Flexible Ureterorenoscope over Guidewire Ureterorenoscopy is performed passing an actively deflecting ureterorenoscope over guidewire which is removed once the ureteroscope advanced past the iliac vessels Irrigation fluid is begun and the instrument is advanced under direct vision to the area of interest.

23. RIRS-Access Straighten urethra and avoid kinking Advance scope with thumb and index finger of left hand

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. RIRS: Points of Technique Low-pressure system Suction / irrigation Suction Irrigation (gravity 60 cm) RIRS: Points of Technique

27. Retrograde Intrarenal Surgery Equipment Employ appropriate energy source for stones: ultrasound, Lithoclast, EHL, Laser(Holmium) for strictures: cold-knife, RF knife, Laser (Holmium) for tumors: RF energy, Laser (Nd:YAG, HoNd:YAG, Holmium ) Universal Urology Energy Source: Holmium Laser

28. Retrograde Intrarenal Surgery Equipment Stone removal: Tipless Nitinol basket, stone grasper

29. RIRS Exemplary Cases SWL has failed: what to do next ? Stone patient with bleeding problem Pediatric patient with cystine stone Stone and intrarenal stricture Upper tract TCC: organ preservation

30. LC Stone Residual after ESWL Indication: lower calyx (s/p failed SWL x 2)

31. RIRS-Holmium Laser Indication: lower calyx (s/p failed SWL) Technique: “ optical dilation” (9.5 + 7.5 Fr. 200 micron fiber “ relocation techniques” Combination RIRS-SWL

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?

36. Lower Calyx Repositioning Technique

37. Lower Calyx Repositioning Technique

38. Lower Calyx Repositioning Technique

39. RIRS – SWL for Lower Pole Stones

40. RIRS - RESULTS STONES Intrarenal stones with basket STONEFREE 93% with Fragmention + basket STONEFREE 82% Overall stonefree rate 85%

41. Complications Sepsis 2/464 outcome: resolved without sequelae Caliceal perforation with minimal extravasation 2/464 outcome: resolved without sequelae Now over 3000 cases performed w/o significant infectious complications Prevention: neg. C&S, ABx cover, low pressure system, diuretic

42. Retrograde Intrarenal Surgery Conclusions RIRS has become a routine procedure with a wide range of indications in the management of stones, strictures, low grade renal TCC Safe, efficacious, out-patient, reproducible In the management of stones RIRS has replaced SWL and PCNL as first choice for a number of indications

44. RIRS Exemplary Cases SWL has failed: what to do next ? Stone patient with bleeding problem Pediatric patient with cystine stone Stone and intrarenal stricture Upper tract TCC: organ preservation

45. RIRS-Holmium Laser Pt. with coagulopathy (OLT failure) A case for direct contact Holmium Litho (10-20 W)

46. RIRS-Holmium Laser Holmium Vaporization: Stone “debulking”

47. RIRS-Holmium Laser 0.6 -1.0 J @ 10 - 5 Hz with “bulky” stone up to 25 W

48. RIRS-Holmium Laser Lower calyx residual: 200 micron fiber (10-5 W) + basketing of gravel

49. RIRS Exemplary Cases SWL has failed: what to do next ? Stone patient with bleeding problem Pediatric patient with cystine stone Stone and intrarenal stricture Upper tract TCC: organ preservation

51. RIRS Exemplary Cases SWL has failed: what to do next ? Stone patient with bleeding problem Pediatric patient with cystine stone Stone and intrarenal stricture 5. Upper tract TCC: organ preservation

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. Multimodality Treatment for Complex Renal Stones “Disappearance” of the easy stone Complex stones or previously failed attempt Endoscopically based multimodal approach for optimal results (E-SWL / RIRS / PCNL / Laparoscopy, medical)

58. An endourological Challenge 53 y/o morbidly obese male with h/o recurrent uric acid stones S/p multiple ESWL, URS, RIRS PMH Morbid obesity: BMI 57 Obstructive sleep apnea HTN Asthma Diabetes Hypercholesterolemia

59. Case Presentation Incidentally found to have bilateral renal stones on US while being evaluated for bariatric surgery Renal scan: 40% left, 69% right, no obstruction

60. Case Presentation CT

61. Case Presentation KUB

62. PATIENT PREPARATION Patient Selection Sterile urine IV hydration IV peri-operative antibiotics (e.g. Ampicillin + Gentamycin) KUB, general /regional (IV sedation)

63. RIRS: Access to the Upper Urinary Tract Dilation of ureteral orifice or higher ureteral segments rarely necessary when “optical dilation” with 9.5 Fr. rigid ureteroscope used

65. RIRS: Points of Technique Low-pressure system Suction / irrigation Suction Irrigation (gravity 60 cm) RIRS: Points of Technique

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. Simultaneous Bilateral RIRS N = 15 Indications : Medical co-morbidities (10; cardiac, pulmonary, anticoagulation) size avg. 2.1 cm Patient request (5) size avg. 1.4 cm

72. Simultaneous Bilateral RIRS Results : Age: 25 – 78 yrs (avg. 56.1) Female/male: 9/6 Sessions: 1.5 (1-3) Treatment time: 1.45 hrs (0.30 – 5.2) Stone free: 11 (75%), CIRF 4 (25%) Hosp.stay: 9 hrs. (4 x 23 hrs, medical) Complications: none surgical

74. Stones in Caliceal Diverticuli Facts ESWL stone free rates 20 - 56 % ESWL symptom free rates up to 80 % PCNL stone free rates greater than 90 % PCNL technically more demanding PCNL higher complication rates PCNL allows fulguration of redundant mucosa

75. RIRS - The Future Preliminary work: RIRS under topical anesthesia (7.5 Fr., f/u of UUT TCC, small stones, strictures)

76. RIRS - Outlook New Horizons : RIRS under topical anesthesia (7.5 Fr., f/u of UUT TCC, small stones, strictures) Selected pts. (female) with small stone burden (RIRS - Holmium vaporization vs. SWL) In the future : less use of SWL; PCNL for very large stone burden and complex anatomical problems

78. Case Presentation 64 y/o male h/o horseshoe kidney Long h/o recurrent stone disease ESWL (’85, ’92) Residual stone fragments PMH: TCCA of bladder, depression Labs: Creatinine 1.0 C/o persistent left flank pain Evaluated with CT and KUB by local urologist

79. Case Presentation CT

80. Case Presentation CT

81. Case Presentation KUB

82. Case Presentation Treatment options? ESWL? PCNL? Retrograde intrarenal surgery? Conservative management?

84. Case Presentation CT

85. Case Presentation KUB

86. Case Presentation Retrograde intrarenal surgery 2 cm stone noted in the renal pelvis Optical dilation with the 9.5 Fr rigid ureteroscope 7.5 Fr flexible ureteroscope, holmium laser used for stone fragmentation

87. Case Presentation Retrograde Pyelogram

88. Case Presentation Retrograde Pyelogram

89. Case Presentation 38 y/o female c/o urgency, frequency, low grade fevers for 1-2 weeks PMH: Unremarkable PSH: Breast augmentation MEDS: Birth control pills

90. Case Presentation Treated with multiple courses of antibiotics without clinical improvement Renal US: Severe right hydronephrosis, large right renal pelvic stone

91. Case Presentation CT Urogram

92. Case Presentation CT Urogram

93. Case Presentation CT Urogram - Delayed Images

94. Case Presentation CT Urogram

95. Case Presentation Attempted right JJ stent placement unsuccessful at outside hospital Underwent emergent right nephrostomy tube placement

96. Case Presentation Nephrostogram

97. Case Presentation Treatment options: ESWL? PCNL? Retrograde intrarenal surgery? Open pyelolithotomy? Laparoscopic pyelolithotomy?

98. Case Presentation Nephrostogram

99. Case Presentation Operative findings Impacted 2 cm right UPJ stone Right retrograde intrarenal surgery Holmium laser lithotripsy (7.26 kJ) Stone basketing JJ stent placed Retrograde Intrarenal Surgery (RIRS)

100. Case Presentation Video

101. Case Presentation Follow-up 7 days later Residual, fragmented stone debris in the lower pole calyx NT taken out in clinic Next step?

102. Case Presentation Follow-up 14 days later Decreased residual stone debris in the lower pole calyx Next step?

103. Case Presentation Second stage RIRS Well fragmented stone debris in the lower pole calyx and ureter Basketing of residual stone debris Stone free based on intra-operative fluoro/ endoscopy SF 2 yrs. follow-up Retrograde Intrarenal Surgery (RIRS)

104. RIRS for Caliceal Diverticuli Material and Methods SELECTION CRITERIA: 96 patients with proven stones in caliceal diverticuli on IVP or retrograde pyelogram (RPG) AGE RANGE 21 - 75 yrs. (Ave. 47 yrs) SEX: Male 39 Female 53 STONE LOCATION: Upper Calyx 53 pts. Mid Calyx 33 pts. Lower Calyx 8 pts. Two patients mid and lower caliceal stones.

105. Stones in the Caliceal Diverticulum Objectives of my talk : Present 15 + yrs experience with retrograde intrarenal surgery (RIRS): technique, outcomes, limitations Present practical treatment algorithm for total MIS management of stones and intrarenal strictures RIRS, PCN, Laparoscopy

106. Sterile urine Flexible cystoscopy and RPG to assess intrarenal architecture and confirm presence of diverticulum Placement of double J stent to allow for gradual passive dilation of upper tract (1-2 weeks prior to RIRS) Re-culture urine 1 week prior to treatment Start antibiotics p.o. 2 - 4 days before Rx. (if indicated) RIRS – the initial experience

107. RIRS Patient Preparation Placement of double J stent to allow for gradual passive dilation of upper tract (1-2 weeks prior to RIRS) 1 stage proc edure : 9.5 Fr. “optical dilation” + 7.5 Fr. RIRS

108. RIRS for Intrarenal Strictures Technique Dilute contrast is injected through the scope to delineate the connection to the stone bearing calyx. Methylene blue also helpful (when tic takes on contrast) Intraluminal ultrasound (optional)

109. RIRS for Intrarenal Strictures Technique A small dimple can usually be seen endoscopically. This indicates the entry point to the narrow caliceal neck.

110. RIRS for Intrarenal Strictures Technique An 0.038 guidewire (or glide-wire) is inserted and maneuvered through the narrow segment under endoscopic and fluoroscopic guidance.

111. RIRS for Intrarenal Strictures Technique A balloon dilator is advanced over the guidewire (1987 – 92). Alternatively, the calyceal neck is incised with the Bugbee electrode (92-94) or Holmium laser ( s 94)

112. RIRS for Intrarenal Strictures Technique Once the calyceal neck is opened, the diverticulum is inspected with the flexible ureterorenoscope.

113. RIRS for Caliceal Diverticulum

114. RIRS for Intrarenal Strictures Current Options for Stone Removal Direct removal of the stone (small stone, calyx spacious enough to allow for basket or three-prong grasper manipulation) Fragmentation of a stone slightly too large for direct removal (Holmium, EHL) RIRS assisted ESWL with active removal of stone debris during SWL procedure.

115. Caliceal Diverticulum RIRS assisted SWL 1. Complete vaporization and fragmentation 2. Active removal of gravel No / Minimal residual Minimally invasive

116. RIRS for Intrarenal Strictures After Care Placement of indwelling stent Discharge home same day with Abx (5 days) The double J stent is preferentially placed into the stone bearing calyx if space permits The double J stent is left indwelling (proximal curl in diverticulum) for 2 weeks.

117. RIRS for Caliceal Diverticuli RESULTS Access to kidney: 100% without dilation (preparatory stent only) 90% advancement of 9.5 Fr. URS as endoscopic dilator 10% Identification of infundibulum: 95% Successful dilation/incision: 95% Balloon 80% Incision (Holmium Laser, electrode) 15% Combination 5%

118. RIRS for Caliceal Diverticuli RESULTS Dilation/Incision: unsuccessful in 4/8 cases of lower pole diverticuli (PCNL done, same session) not enough fulcrum to negotiate balloon in 3 cases (lower pole) electrocautery incision was used to open the caliceal neck

119. RIRS for Caliceal Diverticuli Stone retrieval: Endoscopic grasping/basket: 75% Stonefree 90%(tic 100%) RIRS assisted ESWL: 20% Stonefree 75%(tic 100 %) Primary PCNL: 5 % Stonefree 100% Secondary RIRS (after ESWL): 2.5% Secondary PCNL 2.5%

120. RIRS for Intrarenal Strictures Conclusions In light of the limited success of ESWL monotherapy, and the higher complication rate of PCNL treatment of stones in caliceal diverticuli, our approach of endoscopic intrarenal correction of the outflow alteration, with or without ESWL, has proven to be the better alternative.

121. RIRS for Intrarenal Strictures Conclusions Only 8% of patients had recurrence over a 10 year observation period. 10 + years of follow-up confirms that this treatment approach compared favorably to percutaneous renal surgery with regard to stone-free rates, long-term resolution of symptoms, re-stenosis of the caliceal neck and stone recurrence rates.

122. RIRS for Intrarenal Strictures Conclusions Retrograde endoscopic repair + stone removal yields a 90 % stonefree rate compared to 75% for endoscopic repair +ESWL (tic 100 % free of stone). This approach is preferable for stones in the mid and upper calyces PCNL is used for lower pole calyceal diverticuli and RIRS failures

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

127. Caliceal Diverticulum Role of Laparoscopy Anterior location Large stone burden

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

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. RIRS assisted SWL Procedure RIRS=Retrograde Intrarenal Surgery Employed under the same anesthesia preceeding or simultaneously with SWL SWL with Dornier MFL-5000, STORZ Modulith, Direx

134. RIRS assisted SWL Equipment Multipurpose Lithotriptor (MFL 5000, Storz Modulith, Direx) Simultaneous use of SWL and RIRS Flexible Ureterorenoscopes 10.4, 8.5, and 7.5 Fr.; KSE Holmium Laser (Coherent, Sharplan) EHL Calcutript (KSE) Accessories: Balloon, Basket, Grasper (Microvasive, Cook, Bard)

135. RIRS assisted SWL INDICATIONS Failed SWL, secondary to: Size Stone Composition Anatomic Variances Stones and intrarenal stenosis amenable to RIRS repair (in upper pole / mid renal) Infundibular Stenosis Diverticulum

136. Advances in Endourology: RIRS assisted SWL 1. Complete vaporization and fragmentation 2. Active removal of gravel No / Minimal residual Minimally invasive

137. RIRS-Holmium Laser Indication: lower calyx (s/p failed SWL) Technique: “ optical dilation” (9.5 + 7.5 Fr. 200 micron fiber “ relocation techniques” Combination RIRS-SWL

138. RIRS- Holmium lithotripsy Shockwave Lithotripsy Simultaneous

139. RIRS assisted SWL INDICATIONS RIRS assisted ESWL (stones up to 2.5 cm., routine) Larger stones --- usually PCNL Staghorn stones (RIRS-SWL) using RIRS Holmium “debulking” (up to 25 Watts)

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. Retrograde Intrarenal Surgery Equipment Stone removal: Tipless Nitinol basket, stone grasper

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. Stones in the Reconstructed Urinary Tract Technical Difficulties Stone visibility often poor: Infection stones common: less visible on plain films Stone overlying bony structures (ureter, conduit, pouch) Air “contamination” of plain films Renal insufficiency: IVP of limited value Non-contrast spiral CT, retrograde pyelogram Retrograde Access technically challenging Continent diversion: risk of incontinence Upper tract: difficult identification of anastomosis and lack of fulcrum

144. Stones in the Reconstructed Urinary Tract Conduit: ileum: mostly upper tract stones +/- strictures colon: rarely used Continent Diversion: Pouch stone: frequent (staples, mucous) Upper tract stone ‘ Anatomy’ of ureteral anastomosis Orthotopic anastomosis Nipple anastomosis

145. Stones in the Reconstructed Urinary Tract Ileal Ureterostomy: The “straightforward” case Easy retrograde access with rigid and flexible instrumentation All energy sources

146. Stones in the Reconstructed Urinary Tract Single kidney & Ileal conduit: An easy case Lateral view fluoro identifies anastomosis

147. Stones in the Reconstructed Urinary Tract Ileal conduit RIRS for upper and lower pole stones Placement of safety wire EHL (Laser) fragment- ation (vaporization) Stone removal (basekting)

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. RIRS - RESULTS STONES Intrarenal stones with EHL + basket/grasper STONEFREE 80% with basket /grasper STONEFREE 93% Stones and urinary diversion STONEFREE 84%* *30/68 had larger stones and received ESWL and / or percutaneous stone removal for final stonefree rate of 84% Overall stonefree rate 85%

154. Complications Sepsis 2/464 outcome: resolved without sequelae Caliceal perforation with minimal extravasation 2/464 outcome: resolved without sequelae Contrast extravasation after balloon dilation 34/56* in mid/upper ureter * one-stage procedures with balloon dilation; discontinued after 56 cases Now performed for evaluation of active upper tract hematuria with 7.5 F ureterorenoscope or for small stone burden with 7.5 Fr. or by using 9.5 Fr. rigid scope first “optical” dilation

155. RIRS - RESULTS OTHER INDICATIONS MALE FEMALE TOTAL Intrarenal biopsy (normal upper tract) 44 16 60 Intrarenal biopsy (urinary diversion) 41 13 54 Retrograde incision of UPJ stenosis 2 6 8 (flexible instrument) Retrograde incision of UPJ stenosis 0 22 22 (rigid instrument) TOTAL 87 57 144

156. RIRS - RESULTS: OTHER INDICATIONS EVALUATION OF HEMATURIA/ POSITIVE CYTOLOGY 1. Visualization of the entire renal collecting system was possible in >98% of patients. 2. The source of active renal bleeding was identified in 80% 3. In the presence of incidental high grade positive cytologies (TCC) appreciable lesions were found in only 10 %.

157. RIRS - RESULTS: OTHER INDICATIONS EVALUATION OF HEMATURIA/ POSITIVE CYTOLOGY 4. All cases of papillary tumors biopsied were diagnostic. 5. Biopsies were negative in >90% of cases where no papillary tumors were found (Biopsy of suspicious areas) 6. Random renal biopsies in patients with incidental positive cytology were negative in all cases

158. Advanced Endourology RIRS assisted SWL 1. Complete vaporization and fragmentation 2. Active removal of gravel No / Minimal residual Minimally invasive

159. RIRS assisted SWL Rationale RIRS allows real-time endoscopic monitoring of SWL fragmentation and determination of endpoint of treatment also allows accelerated fragmentation: Holmium / EHL co-fragmentation to remove fragments during SWL localization of poorly opacified stones to correct anatomical problems of stone egress

160. RIRS assisted SWL Procedure RIRS=Retrograde Intrarenal Ureteroscopic Surgery Employed under the same anesthesia preceeding or simultaneously with SWL ESWL with Dornier MFL-5000

161. RIRS assisted SWL INDICATIONS Failed SWL, secondary to: Size Stone Composition Anatomic Variances Stones and intrarenal stenosis amenable to RIRS repair (in upper pole / mid renal) Infundibular Stenosis Diverticulum

162. RIRS assisted SWL INDICATIONS RIRS assisted ESWL (stones up to 2.5 cm., routine) Larger stones --- PCNL Staghorn stones (RIRS-SWL) using RIRS Holmium “debulking” (up to 25 Watts)

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. RIRS assisted SWL Equipment Multipurpose Lithotriptor (MFL 5000, Storz Modulith, Direx) Simultaneous use of SWL and RIRS Flexible Ureterorenoscopes 10.4, 8.5, and 7.5 Fr.; KSE, ACMI Holmium Laser (Coherent, Sharplan) EHL Calcutript (KSE) Accessories: Balloon, Basket, Grasper (Microvasive, Cook, Bard)

165. RIRS assisted SWL RESULTS Determines precise endpoint of fragmentation and eliminates empirical “extra shocks for the road” Allows for co-fragmentation and active removal Allows for repair of anatomical variants

166. RIRS assisted SWL (MFL 5000) RESULTS (1995-1996) TOTALS (All Indications) 45 patients Ave stone 21.4 mm Co-fragmentation: • Holmium 53% • EHL 46% Basket 95% Ave treatment time 115min Stone free rate 84.4%

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. Upper Tract TCC “Staging” and Treatment Planning How to “stage” Papillary : Basket-bx of exophyt ablate base with Holmium (10W=1J@10Hz) Solid: multiple grasper -bx ablate only if “palliative” candidate

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)

174. Renal Pelvis TCC

175. TCC Renal Pelvis Nd:YAG for the base

176. Ureteroscopy for UUT-TCC Ureteral TCC

177. How to Follow UUT TCC “Asymptomatic” Endoscopic surveillance critical for long-term management Possible under topical anesthesia (office) Tx of small recurrence also possible under topical anesthesia

178. Retrograde Intrarenal Surgery Conclusions RIRS has become a routine procedure with a widening range of indications Safe, efficacious, out-patient, reproducible In the management of stones RIRS has replaced SWL and PCNL as first choice for a number of indications

179. RIRS - The Future Preliminary work: RIRS under topical anesthesia (7.5 Fr., f/u of UUT TCC, small stones, strictures)

180. RIRS - Outlook Preliminary work: RIRS under topical anesthesia (7.5 Fr., f/u of UUT TCC, small stones, strictures) Selected pts. (female) with small stone burden (RIRS - Holmium vaporization vs. SWL) In the future : less use of SWL; PCNL for very large stone burden and complex anatomical problems

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. How to Follow UUT TCC “Asymptomatic” Endoscopic surveillance critical for long-term management Done under topical anesthesia (office) Tx of small recurrence also possible under topical anesthesia

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. RIRS: Points of Technique Low-pressure system Suction / irrigation Suction Irrigation (gravity 60 cm) RIRS: Points of Technique

192. RIRS – Treatment in the Office Setting RIRS under topical anesthesia (7.5 Fr., f/u of UUT TCC, small stones, strictures)

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. Simultaneous Bilateral RIRS Simultaneous RIRS with 2 separate teams is a solution for complicated stone disease in select patients (less anesthesia, less sessions) The bilateral treatment is safe, results are comparable to single treatment Logistical challenge but well accepted by pts. with good results

203. RIRS –Endourology Info [email_address] Fax: 310 423 4711 Ph: 310 423 4700