Retrograde Intrarenal Surgery (RIRS) for Kidney Stones

Retrograde Intrarenal Surgery or RIRS is a procedure used to remove kidney stones in a retrograde manner (urinary tract to kidneys) that may require spinal or general anesthesia.

It is the preferred surgical option for the treatment of kidney stones that have a size of less than 2 cm and cannot be successfully treated via other methods.

Do you want to know the treatment option? Please contact our doctor at Medfin.

What is Retrograde Intrarenal Surgery (RIRS)?

Retrograde Intrarenal Surgery or RIRS is a procedure used to remove kidney stones in a retrograde manner (urinary tract to kidneys) that may require spinal or general anesthesia.

A fiber-optic endoscope, a tube (with a camera and light source) is inserted through the urinary tract opening called- urethra, that travels via the ureter-the tube that connects the bladder to the kidneys to access the stone present. 

A laser fiber probe (commonly Holmium: YAG laser) breaks down the kidney stone. The larger ones are broken down into smaller fragments and removed with either forceps or other advanced instruments like stone baskets.

In some cases, a stent is used to improve drainage, which may be inserted before or after surgery. It is an advanced procedure performed by a Urologist or someone with clinical expertise in the procedure of RIRS.

It is the preferred surgical option for the treatment of kidney stones that have a size of less than 2 cm and cannot be successfully treated via other methods.

It is efficient and reliable in its use as it does not require open surgery and combines the ideal principles of ureteroscopy and lithotripsy with holmium laser (efficient for all stones with any composition) for ensuring complete removal of stones with minimal post-operative complications.

This procedure is used as the go-to technique in a variety of cases such as:

  • Stones that cannot be treated or previously treated unsuccessfully with procedures like SWL- shock wave lithotripsy or percutaneous nephrolithotripsy – PCNL.
  • Non-opaque stones not visible in traditional x-rays.
  • Existence of anatomic abnormalities (of the kidneys or Renoureteral malformations).
  • Co-existence of renal and ureteral stones.
  • If both the kidneys have stones, this procedure helps treatment within a single surgery and avoids multiple sessions.
  • Multiple kidney stones including nephrocalcinosis.
  • Bleeding disorders.
  • People who have to be treated completely stone-free (such as pilots, etc.).
  • Combined or secondary procedures following PCNL.
  • A patient who is obese or with musculoskeletal deformities.
  • Stones >3 cm (may require two or more sessions).
  • In children, with kidney stones where a less aggressive approach is preferred.

What is the Pre- Surgery steps for Retrograde Intrarenal Surgery (RIRS)?

Health assessment through physical examination, blood tests, urine analysis, and responsiveness to anesthesia is tested before the procedure.

Antibiotics may be suggested by the doctor in case of infection beforehand. Diagnosing and imaging help to determine the location of the kidney stone.

Pre-operative ureteral stents (Double J stents) are inserted before the procedure to help get better access to the kidney stone by dilating the ureter. They are not always necessary and are generally used in cases of UTI (urinary tract infections) as it helps preserve renal functions.

In children for passive dilatation before ureteroscopy helps the surgeon for better access in cases with ureteral abnormalities that may lead to obstruction of the instrument, also in cases of an emergency.

It is also used for the management of previous unsuccessful RIRS attempts due to ureteral stricture(constrictions). On the day of the surgery, fasting is required 6 hours before the procedure.

How is Retrograde Intrarenal Surgery (RIRS) performed?

General anesthesia is usually preferred over the spine as the patient may be subjected to pain and trauma due to inadequate relaxation of the ureters or uninhibited breathing. 

Guidewires, ureteral stents, or dilators can assist to enter the ureter. A safety guidewire is kept in the ureter and collecting system to prevent loss of access during stone manipulation and enables a DJ stent in case of perforation or after the procedure is completed. 

Ureteral dilators can be placed before to access the stone better, which might be hindered due to ureteral tube or orifice constraints. 

An endoscope – a thin, flexible tube is used to enter the kidney via the ureter and helps identify the stone. The Holmium: YAG laser is used to blast them completely or into fragments using one or more combinations of the three settings of the laser:

  • Fragmentation: Wherein, fragments produced are removed with a stone basket-a nitinol retrieval instrument.
  • Dusting: Where energy is used to reduce the stone to fine dust and fragments smaller than 2 mm in diameter, that will later pass via urine.
  • Popcorn effect: Used after fragmentation to produce smaller pieces. Forceps and other advanced equipment like stone baskets can also be used to remove the fragments.

What is the Post-operative care to be taken after Surgery (RIRS)?

Post completion of the surgery, a urine catheter can be placed for a day or longer in the urethra to reduce pain and problem while urinating. 

A 24-hour bed rest along with lots of fluids intake (at least 2.5 liters) is advised to prevent infections. The patient can resume their activities the following day if he/she feels healthy. A follow-up session with the doctor is crucial to monitor the success of the surgery. 

Post-operative stenting must be considered in patients at increased risk of complications such as ureteral trauma or perforation, residual fragments, pregnancy, urinary tract infection, and bleeding.

However, no DJ stent is required if the procedure is completed without any complication and the clinically insignificant residual stone fragments are left. Patients are discharged on the following day post-surgery.

What are the advantages of Retrograde Intrarenal Surgery (RIRS)?

  • Minimally invasive, Simple, and quicker procedure.
  • Shorter recovery time.
  • Less painful.
  • Minimal bleeding.
  • Fewer risks of damage to renal tissue and other complications.

What are the risks associated with Retrograde Intrarenal Surgery (RIRS)?

Complications or risks associated with RIRS are fairly uncommon and occur only in very few cases.

  • Fever.
  • Flank pain, is a pain in the upper abdomen, back, or sides.
  • Urinary tract infection (UTI).
  • Haematuria is blood in the urine.
  • Inability to urinate. 
  • Procedural errors: Ureteral pelvicalyceal abrasion/Fornix rupture. 
  • Trauma to kidneys.
  • Ureter narrowing and avulsion.
  • Sepsis

Despite the many indications and advantages of RIRS, it may not be the surgical option if the size of the renal stones is more than 20mm in diameter or when several small stones are present; it can be treated better through a different method.

Everyone desires a simple and feasible treatment for their ailments, and RIRS certainly shines as the beacon of hope in the case of kidney stones as it is a reliable and safe surgical option in case of kidney stones.

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