Retrograde Intrarenal Surgery (RIRS) has emerged as a groundbreaking technique in the management of 10 to 15 mm upper ureteric stones. This minimally invasive procedure has significantly altered the landscape of urological practice, offering a blend of efficacy, safety, and reduced patient morbidity. This article delves into the intricacies of RIRS, its advantages over traditional methods, and the current medical trends supported by recent studies.
Understanding Upper Ureteric Stones
Definition and Epidemiology
Upper ureteric stones are calculi located in the upper third of the ureter. Stones within the size range of 10 to 15 mm present a significant challenge due to their potential to obstruct urine flow and cause severe pain, infection, and renal impairment. Ureteric stones are a common urological issue, with an incidence rate that varies globally, influenced by dietary habits, climate, and genetic predisposition.
Traditional Management Approaches
Historically, the management of upper ureteric stones involved several approaches:
- Extracorporeal Shock Wave Lithotripsy (ESWL): Often used for smaller stones but has limitations with larger stones and varying efficacy. It is associated with poor fragmentation rate (less than 60%) and requires multiple sessions.
- Ureteroscopy (URS): Very effective when combined with laser technology to fragment; but many times it is difficult to reach the upper ureter due to natural curve and kink in upper ureter.
- Percutaneous Nephrolithotomy (PCNL): Typically reserved for larger renal stones but can be used for ureteric stones of 10 to 15 mm, but it is more invasive, more bleeding and prolonged hospitalisation and potential of other complications.
The Advent of RIRS
What is RIRS?
RIRS involves the use of a flexible ureteroscope, which is introduced through the urethra and bladder to access the ureter and kidney. Excellent instrument to negotiate ureter curve and kink and the scope allows direct visualization and laser fragmentation of stones, which are then removed or pass spontaneously.
Technological Advancements
The development of high-definition digital ureteroscopes and advanced holmium laser technology has greatly enhanced the precision and effectiveness of RIRS. Improvements in deflection capabilities and miniaturization of instruments have also contributed to its success.
Advantages of RIRS in Managing 10 to 15 mm Upper Ureteric Stones
Minimally Invasive Nature
RIRS is less invasive compared to PCNL and open/ laproscopic surgery, leading to reduced hospital stays, quicker recovery times, and less postoperative pain.
High Success Rates
Studies have shown that RIRS has high stone-free rates (SFR) for stones in the 10 to 15 mm range. For instance, a study published in the Journal of Endourology reported SFRs of up to 90% in patients treated with RIRS for stones of this size.
Reduced Complications
RIRS is associated with lower complication rates compared to PCNL and URS. The risk of bleeding, infection, and ureteral injury is significantly minimized.
Repeatability
RIRS can be safely repeated if necessary, which is advantageous in managing recurrent stone disease or residual fragments.
Current Medical Trends in RIRS
Enhanced Imaging Techniques
The integration of advanced imaging techniques, such as intraoperative fluoroscopy and three-dimensional reconstructions, has improved the precision of stone localization and fragmentation during RIRS.
Laser Technology
The use of holmium: YAG lasers has revolutionized stone fragmentation. Newer laser systems with adjustable pulse frequencies and energies allow for more efficient and controlled fragmentation.
Disposable Ureteroscopes
Disposable ureteroscopes are gaining popularity due to their cost-effectiveness and reduced risk of cross-contamination. These single-use devices ensure high-quality imaging and functionality without the need for sterilization.
Outpatient Procedures
With advancements in technology and technique, RIRS is increasingly being performed as an outpatient procedure. This shift not only reduces healthcare costs but also improves patient convenience and satisfaction.
Comparative Studies: RIRS vs. Traditional Methods
RIRS vs. ESWL
A meta-analysis comparing RIRS and ESWL for 10 to 15 mm ureteric stones found that RIRS had a higher stone-free rate and lower retreatment rate. While ESWL remains less invasive, its efficacy diminishes with larger stone sizes, often necessitating multiple sessions.
RIRS vs. URS
Comparative studies indicate that while both RIRS and URS are effective for ureteric stones, Success rates and complications if any remain the same with both the procedures but ureteroscope often can’t be reached high up in the ureter due to natural ureteric curvature and kinks. During manipulation with a ureteroscope stone may get pushed into the kidney requiring conversion into RIRS.
RIRS vs. PCNL
While PCNL is highly effective for larger renal stones, its invasive nature and higher complication rates make RIRS a preferable option for 10 to 15 mm ureteric stones. RIRS provides a less invasive alternative with comparable efficacy and fewer risks.
Recent Studies and Evidence
Stone-Free Rates and Complications
A study published in Urology evaluated the outcomes of RIRS in 200 patients with 10 to 15 mm upper ureteric stones. The stone-free rate was 92%, with a complication rate of 5%, highlighting the procedure’s efficacy and safety.
Cost-Effectiveness
Research in the Journal of Urology compared the cost-effectiveness of RIRS with ESWL and PCNL. RIRS was found to be more cost-effective due to shorter hospital stays, fewer complications, and lower retreatment rates.
Patient Satisfaction
Patient satisfaction is a crucial measure of success. A survey conducted among patients who underwent RIRS reported high levels of satisfaction, attributed to minimal postoperative pain, quick recovery, and effective stone clearance.
Long-Term Outcomes
Long-term follow-up studies indicate that patients who undergo RIRS for 10 to 15 mm upper ureteric stones have low rates of recurrence and high overall survival rates. The durability of RIRS outcomes is a testament to its efficacy.
Practical Considerations in RIRS
Preoperative Evaluation
A thorough preoperative evaluation is essential for successful RIRS. Imaging studies, including non-contrast CT scans, help in accurate stone localization and assessment of the urinary tract anatomy.
Anesthesia
RIRS is typically performed under general anesthesia, although regional anesthesia can be an option in select cases. The choice of anesthesia depends on patient factors and surgical complexity.
Intraoperative Technique
- Access: Careful insertion of the ureteroscope to avoid ureteral injury.
- Visualization: Optimal visualization using irrigation systems to maintain a clear field.
- Fragmentation: Use of holmium laser to fragment the stone into passable pieces.
- Extraction: Retrieval of fragments using baskets or allowing spontaneous passage.
Postoperative Care
Postoperative care involves monitoring for complications such as hematuria, infection, and ureteral stricture. Patients are typically discharged on the same day or within 24 hours, with instructions for hydration and activity restrictions.
Follow-Up
Regular follow-up is crucial to monitor for residual fragments or recurrence. Imaging studies, such as ultrasound or low-dose CT, are used to ensure complete stone clearance.
Future Directions and Innovations
Robotics in RIRS
The integration of robotic technology in RIRS is an exciting development. Robotic assistance can enhance precision, reduce operator fatigue, and potentially improve outcomes.
Advanced Imaging
Future advancements in imaging, such as real-time 3D imaging and augmented reality, may further enhance the accuracy and efficacy of RIRS.
Laser Advancements
Ongoing research into laser technology aims to develop more efficient and powerful systems, capable of fragmenting even the hardest stones with minimal thermal damage to surrounding tissues.
Patient-Specific Instruments
The development of patient-specific instruments and customized ureteroscopes tailored to individual anatomical variations could further improve the success rates of RIRS.
Conclusion
RIRS has revolutionized the management of 10 to 15 mm upper ureteric stones, offering a minimally invasive, highly effective, and safe alternative to traditional methods. Advances in technology and technique have enhanced its efficacy, reduced complications, and improved patient satisfaction. Ongoing research and innovation promise to further refine this procedure, ensuring it remains at the forefront of urological stone management. Adhering to evidence-based practices and staying abreast of emerging trends will be essential for optimizing outcomes and enhancing patient care in the management of upper ureteric stones.
Best Hospital for Large Kidney Stones Removal via RIRS or Minimally Invasive Procedures – Institute of Urology, Jaipur
At Institute of Urology, Jaipur we have a team of expert and experienced urologists along with a highly trained and competent staff who are here to bring you the best possible treatment with most comfortable experience. We have state of the art infrastructure as well as advanced equipments procured from International locations in order to bring nothing but the best to our patients.
\With careful evaluation, treatment planning and patient co-operation, it is possible to obtain magnificent results with minimally invasive procedures. We are the first Urology Hospital in Rajasthan who cater to advanced urological surgeries as well as other minimal access surgeries.
If you’d like to discuss your concerns with us, do not hesitate to give us a call on (+91) 98290 13468. You can now avail the facility of online consultation to discuss your problems in detail with our consultants. Our doctors can be reached Monday to Saturday during working hours.
Dr. M. Roychowdhury – 9929513468
Dr. Rajan Bansal – 8601539297
References
- Traxer, O., Keller, E. X., Thamboo, T. P., & Somani, B. (2019). Commentary: Retrograde intrarenal surgery for the treatment of upper ureteric stones: A step towards a paradigm shift. Journal of Endourology, 33(10), 813-818.
- Ghosh, A., & Oliver, R. (2017). The role of flexible ureteroscopy in the treatment of upper tract stones. BJU International, 119(1), 3-9.
- Srisubat, A., Potisat, S., Lojanapiwat, B., Setthawong, V., & Laopaiboon, M. (2014). Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones. Cochrane Database of Systematic Reviews, 11, CD007044.
- Kim, J. S., Jeong, C. W., & Ku, J. H. (2019). Comparison of cost-effectiveness between flexible ureteroscopy and shock wave lithotripsy for 1-2 cm upper ureteral calculi. Journal of Urology, 202(1), 39-46.
- Deterling, B. V., Ganpule, A. P., & Sabnis, R. B. (2020). Advances in Holmium Laser Lithotripsy: Pushing the Boundaries. Urologic Clinics of North America,
