ECIRS (Endoscopic Combined Intrarenal Surgery)

Kidney stones do not always behave the same way in every patient. In many patients, a single minimally invasive technique is sufficient to achieve complete clearance. However, there are instances in which the stone burden is extensive, occupies multiple calyces, or persists despite earlier treatment. When stones are distributed in a way that restricts access from a single entry point, achieving adequate visualisation can become more difficult.

In these circumstances, Endoscopic Combined Intrarenal Surgery (ECIRS) may be considered to manage the increased complexity. Instead of staging procedures or relying on a single entry pathway, it allows the surgeon to work through two coordinated access routes during the same operation. Having visibility from both access points can make it easier to address the stone burden that might otherwise need treatment over more than one procedure.

At Gleneagles Hospitals, the option of ECIRS is considered only after reviewing imaging in detail and confirming that the anticipated benefit justifies a combined approach.

ECIRS is performed as a minimally invasive procedure in which the kidney is approached through two endoscopic pathways during the same operation.

• One part of the procedure involves retrograde intrarenal surgery (RIRS). In this step, a flexible ureteroscope is advanced through the urethra and ureter to reach the kidney from within. 

• The other part involves percutaneous nephrolithotomy (PCNL), in which access is gained directly into the kidney through a small flank incision.

When carried out together as ECIRS, these approaches are used in parallel rather than as separate procedures, allowing treatment of the stone burden within a single operative setting. The ureteroscope permits internal navigation of the collecting system, while the nephroscope provides direct access to specific calyces through a controlled percutaneous channel. Access via two routes provides a clearer understanding of the collecting system's internal anatomy and can assist in treating stones in areas otherwise difficult to reach.

Accordingly, ECIRS may be recommended in patients with a significant stone load, particularly when calculi extend into different calyces or when earlier procedures have not achieved complete removal.

Standard endourological techniques remain appropriate for the majority of renal stones. A combined approach is reserved for situations in which imaging suggests that single-route access may not provide adequate reach or complete clearance.

Clinical situations where ECIRS may be considered include:

• Large or branching renal stones

• Calculi located in different calyces

• Anatomical features that limit access through a single pathway

• Residual stone fragments after prior intervention

The purpose of selecting this combined approach is to improve overall stone clearance when a single technique may not adequately address the entire burden.

Patient selection is guided primarily by radiological findings, clinical history, and overall medical suitability for anaesthesia.

Those who may be considered include:

• Individuals with high-volume or anatomically distributed stones

• Patients with calculi involving multiple regions of the collecting system

• Individuals in whom prior procedures have not achieved full clearance

• Patients fit for general anaesthesia

Preoperative preparation involves assessment of renal function, screening for infection, and evaluation of coagulation status. These steps are necessary to minimise operative risk.

There are circumstances in which proceeding with ECIRS would not be advisable.

The procedure may be delayed in patients who have:

• Active, untreated urinary infection

• Significant bleeding tendency

• Haemodynamic instability

• Poorly controlled systemic illness

Optimisation of these conditions is essential before reconsidering surgical intervention.

The operation is undertaken in a fully equipped operating theatre with fluoroscopic and endoscopic imaging support. Before Surgery

Preparation generally includes:

• CT imaging to review the size, position, and distribution of the stones

• Blood investigations to check kidney function and coagulation parameters

• Urine examination to exclude any ongoing infection

• Anaesthetic evaluation before the planned procedure

Patients are instructed to avoid food and fluids for several hours before surgery and to discuss all regular medications, especially anticoagulants, with the medical team.

The procedure is performed under general anaesthesia.

The sequence of steps generally involves:

Introduction of a flexible ureteroscope through the urethra, which is then advanced along the ureter into the kidney for internal visualisation. This allows endoscopic inspection of the collecting system.

Under imaging support, a limited flank entry point is created to allow controlled access into the kidney. Through this entry point, a narrow tract is developed into the kidney, and a nephroscope is inserted.

With both instruments in place, the surgeon is able to:

• Assess the stone burden from two vantage points.

• Fragment stones using laser lithotripsy or other approved energy sources.

• Retrieve fragments through either access route, depending on size and location.

• A ureteral stent or nephrostomy tube may be placed at the end of the procedure if temporary drainage is required.

Operating time varies depending on stone complexity and intraoperative findings.

Postoperatively, patients are monitored in the recovery area before transfer to the ward. Routine monitoring of circulation and urine output continues post-procedure.

In the early phase after surgery, patients may notice:

• Localised soreness at the site of flank access

• Slight blood staining in the urine

• Increased frequency of urination if a stent has been inserted

• Analgesic medication is provided when required. Additional imaging is considered if there is a need to reassess stone clearance.

• The length of hospital stay is generally one to three days, depending on individual recovery and clinical assessment.

Even though ECIRS is performed using minimally invasive techniques, it carries risks comparable to those of other kidney stone procedures.

Possible complications include:

• Bleeding

• Elevated temperature following surgery

• Infection of the urinary tract

• A temporary fall in haemoglobin levels

• Remaining stone fragments that may need additional treatment

Ongoing observation around the time of surgery helps identify and address any complications promptly.

In appropriately chosen patients, ECIRS can provide certain clinical advantages:

• Improved reach to stones located in anatomically challenging regions

• A higher chance of achieving effective stone clearance

• Reduce the likelihood of needing treatment in multiple stages

• Maintenance of minimally invasive surgical principles

This approach is especially relevant in cases involving extensive or multi-calyceal stone involvement.

At Gleneagles Hospitals, ECIRS is performed within an established stone management service.

Available resources include:

• Advanced endoscopic and imaging systems

• Urologists experienced in complex intrarenal surgery

• Dedicated anaesthesia and perioperative support

• Inpatient monitoring facilities

• Integrated laboratory and radiology services

Treatment planning is individualised. The decision to proceed with a combined approach is based on clinical findings rather than routine protocol.

Endoscopic Combined Intrarenal Surgery is an advanced minimally invasive technique used in carefully selected patients with complex renal stones. Providing coordinated retrograde and percutaneous access within a single session, it allows improved visualisation of the collecting system and facilitates comprehensive treatment when single-route methods may be insufficient.

Selecting suitable patients is essential to achieving satisfactory clinical results. At Gleneagles Hospitals, ECIRS is performed after thorough clinical assessment and planned perioperative preparation.