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Retrograde intrarenal surgery (RIRS) refers to the surgical treatment of renal stones with retrograde approach. Recently EAU changed the guideline for stone treatment which expanded the role of RIRS.
This book is accomplished with the help of 3 professors who showed notable performance of RIRS (SY Cho, CW Jeong, JJ Oh).
We hope this to provide momentum for nation-wide discussion on RIRS as one of the best treatments for urolithiasis. 

Basic Principle of Surgical Technique

1. Equipment and Device for RIRS

Check all equipment in a sufficient state of readiness.

1. Flexible and rigid ureteroscopes
2. Fluoruscopy (C-arm) with radiation protectors
3. Guidewires
4. 5-Fr. Ureteral catheter or Dual-lumen Catheter
5. Contrast medium and balloon catheter if needed
6. Ureteral Access sheath (10/12 to 14/16Fr., 28/35/45/55cm)
7. Holmium laser with laser fiber (200/270/365μm)
8. Stone basket (<2Fr.)
9. Irrigation pump and a 50ml syringe

2. Procedure Steps

1. Position the patient: Complete supine Dorsal lithotomy position for RIRS or modified supine position for endoscopic combined IntreRenal Surgery.

Access to ureteral orifice using Cystoscope or Ureteroscope. 

Guidewire is inserted through ureteral orifice.

3. Insert contrast medium to check the location of the renal pelvis, if necessary.

Ureteral catheter is introduced to insert contrast medium.

Check the ureter and renal pelvis.

4. Insert Guidewire.

• Place a Hydophilic guidewire in the renal pelvis under fluoroscopy.
• Place an open-ended 5Fr. Ureteral catheter, remove the hydrophilic guidewire, and place another stiffer guidewire.
• Or place another stiffer guidewire using a dual lumen catheter. (for placement of a safety guidewire.)

[TIP] Narrowed segments from the ureterovesical junction to the ureteropelvic junction can be dilated using a balloon dilation catheter.
[TIP] Placement of a safety guidewire is usually recommended beside the ureteral access sheath. However, selection of an appropriate access sheath and gentle advancement through the orifice is more important than placement of the safety guidewire.
[TIP] If insertion of the access sheath is not available due to the ureteral narrowing or stricture, the flexible ureteroscope can be inserted through the hydrophilic guidewire to the renal pelvis and the dusting techniques should be considered. 

5. Remove the catheter and cystoscope (Ureteroscope).

6. Place a ureteral access sheath: Place the sheath on the guidewire to the level of ureteropelvic junction.

[TIP] The access sheath is smooth which can be slipped out of the body during operation. The sheath is recommended to be fixed to the surgical drape.

Access sheath is fixed to surgical drape with tie.

7. Insert flexible ureteroscope through the access sheath.

8. Set the appropriate pressure of the irrigation pump.
- The appropriate pressure of the irrigation pump would be 40cmHg at the level of patients' kidneys. 
- The setting usually depends on the performance of the irrigation pump.
- The pressure can be elevated to 100, 120, 150, 180 and 200mmHg during lasering or basketing.
>> Higher pressure would be helpful to get a better visual field. However, it might increase the postoperative infection risk.

9. Stone removal using Holmium laser.
-  A laser fiber must be inserted with the working sheath of a flexible URS keeps straight outside the body or inside the ureteral access sheath.
>> Laser power setting: 10-25Watt with 0.5~1.5J and 10-50Hz
>> Laser fier size: Large (365μm), Medium (275μm) and Small (200μm)
>> The URF shaft rotation function enables you to reach and get stones easily located in a difficult situation

[TIP] The small laser fiber is better for good irrigation and operative field than the larger fiber.
[TIP] Memorise the location of the laser fier in the monitor (e.g. Diretion of 9 or 10 O’clock)
[TIP] The laser fiber sheath may have a preventive role to avoid traumatic damage inside the working channel of flexible ureteroscopes or laser beam distraction. The advantages and disadvantages of stripping the laser fiber can be discussed later. 

10. Retrieve the stones using a basket (=< 1.9Fr.)

[TIP] The working sheath should be kept straight when you remove the flexible ureteroscope to minimize the injury of the outer sheath.

11. Place a ureteral stent.
- Remove the scope and insert a ureteral stent using the guidewire, if necessary.

[TIP] Dusting VS. Basketing
>>  If the stone is too small to catch with a basket, stone dusting would be appropriate.
>>  Move the lower pole stone to upper pole, if necessary.
>>  If too much dust hinders your view, you can aspirate the dust with a 50ml syringe.
>>  Combined procedure of dusting and basketing is appropriate to maximise surgical efficiency and accomplish complete stone-free status.

Maintenance Guide for the Flexible Ureteroscope


• Education of sterilization and storage of the flexible ureteroscope for steps important.
• Before surgery :
- Always keep the flexible ureteroscope straight while you handle it.
- Check the maximal deflection of the working sheath.
• After Surgery:
- Check the presence of pressure leak after surgery immediately.
- Disconnect the connector and irrigate inside the working sheath with clean water.
- Keep the lenses in the pure water and wipe the surface after flushing inside the working sheath.
- Check whether the working sheath keeps straight and whether ETO cap is attached to the flexible ureteroscope before sterilization.

URF-P6 [left]

URF-V2 [right]

• When there is any pressure leak, stop the use of the flexible ureteroscope and contact the company immediately. Sterilize the scope with EO gas, if needed.
• Keep the scope dry before the next surgery.

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