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

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

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

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%

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

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

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

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

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”

60. Case Presentation CT

61. Case Presentation KUB

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

79. Case Presentation CT

80. Case Presentation CT

81. Case Presentation KUB

84. Case Presentation CT

85. Case Presentation KUB

87. Case Presentation Retrograde Pyelogram

88. Case Presentation Retrograde Pyelogram

91. Case Presentation CT Urogram

92. Case Presentation CT Urogram

93. Case Presentation CT Urogram - Delayed Images

94. Case Presentation CT Urogram

96. Case Presentation Nephrostogram

98. Case Presentation Nephrostogram

100. Case Presentation Video

113. RIRS for Caliceal Diverticulum

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

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

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)

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

138. RIRS- Holmium lithotripsy Shockwave Lithotripsy Simultaneous

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

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?

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

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

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

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

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

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

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

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

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

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