Endoscopic Combined IntraRenal Surgery (ECIRS): Rationale
The present chapter reviews the rationale of ECIRS (Endoscopic Combined IntraRenal Surgery), the logical evolution of PNL and of the old prone split-leg position. ECIRS would not exist without the Galdakao-modified supine Valdivia position, specifically s
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Endoscopic Combined IntraRenal Surgery (ECIRS): Rationale Cesare Marco Scoffone, Cecilia Maria Cracco, and Roberto Mario Scarpa
Abstract The present chapter reviews the rationale of ECIRS (Endoscopic Combined IntraRenal Surgery), the logical evolution of PNL and of the old prone split-leg position. ECIRS would not exist without the Galdakao-modified supine Valdivia position, specifically supporting this versatile antero-retrograde approach to the upper urinary tract. ECIRS is a synergic approach in all its aspects, being a combination of retrograde intrarenal surgery (RIRS) and antegrade PNL and including essential intraoperative interactions among all operators (urologists, anaesthesiologists, nurses, scrub nurse, radiology technician, with the respective armamentaria), rigid and flexible instruments, endoscopes and accessories, intraoperative imaging techniques for renal puncture, ECIRS itself, and other surgical techniques. The anesthesiological, urological, and management advantages of ECIRS are described in detail.
10.1
Introduction
Percutaneous nephrolithotomy (PNL) has been practiced for more than 35 years and is still considered the treatment of choice for the management of large volume and/or otherwise complex renal stones [1]. From its introduction in the 1970s [2, 3],
C.M. Scoffone, MD (*) • C.M. Cracco, MD, PhD Department of Urology, Cottolengo Hospital, Via Cottolengo 9, 10152 Torino, Italy e-mail: [email protected]; [email protected] R.M. Scarpa Department of Urology, San Luigi Hospital, University of Torino, Regione Gonzole, 10, 10043 Orbassano, Torino, Italy e-mail: [email protected] C.M. Scoffone et al. (eds.), Supine Percutaneous Nephrolithotomy and ECIRS, DOI 10.1007/978-2-8178-0459-0_10, © Springer-Verlag France 2014
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PNL procedure has undergone considerable evolution, mainly driven by the improvement in access techniques, endoscopic instrumentation technology, lithotripsy devices, and drainage management [4]. The consequent progressive improvement in PNL outcomes confirmed its essence of minimally invasive approach. All the same, although considered safe and effective in expert hands, PNL requires experience and permanent training and is not exempt from specific intra- and postoperative complications including visceral injury, hemorrhage requiring blood transfusions, and infectious events. Efforts have been made to decrease PNL perioperative morbidity, starting from the issue of patient positioning, often overlooked in the past and only recently recognized as a critical part of this as of any other surgical procedure, thus a real matter of discussion.
10.2
The Conventional Prone Position for PNL
The conventional position for PNL has always been the prone one in the past, because – as explained in Chap. 1 – initially the radiologists aimed at the direct puncture of the renal pelvis without passing through the renal parenchyma. Also when puncturing the kidney via the calyceal papilla became the habit, it was not considered necessary to modify the pati
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