V11-07: ECIRS (Endoscopic Combined IntraRenal Surgery) in the Galdakao-modified supine Valdivia position
ECIRS (Endoscopic Combined IntraRenal Surgery) is a combined rigid and flexible antegrade and retrograde approach for the treatment of large and/or complex urolithiasis, usually performed in the Galdakao-modified supine Valdivia (GMSV) position. The aim of the present video is to describe the main distinctive and standardized steps of this surgical procedure, and to highlight the relatedadvantages in terms of safety and efficacy.
From 2004 until 2016 more 750 ECIRS have been performed in our Department. Year after yearall the procedure has been standardized step-by-step, starting from patient positioning in the GMSV position (part 1 of the video). Since ECIRS involves manypeople and a number of devices the operating room is very crowded, and a meticulous organization is needed (part 2 of the video). Being a suitable percutaneous access key to the success of any percutaneous nephrolithotomy (PNL), a combined and reproducible guidancemethod for the renal puncture has been developed, performing an ultrasound-assisted, fluoroscopy-guided and endoscopy-checked percutaneous access (part 3 of the video). Retrograde semirigid and flexible ureteroscopy before and during PNL has both a diagnostic and active role, contributing to improve safety and efficacy of ECIRS (part 4 of the video).
All the team in the operating room (urologists, anaesthetist, nurses) shares the responsability of positioning the patient correctly in the GMSV position, combining the supine Valdivia position with a modified arrangement of the lower limbs. This position presents a variety of anaesthesiological, urological and management advantages, optimally supporting ECIRS. The diagnostic role of retrograde ureteroscopy includes the preliminary evaluation of the dynamic anatomy of both lower and upper urinary tract, for a tailoringof the intraoperative choices (calyx of access, tract size, dilation method) on the single clinical case. Endovision control of each step of the renal access reduces radiation exposure and the risk of complications due to the insufficient introduction of the devices or to their overadvancement. Retrograde ureteroscopy allows treatment of stones in calyces parallel to the access tract. Final flexible nephroscopy and ureteroscopy optimize stone-free rates.
ECIRS represents a safe, effective and comprehensive approach to PNL, allowing a versatile personalized stone management, and a perfect tailoring of all the intraoperative choices on the real-time situation of the patient._x000D_ _x000D_