Overview of RIRS
Retrograde Intrarenal Surgery (RIRS) is a minimally invasive procedure used to treat kidney stones. The procedure involves using a thin, flexible telescope called a uretero-renoscope, which is passed into the bladder through the urethra (waterpipe). The stones are then fragmented using laser energy delivered through a small laser fibre. RIRS has significantly reduced the need for traditional open surgery to remove kidney stones.

Alternative Treatments for Kidney Stones

1. Observation:
   Small stones (less than 5mm) often pass on their own, but stones larger than 7mm rarely do.
   
   
2. Extracorporeal Shock Wave Lithotripsy (ESWL):
   This technique uses shock waves that travel through your skin to break the stone into smaller fragments, which are then passed naturally by the body.
   
   
3. Percutaneous Nephrolithotomy (PCNL):
4.  This is used for larger stones in the kidney that may not be treatable with flexible ureteroscopy.
   
   
5. Open Stone Removal:
   Though rarely necessary today, open surgery may be required if other methods fail. This involves an incision in your side to remove the stone(s).
   
   

Details of the RIRS Procedure

Before the procedure, your urologist will review your medical history, medications, and discuss the surgery with you to obtain your consent. You will meet with an anesthetist to discuss anesthesia options—either general or spinal—and pain relief options after the procedure.

Anesthesia:
The procedure is usually performed under general anesthesia, so you will be asleep during the surgery. Antibiotics are often administered prior to the procedure, after checking for any allergies.

Steps of RIRS:

1. Semirigid Ureteroscopy: A semirigid telescope is inserted into your bladder via the urethra. A guidewire is then placed into your kidney, using X-ray guidance. The feasibility of RIRS depends on whether the ureter is wide enough to accommodate the flexible ureteroscope. There are two possibilities:
   
   
   • Normal Calibre Ureter: If the ureter is wide enough, a ureteric access sheath (UAS) is inserted, through which a flexible scope can pass to examine the kidney.
     
     
   • Tight or Narrow Ureter: If the ureter is narrow, a DJ stent is placed for 2 weeks to dilate the ureter, allowing for the RIRS procedure to be completed. This is known as “pre-stenting.”
     
     
2. Stone Fragmentation: After placing the UAS and scope, your urologist will examine the kidney and locate the stone(s). Using a holmium laser (30 watts), the stones are either dusted into tiny fragments that can pass naturally or broken into smaller pieces that can be removed using special grasping devices.
   
   
3. Post-Procedure Drainage: A temporary drainage tube (DJ stent) may be inserted into the ureter at the end of the procedure. The stent will be removed after 3 weeks.
4. Occasionally, a “Second-Look” Procedure May Be Required:  If any residual stones remain, a second ureteroscopy may be performed at a later stage to remove them. A stent may be left in place until the follow-up procedure.

A bladder catheter may also be placed and removed the following morning.

Most patients can go home on the same day or the first post-operative morning.

Potential After-Effects (Source: BAUS)

The following are potential after-effects of RIRS. The impact varies for each patient, and some effects may resolve on their own while others may not.

• Mild Burning or Bleeding:
  It is common to experience mild burning or bleeding when passing urine, especially if a ureteric stent was used.
  
  
• Stone Recurrence:
  Around 50% of patients may experience new stone formation within 5 to 10 years, which may require further treatment.
  
  
• Residual Stones:
  Between 5% and 15% of patients may have residual stones that require further treatment, especially if the stones are located closer to the kidney.
  
  
• Failed Access:
  In about 5% of cases, the procedure may fail to reach the stone, necessitating additional surgery.
  
  

What to Expect After the Procedure

• Recovery Instructions:
  You will receive advice on recovery and a discharge summary upon leaving the hospital.
  
  
• Increased Fluid Intake:
  Drink twice as much fluid as usual for the first 24-48 hours to flush your system and reduce the risk of infection.
  
  
• Return to Work:
  Recovery is typically rapid. Most patients can return to work when they feel comfortable and their doctor is satisfied with their progress.
  
  
• Pain and Discomfort:
  If you had a stent placed, you may experience pain in the kidney area when passing urine or in the bladder. This usually resolves quickly, but if you feel unwell or develop a fever, contact your urologist for evaluation.
  
  
• Signs of Complications:
  Contact your urologist immediately if you experience fever, severe kidney pain, difficulty passing urine, or worsening bleeding.
  
  

This article provides general information on RIRS for kidney stones. Your urologist will discuss any specific concerns and answer your questions.