RIRS for Kidney and Ureteral Stones

What Is RIRS?

RIRS stands for Retrograde Intrarenal Surgery. It is a minimally invasive procedure used to treat kidney stones and stones in the upper ureter without making an external surgical incision.

During the procedure, a small flexible endoscope is passed through the:

๐ Urethra

๐ Bladder

๐ Ureter

๐ Collecting system inside the kidney

Once the stone is located, the urologist uses a specialised laser to break it into small fragments. These fragments may then pass naturally through the urine or be removed using small instruments.

Unlike conventional open surgery, RIRS does not require an incision through the abdomen or skin. This generally results in less pain, faster recovery, and a shorter hospital stay.

Who Is RIRS Suitable For?

RIRS may be considered for patients with specific types or locations of urinary stones.

Kidney and Upper Ureteral Stones

The procedure is commonly used for:

๐ Kidney stones

๐ Stones in the upper part of the ureter

๐ Stones measuring approximately 0.5-2 centimetres

๐ Multiple small stones distributed within the kidney

๐ Stones located in areas that are difficult to reach using other methods

The most appropriate treatment still depends on the stone’s size, location, density, number, and the patient’s overall health.

Patients Who May Not Be Suitable for Major Surgery

RIRS may be considered for:

๐ Older adults

๐ Patients with heart disease

๐ People with diabetes or high blood pressure

๐ Patients who may have a higher risk of complications from major surgery

๐ People with physical weakness or other ongoing medical conditions

๐ Patients in whom avoiding injury to kidney tissue is particularly important

Anaesthetic suitability must still be assessed because RIRS is normally performed under general anaesthesia.

Patients Whose Previous Treatment Was Unsuccessful

RIRS may be appropriate when:

๐ Extracorporeal Shock Wave Lithotripsy, or ESWL, did not successfully break or clear the stone

๐ Stone fragments remain after a previous procedure

๐ The stone lies in a narrow or deep position that is difficult to access using another technique

Advantages of RIRS

No External Surgical Incision

The flexible endoscope reaches the kidney through the natural urinary tract. There is no abdominal incision, external wound, or visible surgical scar.

Less Pain and Faster Recovery

Because no incision is made through the skin or kidney, postoperative discomfort is generally lower than with more invasive procedures.

Many patients can leave hospital within 24-48 hours and return to normal daily activities relatively quickly.

Lower Risk of Bleeding

RIRS does not require a tract to be created through the skin and kidney tissue. It therefore generally carries a lower risk of significant bleeding than percutaneous kidney-stone surgery.

Accurate Stone Treatment

A flexible ureteroscope allows the doctor to directly view the stone and reach many parts of the kidney.

Specialised laser systems, such as the Holmium laser or Thulium fibre laser, can fragment stones with different levels of hardness, including some stones that may not respond well to ESWL.

Preservation of Kidney Tissue

Because the procedure uses the natural urinary tract, it avoids creating a surgical channel through the kidney. This may be beneficial for selected patients with reduced kidney function or those at risk of kidney damage.

RIRS Treatment Process

1. Preparation Before Treatment

Before the procedure, the doctor will assess the patient’s overall health and examine the stone’s size, number, location, and density.

The assessment may include:

๐ Physical examination

๐ Blood tests

๐ Urine testing and urine culture

๐ Kidney-function testing

๐ X-ray or ultrasound examination

๐ Computed Tomography, or CT scan

Patients are usually advised to:

๐ Avoid food and drinks for approximately 6-8 hours before the procedure

๐ Stop certain medicines that affect blood clotting when instructed by the doctor

๐ Inform the medical team about all medicines, supplements, allergies, and existing conditions

๐ Receive treatment for any urinary infection before undergoing RIRS

Blood-thinning medicines should never be stopped without medical instructions.

2. Flexible Ureteroscopy and Laser Fragmentation

The patient receives general anaesthesia and remains unconscious throughout the procedure.

The urologist passes a Flexible Ureteroscope through the urethra, bladder, and ureter until it reaches the kidney.

After locating the stone, the doctor uses a Holmium laser or Thulium fibre laser to:

๐ Break the stone into very small particles

๐ Fragment the stone into pieces that can be removed

๐ Dust the stone into fine particles that may pass through the urine

A small basket or other instrument may be used to retrieve larger fragments.

3. Double-J Stent Placement

A Double-J stent is a thin temporary tube positioned between the kidney and bladder.

It may be inserted to:

๐ Keep the ureter open

๐ Improve urine drainage

๐ Reduce obstruction caused by postoperative swelling

๐ Help small stone fragments pass

๐ Support healing of the ureter

The stent is generally removed according to the doctor’s appointment, often within one to two weeks. However, the timing may vary depending on the patient’s condition.

Some patients have a ureter that is too narrow for the flexible scope to pass safely. In this situation, the doctor may first insert a Double-J stent for approximately two weeks to allow the ureter to relax and widen before performing RIRS during a second procedure.

4. Treatment and Recovery Time

RIRS normally takes approximately one to two hours, although the duration depends on the size, number, hardness, and location of the stones.

Most patients:

๐ Stay in hospital for approximately one night

๐ Return home within 24-48 hours

๐ Resume light daily activities within several days

๐ Avoid heavy exercise for approximately one to two weeks

Possible Side Effects and Complications

Although RIRS is considered minimally invasive, temporary symptoms and complications may still occur.

Common Temporary Symptoms

๐ Burning or discomfort during urination

๐ Frequent or urgent urination

๐ Mild lower abdominal or flank discomfort

๐ A small amount of blood in the urine

These symptoms commonly improve within one to three days. They may continue intermittently while a Double-J stent remains in place.

Less Common Complications

๐ Urinary tract infection

๐ Swelling or inflammation of the ureter

๐ Injury to the ureteral wall

๐ Difficulty passing urine

๐ Residual stone fragments

๐ Narrowing of the ureter after healing

๐ Severe infection or sepsis

Sepsis may occur when bacteria within the urinary tract or stone enter the bloodstream during stone fragmentation. Preoperative urine testing, appropriate antibiotics, and careful monitoring help reduce this risk.

Warning Signs After RIRS

Patients should contact the hospital or seek urgent medical care if they experience:

๐ High fever or chills

๐ Severe or worsening abdominal or flank pain

๐ Persistent vomiting

๐ Inability to pass urine

๐ Large amounts of blood or blood clots in the urine

๐ Cloudy or foul-smelling urine

๐ Severe weakness, dizziness, or confusion

RIRS Compared with Other Stone Treatments

Extracorporeal Shock Wave Lithotripsy

ESWL uses shock waves from outside the body to break stones into fragments.

It is often considered for smaller stones, commonly below approximately 1.5 centimetres, depending on their position and hardness.

Advantages of ESWL

๐ No endoscope or skin incision is required.

๐ It may be performed as a day procedure.

๐ Recovery is usually rapid.

Limitations of ESWL

๐ Some hard stones do not fragment effectively.

๐ Lower-pole stones may not clear easily.

๐ Multiple treatment sessions may be required.

๐ Stone fragments must pass naturally through the urinary tract.

Percutaneous Nephrolithotomy

PCNL involves creating a small tract through the skin directly into the kidney.

It is generally considered for:

๐ Stones larger than approximately two centimetres

๐ Staghorn stones

๐ Large or complex stone burdens

Advantages of PCNL

๐ It can remove a large volume of stones during one treatment.

๐ It is highly effective for large or complex kidney stones.

Limitations of PCNL

๐ It requires an incision and access through the kidney.

๐ The risk of bleeding is generally higher than with RIRS.

๐ Hospitalisation and recovery may be longer.

When Is RIRS the Most Appropriate Option?

RIRS may be particularly suitable for:

๐ Kidney or upper ureteral stones measuring up to approximately two centimetres

๐ Stones that did not respond to ESWL

๐ Multiple small stones inside the kidney

๐ Stones in difficult-to-reach locations

๐ Patients who wish to avoid an external incision

๐ Selected patients who may have a higher risk from more invasive surgery

Large or highly complex stones may require PCNL or more than one RIRS session. The urologist will recommend treatment based on imaging findings and the patient’s medical condition.

Care After RIRS

Drink Sufficient Water

Unless fluid intake is restricted because of heart or kidney disease, patients may be advised to drink approximately two litres of water per day.

Adequate hydration may help:

๐ Flush small stone fragments from the urinary tract

๐ Reduce concentrated urine

๐ Support normal urine flow

Avoid Strenuous Activity

During the first one to two weeks, avoid:

๐ Heavy lifting

๐ High-impact exercise

๐ Strenuous physical activity

๐ Activities that increase pain or visible bleeding in the urine

Light walking is usually encouraged when the patient feels comfortable.

Take Medication as Prescribed

The doctor may prescribe:

๐ Pain-relieving medication

๐ Antibiotics when clinically necessary

๐ Medicine to reduce bladder or stent discomfort

๐ Medicine that helps relax the ureter and support stone passage

Patients should take all medicines according to the prescribed instructions.

Attend Follow-Up Appointments

A follow-up visit is commonly arranged within one to two weeks.

The doctor may perform:

๐ Urine testing

๐ Kidney-function testing

๐ X-ray, ultrasound, or CT imaging

๐ Double-J stent removal

๐ Stone analysis

๐ Assessment for residual stones

Preventing Recurrent Kidney Stones

Kidney stones may return depending on the stone type, metabolic condition, anatomy, dietary habits, and fluid intake.

Preventive measures may include:

๐ Drinking enough water throughout the day

๐ Reducing excessive salt intake

๐ Avoiding excessive intake of animal protein

๐ Maintaining an appropriate body weight

๐ Following dietary recommendations based on the stone type

๐ Completing blood and urine testing when recommended

๐ Sending removed stone fragments for laboratory analysis

Calcium should not be excessively restricted unless advised by a doctor. Dietary calcium and calcium supplements can affect stone risk differently, and recommendations should be personalised.

Frequently Asked Questions

Is RIRS Painful?

The procedure is performed under general anaesthesia, so the patient does not feel pain during treatment.

Afterwards, mild discomfort, burning during urination, urinary urgency, or flank pain may occur. These symptoms usually improve within a few days, although stent-related discomfort may continue until the Double-J stent is removed.

How Long Must I Stay in Hospital?

Most patients stay for approximately one night and return home the following day. Some may require longer observation depending on their health, infection risk, or the complexity of the procedure.

Must I Avoid Food and Drinks Before RIRS?

Yes. Patients are generally required to stop eating and drinking for approximately 6-8 hours before general anaesthesia.

The hospital will provide specific fasting instructions based on the scheduled procedure time and the patient’s medical condition.

Can Kidney Stones Return After RIRS?

Yes. RIRS removes existing stones but does not eliminate the underlying tendency to form new stones.

The risk of recurrence depends on:

๐ Stone composition

๐ Low fluid intake

๐ High salt intake

๐ Excessive animal protein or purine intake

๐ Metabolic abnormalities

๐ Urinary tract anatomy

๐ Certain medical conditions and medicines

Long-term prevention requires lifestyle adjustment, stone analysis, and regular medical follow-up.

Specialist and Technology

RIRS should be performed by a urologist experienced in endoscopic kidney-stone treatment.

Technology used may include:

๐ Flexible Ureteroscope

๐ Holmium:YAG Laser

๐ Thulium Fibre Laser

๐ Stone-retrieval baskets

๐ Ureteral access sheath

๐ Fluoroscopic or endoscopic imaging systems

The available laser system and instruments vary by hospital. The treating urologist will select the most suitable technology based on the stone and the patient’s individual condition.

 

Reference :

Bangkok Hospital Phuket RIRS for Kidney and Ureteral Stones

ArokaGO Providers Bangkok Hospital Phuket