Minimally Invasive Stone Treatment
High-Power Laser Lithotripsy & PCNL
Modern endourology offers minimally invasive techniques for treating stones in the kidney, ureter and bladder. Ureteroscopy, RIRS, High Power Laser lithotripsy and percutaneous nephrolithotomy (PCNL) allow treatment to be tailored to the size, location, anatomy and complexity of the stone disease.
Advanced Technology for Stone Treatment
Initial evaluation of stone disease β imaging, laboratory work-up and clinical assessment β takes place at our practice in Rhodes. When endoscopic or percutaneous treatment is indicated, the procedure is arranged at LEFKOS STAVROS β The Athens Clinic, where a dedicated Urology Center operates with a full range of latest-generation endourological equipment.
The choice of technique β ureteroscopy, RIRS, PCNL or ECIRS β is individualised according to the size, location and composition of the stone, as well as the patient's anatomy.
Available Endourological Equipment
DORNIER MEDILAS H-140
High Power Holmium Laser
Flexible Endoscopes
Latest-Generation Ureterorenoscopes
Fluoroscopic Guidance
Percutaneous Access for PCNL
The Spectrum of Modern Stone Treatment
This sequence does not represent a mandatory treatment pathway. The appropriate technique is selected individually, according to stone characteristics and patient anatomy.
DORNIER MEDILAS H-140 β High Power Holmium Laser
The high-power Holmium laser is used for endoscopic fragmentation and dusting of stones, delivering energy through thin laser fibers that pass through rigid or flexible endoscopes.
Precision
Controlled delivery of laser energy directly onto the stone.
Dusting
Fragmentation into very small particles, where clinically appropriate.
Flexible Access
Delivery through flexible endoscopes during RIRS.
Versatility
Treatment of stones at different levels of the urinary tract, depending on the selected endoscopic approach.
Ureteroscopy & Laser Lithotripsy
Ureteroscopy is performed through the natural urinary tract β urethra, bladder, ureter β without any external incision. Depending on the stone's location, a rigid or flexible endoscope is used.
After direct visualisation of the stone, a Holmium laser is applied for fragmentation or dusting. Fragments can be retrieved with a dedicated grasper, and a temporary ureteral stent (JJ) is often placed to relieve the ureter.
- Access through the natural urinary tract, no skin incision
- Direct visualisation of the stone
- Fragmentation or dusting with Holmium laser
- Possible temporary ureteral stent placement
RIRS β Flexible Ureterorenoscopy
RIRS (Retrograde Intrarenal Surgery) allows access to the kidney's collecting system via a retrograde, endoscopic route, using a flexible ureteroscope introduced through the natural urethral pathway.
The flexible endoscope adapts to the anatomy of the renal calyces, allowing direct visualisation and application of Holmium laser for fragmentation or dusting of stones. Fragments can be retrieved with dedicated instruments when necessary, and a temporary ureteral stent is often placed.
RIRS does not require a skin incision. It is not, however, always the most suitable option β its indication depends on the size, number and location of the stones.
- Retrograde intrarenal access through the natural urinary tract
- Flexible ureteroscope with access to the collecting system
- Laser lithotripsy or dusting under direct vision
- No skin incision
PCNL β Percutaneous Nephrolithotomy
Percutaneous nephrolithotomy (PCNL) is an endourological technique for treating large or complex kidney stones through a small percutaneous access route to the kidney.
Steps of the Procedure
- 1Percutaneous access to the kidney is created through a small skin entry point.
- 2Access is performed under fluoroscopic and/or ultrasound guidance.
- 3The percutaneous tract is progressively prepared (dilated).
- 4An access sheath is placed, creating a working channel between the skin and the kidney.
- 5A nephroscope is introduced into the collecting system.
- 6The stone is directly visualised.
- 7Stone fragmentation is performed using an appropriate intracorporeal lithotripsy system.
- 8Fragments are removed using suction and/or endoscopic graspers.
- 9Depending on the individual case, drainage with a nephrostomy tube or ureteral stent (JJ) may be required.
When PCNL Is Considered
PCNL has an important role particularly in the following situations:
- Large kidney stones
- Complex stone burden
- Staghorn calculi
- Stones occupying a substantial part of the collecting system
- Selected cases where other techniques are unlikely to achieve effective stone clearance
PCNL is often a first-choice treatment for large kidney stones, particularly when the stone burden exceeds approximately 2 cm or is complex. The final indication is always individualised, after complete clinical and imaging assessment.
RIRS or PCNL?
RIRS
- Access through the natural urinary tract
- Flexible ureteroscope
- No percutaneous renal tract
- Generally suited to selected small-to-moderate stone burdens
- May require staged treatment for larger stone burden
PCNL
- Direct percutaneous renal access
- Nephroscope
- Particularly useful for large or complex stone burden
- Allows direct fragment extraction
- More invasive than RIRS, but may offer more efficient clearance in selected large stones
ECIRS
- Combined retrograde and percutaneous access
- Selected complex cases
- Simultaneous access from two directions
The choice between RIRS, PCNL and ECIRS does not follow rigid rules β it is individualised according to the characteristics of the stone disease and the patient.
ECIRS β Combined Percutaneous & Endoscopic Treatment
ECIRS (Endoscopic Combined IntraRenal Surgery) simultaneously combines percutaneous renal access with flexible, retrograde ureterorenoscopic access, within the same surgical session.
This technique may be considered in selected, more complex stone cases, where combined access facilitates treatment of difficult-to-reach areas of the collecting system.
- Access to the collecting system from two directions
- Facilitates access to difficult calyces
- Management of complex stone distribution
- Potential reduction in the need for additional percutaneous tracts
Preoperative Planning
Planning the appropriate treatment approach is based on comprehensive clinical and laboratory assessment.
History & Clinical Examination
Detailed medical history and clinical examination of the patient.
Urinalysis & Urine Culture
Excluding active urinary infection before the procedure.
Renal Function & Blood Tests
Assessment of renal function and general blood/biochemical work-up.
CT Imaging
Non-contrast (spiral) CT when indicated, for precise characterisation of the stone and anatomy.
Kidney & Bladder Ultrasound
Initial imaging assessment of the kidneys and bladder.
Anatomical Assessment
Evaluation of anatomical features that may influence the choice of technique.
Anticoagulant/Antiplatelet Medication
Assessment and adjustment of medication before the procedure.
Anaesthetic Assessment
Preoperative anaesthetic evaluation for the safe conduct of the procedure.
After Stone Removal
Removing the stone does not always mark the definitive resolution of stone disease. Preventing recurrence relies on further metabolic investigation.
Depending on history and recurrence risk, additional testing and individualised dietary or medical guidance may be recommended.
- Stone composition analysis
- Metabolic evaluation
- Relevant blood testing
- Urinalysis
- 24-hour urine collection in selected high-risk patients
- Preventive dietary and medical recommendations
Alternative Treatment Options
Not every stone requires treatment with RIRS or PCNL. Depending on the clinical situation, treatment options may include observation, medical expulsive therapy where appropriate, extracorporeal shock-wave lithotripsy (ESWL), ureteroscopy, RIRS or PCNL.
ESWL is a non-invasive option for fragmenting stones using shock waves, suitable for selected stone size and location.
Related Conditions & Procedures
Kidney Stones
A complete guide to kidney stones: causes, symptoms, diagnosis and treatment options.
Learn moreUreteral Stones
Treatment of stones located in the ureter.
Learn moreBladder Stones
Treatment of stones inside the urinary bladder.
Learn moreRenal Colic
Recognising and managing acute renal colic.
Learn moreEndoscopic Ureteral Lithotripsy
A detailed overview of endoscopic laser treatment for ureteral stones.
Learn moreUreteral Stent Placement
Information on temporary ureteral (JJ) stent placement.
Learn moreFrequently Asked Questions
What is the difference between RIRS and PCNL?
RIRS is performed through the natural urinary tract with a flexible ureteroscope, without a skin incision, while PCNL requires small percutaneous access to the kidney via a nephroscope. The choice mainly depends on the size and complexity of the stone burden.
Is the procedure painful?
Procedures are performed under anaesthesia. Postoperatively, mild discomfort may occur, managed with standard analgesic medication.
How long is recovery after RIRS or PCNL?
Recovery after RIRS is usually faster, while PCNL may require a slightly longer hospital stay, depending on stone size and the clinical situation.
Is a ureteral (JJ) stent always needed?
Not always. The need for a temporary stent depends on factors such as stone size, ureteral swelling and findings during the procedure.
What is dusting?
Dusting is a technique that fragments the stone into very small particles using Holmium laser, which can pass naturally without always requiring active retrieval.
When is ECIRS considered instead of PCNL or RIRS alone?
ECIRS may be considered in selected, more complex stone cases, where simultaneous access from two directions can facilitate treatment of difficult-to-reach areas of the kidney.
Can stone disease recur after treatment?
Yes, stone disease tends to recur. Metabolic evaluation, stone composition analysis and preventive recommendations help reduce the risk of future episodes.
References
- EAU Guidelines on Urolithiasis, 2024 β uroweb.org
- TΓΌrk C, et al. EAU Guidelines on Interventional Treatment for Urolithiasis. Eur Urol 2016;69:475β482.
- Assimos D, et al. Surgical Management of Stones: AUA/Endourological Society Guideline, PART II. J Urol 2016;196:1161β1169.
- LEFKOS STAVROS β The Athens Clinic, Urology Center β information on available equipment and infrastructure (DORNIER MEDILAS H-140, endoscopes, PCNL/ECIRS equipment).