My Clinical Experience with Laser RIRS
RIRS with laser lithotripsy is today the cornerstone of minimally invasive management for kidney stones 1–2 cm. The absence of any incision, rapid recovery, and high stone-free rate make it an outstanding choice for patients who want to return quickly to their daily activities.
- EAU 2024 first choice for kidney stones 1–2 cm.
- No incision — ureteronephroscope passed through the urethra.
- Stone-free rate 80–90% for stones 1–2 cm.
- Hospitalization 0–1 day — return to activities in 1–3 days.
What is Laser Kidney Stone Lithotripsy (RIRS)?
RIRS (Retrograde IntraRenal Surgery) uses a flexible ureteronephroscope (fURS) passed retrogradely through the urethra → bladder → ureter → renal pelvis → calyceal system, without any external incision. Through the working channel, a thin laser fiber fragments the stone.
Flexible Ureteronephroscope
Diameter ~7–9 Fr, fully deflectable for access to all calyceal compartments, including the lower pole.
Holmium:YAG vs Thulium Fiber Laser
Ho:YAG: classic, reliable for all stone types. TFL: newer, superior dusting efficiency, less scope damage, ideal for hard stones.
Dusting vs Fragmentation
Dusting: fragmentation into powder <0.5 mm → spontaneous passage. Fragmentation: 2–4 mm pieces → basket extraction. Technique chosen based on stone characteristics.
Indications & Stone Selection
Kidney Stones 1–2 cm
EAU 2024: first choice. Stone-free 80–90% in a single session. Comparable to mini-PCNL for 1–2 cm depending on stone hardness, anatomy, and center experience.
Stones <1 cm (alternative to ESWL)
Both methods appropriate. RIRS: higher stone-free rate, single session. ESWL: non-invasive but multiple sessions required.
Lower Calyx Stones
Ideally suited for RIRS — the fURS reaches the lower calyx directly, where ESWL has low efficacy due to gravitational drainage difficulties.
ESWL Failure or Contraindication
Stones that failed ESWL, or ESWL contraindications (pregnancy, pacemaker, anticoagulation): RIRS is an excellent alternative.
RIRS vs PCNL: For stones >2 cm or hard staghorn/branched calculi, PCNL is superior (stone-free 85–95% vs 60–75% for RIRS with those stones).
Preoperative Assessment
Low-Dose CT (Urolithiasis Protocol)
Mapping of stone size, location, and density (Hounsfield Units). Stones >1200 HU: increased laser time — consider mini-PCNL.
Urine Culture
Rule out active infection — active UTI is a contraindication for RIRS. Treat first.
Ureteral Assessment
Pre-stenting with a DJ stent 1–2 weeks before RIRS: improves passive ureteral dilation for easier access. Not always required.
How RIRS Works
Anesthesia & Cystoscopy
General or spinal anesthesia. Initial cystoscopy to identify the ureteral orifice and place a ureteral access sheath (UAS) to facilitate ureteronephroscope insertion.
Retrograde Access to the Kidney
Flexible ureteronephroscope advanced through the ureter into the renal pelvis. All calyceal compartments are inspected to locate the stone.
Laser Lithotripsy
A thin laser fiber (200–550 μm) is introduced through the working channel. Stone fragmented with Holmium:YAG or TFL. Dusting or fragmentation technique selected based on stone.
Fragment Removal & DJ Stent
Fragments removed with mini-baskets or passed spontaneously (dusting). A double-J stent is placed. The stent is removed 1–2 weeks post-operatively in the office.
Anesthesia & Hospitalization
Recovery & Follow-up
At Home
Mild hematuria and discomfort from the DJ stent (frequency, urgency): normal. Pain medication, hydration >2 L/day.
Stent Removal
Outpatient at 1–2 weeks: cystoscopy or string removal. Procedure <5 minutes, no anesthesia.
Stone-Free Check
Low-dose CT or ultrasound + X-ray 4–6 weeks after surgery. If residual stone remains: repeat RIRS or change strategy.
Metabolic Evaluation
Stone analysis + 24-hour urine for recurrence prevention. Dietary counseling (hydration, dietary calcium, oxalate restriction).
RIRS vs ESWL & PCNL
RIRS vs ESWL (for 1–2 cm)
Stone-free: RIRS 80–90% vs ESWL 50–70% for 1–2 cm. RIRS: single session, higher stone-free rate, but requires anesthesia. ESWL: non-invasive but multiple sessions, lower stone-free rate.
RIRS vs PCNL (for 1–2 cm)
For 1–2 cm: equivalent outcomes for RIRS vs mini-PCNL. RIRS: no incision, faster recovery. PCNL: superior for >2 cm, hard, staghorn stones.
Unique Advantage of RIRS
Direct access to the lower pole calyx without any incision — a location where ESWL has poor results and PCNL requires an additional puncture.
Possible Complications
Infection / Urosepsis (1–3%)
SeriousRisk in patients with infected stones (struvite). Prevention: sterile urine confirmed pre-op + antibiotic prophylaxis.
Ureteral Injury (<1%)
RareStricture or perforation: rare with ureteral access sheath. Managed with prolonged DJ stent placement.
Residual Stones (5–20%)
ExpectedFragments <4 mm: pass spontaneously. Larger pieces: repeat RIRS or ESWL.
DJ Stent Discomfort
CommonUrinary frequency, urgency, mild hematuria: normal during stent indwelling period. Transient — resolves after stent removal.
Frequently Asked Questions
What is laser kidney stone lithotripsy (RIRS)?
RIRS (Retrograde IntraRenal Surgery) is retrograde endoscopic surgery inside the kidney. A flexible ureteronephroscope (fURS) is passed retrogradely through the urethra — without any incision — up to the kidney. The stone is fragmented with a Holmium:YAG or Thulium Fiber Laser (TFL) and either removed with a basket or allowed to pass naturally.
What is the difference between Holmium:YAG and Thulium Fiber Laser (TFL)?
Holmium:YAG (Ho:YAG): the classic laser, reliable, available worldwide, 2090 nm wavelength. TFL (Thulium Fiber Laser): newer technology (1940 nm), twice the water absorption, higher dusting efficiency, less risk of scope damage. TFL is superior for dusting technique on hard stones.
Which stones are best treated with RIRS?
EAU 2024: RIRS is the first-choice treatment for kidney stones 1–2 cm. Also an alternative for stones <1 cm (vs ESWL). Excellent for soft to medium-hard stones. For hard stones (brushite, cystine, calcium oxalate monohydrate) with HU >1200: PCNL is more effective. For >2 cm: PCNL remains first choice.
Does RIRS require hospitalization?
RIRS is performed as an outpatient procedure or with 1-night admission. General or spinal anesthesia is used. Recovery is rapid — return to office work in 1–3 days.
Is a DJ stent needed after RIRS?
Yes — a double-J (DJ) stent is typically placed at the end of the procedure for 1–2 weeks. The stent prevents obstruction from ureteral edema and facilitates fragment passage. Stent removal: outpatient, 5–10 minutes, without anesthesia.
What is the dusting technique in laser lithotripsy?
Dusting: fragmentation of the stone into very fine powder (<0.5 mm) that passes spontaneously without forceps removal. Ideal for larger stones — reduces operative time. Fragmentation/basketing: fragmentation into 2–4 mm pieces and removal with a stone basket. The surgeon selects the technique based on the stone.
What is the stone-free rate of RIRS?
For stones 1–2 cm: stone-free rate 80–90% after one session. For stones <1 cm: 85–95%. For >2 cm: 60–75% — lower than PCNL (85–95%). Hard stones >1200 HU: lower rate with RIRS.
What is a SURS (Single-Use Flexible URS) and what are its advantages?
A single-use flexible ureteroscope: used once per patient. It eliminates the risk of cross-contamination, is always in perfect condition, and carries no repair or sterilization costs. In many centers it has replaced reusable scopes for safety and cost reasons.
Related Topics
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Bibliography & References
- EAU Guidelines on Urolithiasis 2024 — uroweb.org
- Traxer O, Thomas A. Prospective Evaluation and Classification of Ureteral Wall Injuries Resulting From Insertion of a Ureteral Access Sheath. J Urol 2013;189:580–584.
- Sarica K, et al. Thulium Fiber Laser in Urological Practice. Eur Urol 2021;79:723–729.
- Turk C, et al. EAU Guidelines on Urolithiasis. Eur Urol 2016;69:475–482.
Medical Author
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas performs RIRS (flexible URS + Holmium:YAG/TFL laser) for kidney stones 1–2 cm, individualizing technique (dusting vs fragmentation) based on stone characteristics.
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