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 2026 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.
High-Power Holmium:YAG Laser
A high-power Holmium:YAG laser is available at Lefkos Stavros. Its energy is delivered through a thin optical fibre that passes through the flexible ureteroscope.
Dusting vs Fragmentation
Dusting: fragmentation into fine powder <0.5 mm that passes spontaneously. Fragmentation: pieces of 2–4 mm removed with baskets. Technique choice depends on the stone and the scope.
High-Power Holmium Laser in Laser Kidney Stone Lithotripsy
A high-power Holmium:YAG laser is available at Lefkos Stavros for endourological lithotripsy. During RIRS, laser energy is delivered through a thin fibre that passes through the flexible ureteroscope and is applied directly to the stone under endoscopic vision. Depending on the stone and surgical strategy, it may be used for fragmentation into small pieces or for dusting techniques.
What «High-Power» Means
The term «high-power» describes the laser platform’s capacity to support a wide range of energy settings and lithotripsy techniques.
The device’s nominal power is not the same as the energy continuously applied to the stone. Parameters are adjusted by the surgeon depending on the stone, anatomy, and surgical strategy.
Dusting and Fragmentation With Holmium
Dusting
The stone is fragmented into very small particles, so that much of it can pass spontaneously or be removed more easily.
Fragmentation
The stone is divided into larger controlled fragments, which can be removed with a basket when appropriate.
Neither technique is presented as universally superior — the choice depends on stone burden, hardness, location, anatomy, visibility, and surgical strategy.
The high-power Holmium laser is an advanced lithotripsy tool, but the outcome does not depend on laser power alone. Stone clearance also depends on:
- •Total stone burden
- •Number of stones
- •Their location
- •The anatomy of the collecting system
- •Stone hardness / composition
- •Ureteral access
- •Operative time
- •Infection risk
- •The need for staged treatment
High-Power Holmium or Thulium Fiber Laser (TFL)
Holmium:YAG is an established laser technology in endourology and lithotripsy. Thulium Fiber Laser (TFL) is a different laser technology, with different physical characteristics. At Lefkos Stavros, the confirmed available system is the high-power Holmium:YAG laser.
Differentiation From PCNL
Laser Kidney Stone Lithotripsy (RIRS) uses a high-power Holmium:YAG laser through a flexible ureteroscope, for intracorporeal laser lithotripsy. In PCNL, where indicated, the Swiss LithoClast® Trilogy may be used through percutaneous access, combining ultrasonic and ballistic energy with suction. These are not the same technology.
PCNL with Swiss LithoClast® Trilogy for larger or complex stone burden
Indications & Stone Selection
Kidney Stones 1–2 cm
EAU 2026: 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 with Swiss LithoClast® Trilogy for larger or complex stone burden 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. The stone is fragmented with the high-power Holmium:YAG laser. Dusting or fragmentation technique selected based on the 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 the high-power Holmium:YAG laser available at Lefkos Stavros and either removed with a basket or allowed to pass naturally.
What is the High-Power Holmium Laser?
It is a modern Holmium:YAG laser platform that supports a wide range of energy settings and endourological lithotripsy techniques. A high-power Holmium:YAG laser is available at Lefkos Stavros for use in RIRS and other endoscopic lithotripsy procedures.
Does a stronger laser fragment every stone better?
No. The nominal power of the device is not the same as the energy continuously applied to the stone. Stone composition, surgical strategy, anatomy, and ureteral access all matter.
High-Power Holmium or Thulium Fiber Laser (TFL)?
Holmium:YAG is an established, widely used laser technology in lithotripsy. Thulium Fiber Laser (TFL) is a different technology, with different physical characteristics. Neither technology is universally superior for every stone — at Lefkos Stavros, the confirmed available system is the high-power Holmium:YAG laser.
Does High-Power Laser mean all stones are treated in one session?
No. Large or multiple stone burdens may still require a staged RIRS or a PCNL strategy. High-power Holmium laser is a powerful tool, but it does not guarantee a stone-free outcome in a single session for every patient.
Which stones are best treated with RIRS?
EAU 2026: 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 2026 — 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 + high-power Holmium:YAG laser) for kidney stones 1–2 cm, individualizing technique (dusting vs fragmentation) based on stone characteristics.
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