Complex staghorn calculus – an enhanced Endoscopic Combined Intra-Renal Surgery (ECIRS) approach using mini-PCNL and suction sheaths

To demonstrate the utility of 3D Modelling to help guide Percutaneous Nephrolithotomy (PCNL) puncture in a complex case of staghorn calculi with a limited window for safe access. Additionally, we demonstrate the efficacy of Endoscopic Combined Intra-Renal Surgery (ECIRS) with use of suction ureteric access sheath and nephrostomy, to perform efficient and total clearance of a complete staghorn calculi. Following detailed discussion and obtainment of informed consent, a complete staghorn calculus was treated with ECIRS. Owing to overlying anatomy including lung, bowel and spleen, the window for safe puncture was miniscule. Using 3D-modelling constructed with non-contrast CT scans, a safe window and calyx was identified and correlated with intra-operative fluoroscopy. A suction ureteric access sheath (ClearPetra, Guangzhou, China) was inserted prior to prone positioning. Following puncture, a mini-PCNL suction nephrostomy tube (ClearPetra, Guangzhou, China) was inserted to facilitate laser lithotripsy. After stone clearance, an indwelling catheter and ureteric stent was left-in-situ, without need for nephrostomy tube. This study demonstrates the principal surgical steps involved with performing endourological treatment of a complex, complete Staghorn Calculi. Steps include pre-operative planning with 3D-modelling, intra-operative puncture under fluoroscopic and direct vision with use of pyeloscopy (ECIRS), use of ureteric access sheath for prevention of ureteric assessment and prevention stone migration, laser lithotripsy via mini-PCNL, and post-operative follow-up. CT imaging on post-operative day 1 confirmed complete stone clearance. Post-operatively the patient was monitored for 2 days with no complications, and catheter was removed prior to discharge. For complex endourological cases, thorough pre-operative planning is vital to ensure good operative outcomes. This case demonstrates the use of 3D-modelling to plan accurate and safe puncture trajectory within a limited window of safety. Additionally, ECIRS with suction sheaths is utilised to effectively and efficiently clear large stone burden.