The lesson I have learned from my first 25 ECIRS cases: Notes of technique by a young urologist during his learning-curve.

ntroduction & Objectives: PCNL learning curve is quite long. The first approach to the technique can be particularly difficult with the increase of indications for RIRS, reserving PCNL for more complex stone cases. On the other hand ECIRS can give more confidence to the operator during his learning curve. We wanted to identify technical aspects that can positively influence the first approach and the learning curve of a young urologist to PCNL. Material & Methods: We retrospectively analyzed the first 25 ECIRS performed by a single young urologist in a high- volume Stone Center where the indications for PCNL were limited to complex and multiple stone cases. We describe the technique that we adopted and progressively refined with the objective to treat complex stones since the learning curve. We considered the capability to gain a correct percutaneous access, to conclude the procedure with satisfying results and to avoid major complications. Results: An ECIRS in Valdivia-Galdakao modified supine position was performed and a single percutaneous access at the inferior posterior calyx was gained in all cases. Percutaneous puncture was performed under direct endoscopic view, radioscopic guidance and US assistance targeting the centre of the papilla. Progressive or balloon dilation was performed. A 17 Fr nephroscope through a 24 Fr Amplatz sheath was used with fluid irrigation at human body temperature and ultrasound and/or pneumatic lithotripsy. Fragments were evacuated by simple irrigation fluid outflow and residuals removed with basket. A final inspection of all calyxes was done with a flexible cystoscope through the Amplatz sheath and with the flexible ureteroscope. Further Olmium laser lithotripsy and fragments removal with basket were performed when needed. A double J ureteral stent and a nephrostomy catheter 12 Fr with distal pig-tail in the renal pelvis were eventually placed and an antegrade pielography performed. In all cases the intervention was concluded in a satisfactory manner without need for surgical conversion and further percutaneous procedures. The nephrostomy was clamped in I-II post-operative day and removed the day after. We had 3 major complications: 1 arteriovenous fistula and 2 septic shock. They all occurred in the first 15 cases of the series and they were successfully treated by selective arterial embolization and by amine support and specific prolonged antibiotic therapy. Conclusions: The standardized ECIRS technique that we reproduced and synthesized in this paper enabled us to treat complex stones also during the beginning of the learning curve, gain a correct access to the collecting system and conclude the procedure with satisfying results in all cases. The refinement of the technique allowed us to reduce peri-operative complications.