Kidney stones form when minerals in the urine crystallize and harden into stone-like deposits within the kidney. Their size can range from less than 4 mm to more than 2 cm, and depending on their location, they may obstruct urine flow in areas such as the renal pelvis, calyces, or ureter. Common symptoms include flank pain, hematuria, and vomiting, although some stones are discovered incidentally without any symptoms. Small stones may pass naturally with increased hydration, but larger or irregularly shaped stones often require active surgical treatment.
Large or complex kidney stones—especially those greater than 2 cm or located in the lower calyx—are difficult to treat with extracorporeal shock wave lithotripsy (ESWL) or single endoscopic procedures alone. Traditionally, these patients have required surgery under general anesthesia at tertiary hospitals. However, not all patients are suitable candidates for general anesthesia. For this reason, our institution has been performing advanced stone surgery using ECIRS (Endoscopic Combined Intrarenal Surgery) under spinal anesthesia.
From May to November of last year, we performed the first 10 cases of ECIRS under spinal anesthesia and analyzed the outcomes. These results were presented at the annual meeting of the Korean Society of Endourology and Robotics this year. ECIRS combines percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) simultaneously, allowing for effective removal of large and complex stones.
The study included 10 patients (8 men and 2 women) with a mean age of 49 years (range, 28–67). The average stone size was 26 mm, with the largest measuring 46 mm. Six patients had a prior history of urinary stones, and five had previously undergone ESWL. Some patients had a functionally single kidney, and several cases involved recurrent stones that were particularly challenging to treat.
All procedures were performed under spinal anesthesia, and five patients additionally received sedation at their request. No cases required conversion to general anesthesia or intraoperative termination. A temporary decrease in hemoglobin levels was observed immediately after surgery and on the following day, but most patients recovered within one week. Importantly, there were no cases requiring blood transfusion or resulting in urinary tract infection.
Several cases were particularly noteworthy. A 67-year-old male with a functionally single kidney had an anteriorly rotated lower calyx, making endoscopic access difficult. Despite this, complete stone removal was successfully achieved using ECIRS. Another case involved a 28-year-old female who had experienced repeated recurrences despite undergoing 14 sessions of ESWL and two ureteroscopic surgeries. She preferred to avoid general anesthesia and underwent ECIRS under spinal anesthesia, recovering without complications.
These findings demonstrate that with appropriate patient selection and thorough preoperative planning, advanced kidney stone surgery can be performed safely even in a primary care setting. Performing ECIRS under spinal anesthesia offers a meaningful alternative for patients who are not suitable for general anesthesia or who have difficulty accessing large tertiary hospitals.
Kidney stone treatment continues to evolve, and approaches such as ECIRS expand the available options for managing complex cases more safely and effectively.