ERAS 2025: Perioperative Management in PCNL/ECIRS
Perioperative Management in ECIRS and PCNL: Tailoring Technique to the Patient
Endourological management of large renal stones continues to evolve, with percutaneous nephrolithotomy (PCNL) and endoscopic combined intrarenal surgery (ECIRS) established as the mainstays for stones ≥2 cm, or ≥1 cm in the lower pole with unfavorable factors for ESWL, as outlined by EAU and AUA guidelines. While both techniques are effective, ECIRS offers the unique advantage of simultaneous retrograde access, providing stepwise intraoperative control, improved stone-free rates, reduced operative times, and fewer tracts—translating into a lower risk of bleeding.
The safety of these approaches hinges on meticulous perioperative management. Multiple tracts significantly increase hemorrhage risk, particularly beyond the second puncture. ECIRS enhances precision, allowing real-time identification of the optimal papilla and trans-papillary puncture, thereby reducing vascular injury. Nonetheless, the retrograde component introduces risks, particularly ureteral trauma and subsequent stricture, especially if access sheaths are used improperly. Careful handling and avoidance of unnecessary sheaths can mitigate this complication.
Personalizing PCNL/ECIRS extends to tract size and patient positioning. Downsizing (mini, ultra-mini, or micro tracts) reduces bleeding, renal trauma, postoperative pain, and length of stay, while upsizing improves irrigation, visualization, fragment clearance, and procedural efficiency. Similarly, positioning—prone versus modified supine—should be individualized. Supine facilitates anesthesia and patient safety, while prone offers superior visualization and stability but increases radiation exposure to the surgeon. Adjunctive techniques such as the “kebab wire” can compensate for the kidney mobility encountered in supine cases.
Ultimately, ECIRS and PCNL exemplify precision endourology: success depends not on rigid adherence to one technique but on tailoring access, tract size, and position to the patient and stone burden. Integrating these perioperative considerations into standardized protocols ensures optimized outcomes while minimizing complications, advancing the balance between efficacy and safety in complex stone surgery.
Presented by: Eugenia Vercelli, University of Turin, Turin, Italy
Written by: Stephen B. Williams, MD, MBA, MS, FACS, FACHE @SWilliams_MD on Twitter during the 11th Enhanced Recovery After Surgery (ERAS®) World Congress, September 17-19, 2025, Turin, Italy