Renal calculi measuring ≥20 mm have traditionally been managed with percutaneous approaches. However, with advancements in endourology, Retrograde Intrarenal Surgery has emerged as a minimally invasive and effective alternative in selected cases. We present the case of a 28-year-old female diagnosed with a 20 mm right renal stone, successfully treated using RIRS with laser lithotripsy. The procedure was performed under the expert care of Dr. M. Roychowdhury and Dr. Rajan Bansal. The patient had an uneventful recovery with excellent clinical outcome. This case highlights the expanding role of RIRS in managing larger renal stones and underscores the importance of expertise and advanced technology in achieving optimal results.
Introduction
Kidney stone disease continues to be a significant global health concern, particularly among young adults. Traditionally, renal stones larger than 15–20 mm were managed with percutaneous nephrolithotomy (PCNL). However, recent advancements in flexible ureteroscopy and laser technology have enabled the use of Retrograde Intrarenal Surgery even for larger stones in selected patients.
RIRS offers a minimally invasive, incision-free approach, making it increasingly popular due to reduced morbidity, shorter hospital stay, and quicker recovery.
Case Presentation
A 28-year-old female presented with complaints of intermittent right flank pain for several weeks. The pain was colicky in nature, occasionally radiating towards the groin, and associated with mild discomfort during urination. There was no history of fever, hematuria, or previous surgical intervention.
The patient had no known comorbidities and no history of drug allergies.
Investigations
A detailed evaluation was carried out:
- Ultrasound KUB: Revealed a large calculus in the right kidney
- Non-contrast CT (NCCT KUB): Confirmed a 20 mm right renal stone, located within the renal pelvis extending into calyceal system
- Serum Creatinine: Within normal limits
- Urine Routine Examination: No active infection
- Pre-anesthetic evaluation: Fit for surgery
These findings confirmed the diagnosis and suitability for minimally invasive intervention.
Diagnosis
- Right renal calculus (20 mm)
Treatment Planning
Considering:
- Patient’s young age
- Stone size and location
- Patient preference for minimally invasive treatment
A decision was made to proceed with Retrograde Intrarenal Surgery with laser lithotripsy.
The patient was counselled regarding:
- Procedure details
- Possible need for staged treatment
- Role of DJ stenting
- Expected outcomes
Surgical Procedure
The procedure was performed under general anesthesia by Dr. M. Roychowdhury and Dr. Rajan Bansal.
Steps of Procedure:
- Cystoscopy performed; urethra and bladder were normal
- Ureteral access sheath placed
- Flexible ureteroscope advanced into the right kidney
- Visualization of a large renal pelvic stone extending into calyces
- Laser lithotripsy performed using holmium laser
- Stone fragmented using dusting technique into fine particles
- Adequate clearance achieved
- DJ stent placed for postoperative drainage
Intraoperative Findings
- Single large stone (~20 mm) in renal pelvis with calyceal extension
- No anatomical abnormalities
- Complete fragmentation achieved
Postoperative Course
The patient tolerated the procedure well.
- No intraoperative or postoperative complications
- Minimal pain postoperatively
- Early mobilization
- Discharged in stable condition
Follow-up was planned for:
- Stent removal
- Imaging to confirm stone clearance
Discussion
Kidney Stones in Young Patients
Stone disease in young individuals requires:
- Effective treatment
- Minimal morbidity
- Preservation of renal function
RIRS: Expanding Indications
Traditionally, stones ≥20 mm were treated with PCNL. However, advancements in technology have expanded the indications of RIRS.
Advantages of RIRS
- No incision
- Minimal bleeding
- Lower complication rates
- Short hospital stay
- Faster recovery
- Suitable for high-risk patients
RIRS vs PCNL
| Feature | RIRS | PCNL |
|---|---|---|
| Invasiveness | Minimally invasive | More invasive |
| Hospital stay | Short | Longer |
| Recovery | Faster | Moderate |
| Bleeding risk | Minimal | Higher |
👉 In selected cases, RIRS provides comparable outcomes with better patient comfort.
Role of Laser Technology
Holmium laser lithotripsy allows:
- Precise fragmentation
- Dusting technique
- Minimal trauma
This has significantly improved:
👉 Success rates of RIRS
Clinical Significance of This Case
This case demonstrates:
- Feasibility of RIRS in 20 mm stone
- Excellent outcomes with experienced surgeons
- Importance of patient selection
Postoperative Considerations
- DJ stent placement helps prevent obstruction
- Follow-up ensures complete clearance
- Lifestyle modification reduces recurrence
Conclusion
This case highlights the successful use of Retrograde Intrarenal Surgery in managing a 20 mm renal stone in a young female patient.
With advancements in endourology, RIRS has emerged as a safe, effective, and patient-friendly alternative for selected larger stones.
👉 The key to success lies in:
- Proper patient selection
- Advanced technology
- Surgical expertise
Expertise at the Institute of Urology, Jaipur
Complex stone disease requires not just technology, but experience and precision.
At the Institute of Urology, Jaipur, patients receive world-class care through:
- Advanced endourology systems
- High-definition flexible ureteroscopy
- State-of-the-art laser technology
Under the expert guidance of Dr. M. Roychowdhury and Dr. Rajan Bansal, even challenging cases are managed with exceptional outcomes.
The institute is recognized as one of the most advanced single-specialty urology centers in Jaipur, Rajasthan, offering:
- Comprehensive consultation
- Advanced diagnostics
- Minimally invasive surgeries
- Complete patient care under one roof
Their unmatched expertise and patient-centric approach ensure the highest standards of treatment in all urological conditions.
