title: ECIRS (Endoscopic Combined Intrarenal Surgery) in the Galdakao-modified supine Valdivia position: a new life for percutaneous surgery?
abstract: BACKGROUND
  Percutaneous nephrolithotomy (PNL) is still the gold-standard treatment for large and/or complex renal stones. Evolution in the endoscopic instrumentation and innovation in the surgical skills improved its success rate and reduced perioperative morbidity. ECIRS (Endoscopic Combined IntraRenal Surgery) is a new way of affording PNL in a modified supine position, approaching antero-retrogradely to the renal cavities, and exploiting the full array of endourologic equipment. ECIRS summarizes the main issues recently debated about PNL.
  
  
  METHODS
  The recent literature regarding supine PNL and ECIRS has been reviewed, namely about patient positioning, synergy between operators, procedures, instrumentation, accessories and diagnostic tools, step-by-step standardization along with versatility of the surgical sequence, minimization of radiation exposure, broadening to particular and/or complex patients, limitation of post-operative renal damage.
  
  
  RESULTS
  Supine PNL and ECIRS are not superior to prone PNL in terms of urological results, but guarantee undeniable anesthesiological and management advantages for both patient and operators. In particular, ECIRS requires from the surgeon a permanent mental attitude to synergy, standardized surgical steps, versatility and adherence to the ongoing clinical requirements. ECIRS can be performed also in particular cases, irrespective to age or body habitus. The use of flexible endoscopes during ECIRS contributes to minimizing radiation exposure, hemorrhagic risk and post-PNL renal damage.
  
  
  CONCLUSIONS
  ECIRS may be considered an evolution of the PNL procedure. Its proposal has the merit of having triggered the critical analysis of the various PNL steps and of patient positioning, and of having transformed the old static PNL into an updated approach.
authors: Department of Urology, Cottolengo Hospital, Via Cottolengo 9, 10152, Turin, Italy.
authors: Cecilia Maria
authors: CM
authors: Cracco
authors: Cesare Marco
authors: CM
authors: Scoffone
mesh_terms: D004724:Endoscopy / Q000295:instrumentation / Q000379:methods / Q000639:trends*; D006801:Humans; D007668:Kidney / Q000601:surgery; D007669:Kidney Calculi / Q000601:surgery*; D009403:Nephrostomy, Percutaneous / Q000295:instrumentation / Q000379:methods / Q000639:trends*; D056888:Patient Positioning; D011187:Posture; D016683:Supine Position