Advanced Urology Procedures: Laser Technology & Minimally Invasive Care

What is RIRS surgery for kidney stones?

Retrograde Intrarenal Surgery (RIRS) is a state-of-the-art, incision-free procedure for treating kidney stones located within the kidney itself. Using a flexible digital ureteroscope — a thin, steerable camera thinner than a pencil — the surgeon navigates through the natural urinary passage (urethra → bladder → ureter → kidney) to reach the stone directly, without making a single cut in the body. A laser fibre is then passed through the scope to pulverise the stone into fine dust that passes naturally in urine.

RIRS has become the procedure of choice for stones up to 2 cm in Mumbai's leading urology centres. Dr. Anand Utture performs RIRS using the latest single-use digital flexible ureteroscopes paired with holmium or thulium fibre laser systems — delivering higher stone-free rates with a complication profile that approaches zero.

How RIRS is performed — step by step

1. Pre-operative evaluation

   A CT urogram maps the stone's exact size, location, and density. Urine culture rules out infection. Blood tests assess kidney function. A ureteral stent is sometimes placed 1–2 weeks prior to dilate the ureter for easier scope passage.

2. Anaesthesia and positioning

   The procedure is performed under general or spinal anaesthesia. The patient lies in the lithotomy position (on their back, legs elevated) — the same as for routine cystoscopy.

3. Scope navigation to the kidney

   The flexible ureteroscope is passed through the urethra, into the bladder, up the ureter, and into the renal pelvis. Real-time fluoroscopic guidance confirms position. The entire navigation takes under five minutes in experienced hands.

4. Laser lithotripsy

   A 200–272 micron holmium or thulium fibre laser is deployed through the working channel. Laser pulses fragment the stone into dust particles smaller than 1 mm (the "dusting" technique), which pass spontaneously in urine over the following days.

5. Ureteral stent placement

   A temporary double-J stent is placed at the end of the procedure to ensure unobstructed urine drainage while post-operative swelling settles. It is removed under local anaesthesia in the clinic after 1–2 weeks.

6. Discharge and recovery

   Most patients go home the same evening with oral painkillers and an alpha-blocker to ease stent discomfort. A follow-up ultrasound or X-ray at 4 weeks confirms stone-free status.

PCNL surgery: procedure, benefits & recovery

Percutaneous Nephrolithotomy (PCNL) is the gold standard for treating large kidney stones (above 2 cm), staghorn calculi (stones that occupy multiple branches of the kidney's collecting system), and complex stones that cannot be managed with RIRS or ESWL. Despite involving a small incision, modern PCNL — particularly Mini-PCNL (mPCNL) and Ultra-mini PCNL — has become a highly refined, low-complication procedure with excellent stone-clearance rates.

What to expect: before, during, and after PCNL

1. Pre-operative workup

   CT urogram defines stone burden, anatomy, and access planning. Urine must be sterile (culture-negative) before surgery. Blood group, cross-match, coagulation screen, and renal function are assessed. Anticoagulants are paused according to standard protocols.

2. Prone positioning and access

   Under general anaesthesia, the patient lies face down (prone). A ureteral catheter is passed to opacify the collecting system. Using fluoroscopic and/or ultrasound guidance, a needle is advanced through the back skin into the kidney under real-time imaging — a step that demands considerable experience to minimise risk.

3. Tract dilation and sheath placement

   The needle track is progressively dilated over a guidewire to accept the working sheath (14–30 Fr depending on technique). The nephroscope is then passed through this sheath directly into the kidney.

4. Stone fragmentation and extraction

   Using an ultrasonic, pneumatic, or laser lithotripter, stones are broken into fragments under direct vision. Larger fragments are grasped and removed; smaller pieces are washed out. The entire collecting system is inspected to confirm clearance.

5. Nephrostomy tube placement

   A small nephrostomy drainage tube may be left through the access tract overnight to drain residual debris and allow post-operative imaging. In selected cases ("tubeless PCNL"), no tube is placed, reducing discomfort and allowing same-day discharge.

6. Post-operative imaging and discharge

   A plain X-ray or CT the following morning confirms stone clearance. The nephrostomy tube, if placed, is removed before discharge. Most patients are home within 24–48 hours and return to work within one week.

Laser surgery for enlarged prostate explained

For men whose benign prostatic hyperplasia (BPH) does not respond adequately to medication, laser prostate surgery has become the preferred surgical option at leading urology centres worldwide — including Dr. Utture's practice in Mumbai. Laser procedures offer the efficacy of open prostatectomy with a fraction of the blood loss, a shorter hospital stay, and a faster return to daily activity.

Three laser techniques are in clinical use. The choice between them depends on prostate size, surgeon expertise, and patient factors:

Key advantages of laser prostate surgery over conventional TURP

• Safe on anticoagulants — The laser seals blood vessels as it cuts. Patients on warfarin, aspirin, or newer anticoagulants (rivaroxaban, apixaban) can undergo HoLEP without stopping their blood-thinning medication — a critical advantage for elderly men with cardiac conditions.
• No size limit — HoLEP and ThuLEP can treat prostates of 30 mL to over 300 mL with equal safety and efficacy. Standard TURP is limited to approximately 80 mL before operative risk increases significantly.
• Catheter removal within 24 hours — Most patients have their urinary catheter removed the morning after surgery and are discharged that day, compared to 3–5 days for conventional TURP.
• Extremely low retreatment rate — Because the entire obstructing tissue is removed (enucleation rather than partial resection), the risk of symptom recurrence is under 2% at 10 years — the lowest of any BPH surgical technique.
• Tissue available for cancer detection — Unlike vaporisation techniques, HoLEP retrieves all removed tissue for pathological examination, allowing incidental prostate cancer to be detected in approximately 5–8% of cases.
• No TUR syndrome risk — Conventional TURP uses hypotonic irrigating fluid that can cause dangerous electrolyte disturbance (TUR syndrome) in long cases. Laser enucleation uses saline, completely eliminating this risk.

Flexible ureteroscopy: what patients should know

Flexible ureteroscopy (fURS) is the foundational technology that makes RIRS and many other minimally invasive urological procedures possible. A flexible ureteroscope is a thin (2.5–3.3 mm diameter), steerable fibre-optic or digital camera that can navigate the entire urinary tract — from the urethra all the way to every corner of the kidney — without any incision. Understanding how this technology works helps patients appreciate what makes modern urology so transformative.

Clinical applications of flexible ureteroscopy

Benefits of minimally invasive urology procedures

The shift from open surgery to minimally invasive endourology over the past two decades represents one of the most significant advances in surgical medicine. For patients, the difference is transformative — what once required a week-long hospitalisation and months of recovery can now be achieved through a natural body passage or a 5 mm incision, with a return to work measured in days. Here is what the evidence and clinical experience consistently show:

Open surgery vs minimally invasive urology: at a glance