The Era of ECIRS: Prone Still Matters!

Deok-Hyun HanKorea (Republic of) Speaker The Era of ECIRS: Prone Still Matters!Endoscopic combined intrarenal surgery (ECIRS) couples antegrade and retrograde endoscopy to raise stone-free rates while limiting morbidity. Although the Galdakao-modified supine position is widely used, surgeons experienced with prone percutaneous nephrolithotomy (PCNL) can realize distinct advantages when ECIRS is performed in the prone split-leg position. This lecture reviews practical operating-room setup and positioning—including feasible workarounds when a split-leg positioner is unavailable—monitor layout, and puncture trajectory planning. It details endoscope-guided puncture and coordinated intrarenal navigation, and highlights scenarios where prone ECIRS is particularly advantageous: posterior and upper-pole access, narrow calyces, complex collecting-system anatomy, and situations requiring stable distension and visualization. We discuss how prone positioning can improve irrigation dynamics, enable a “vacuum-cleaner” effect for fragment clearance, reduce thermal injury risk, and limit retrograde fragment migration—often without a ureteral access sheath. Strategies for comprehensive residual-fragment assessment and efficient D-J stent placement are outlined, along with trade-offs (airway considerations, workspace and monitor configuration, and the brief learning curve for retrograde orientation). In sum, prone ECIRS is a feasible, reproducible extension of prone PCNL that offers a natural transition path for prone PCNL surgeons and may improve stone-free outcomes in selected patients. Further prospective data and standardized workflows will refine its role.