Staghorn calculi are large, branching stones that occupy the renal pelvis and extend into multiple calyces, often forming a configuration resembling a stag’s antlers. These stones are commonly composed of struvite (magnesium ammonium phosphate) and are typically associated with recurrent urinary tract infections (UTIs), especially those caused by urease-producing organisms like Proteus mirabilis. If left untreated, staghorn calculi can lead to chronic kidney disease, renal failure, sepsis, and even mortality. Historically, open surgery such as nephrolithotomy was the mainstay of treatment for large renal stones. Over the past few decades, there has been a paradigm shift toward minimally invasive techniques. Percutaneous nephrolithotomy (PCNL) has become the standard of care for managing staghorn calculi due to its high stone-free rates and reduced morbidity compared to open procedures. However, in patients with prior renal surgery, altered anatomy, or particularly complex stone burdens, PCNL may be less effective or associated with greater complication rates. Endoscopic combined intrarenal surgery (ECIRS) is an innovative technique that merges the advantages of both percutaneous nephroscopy and flexible ureteroscopy. By combining antegrade and retrograde approaches, ECIRS enhances intrarenal access, improves visualization, and increases the likelihood of complete stone clearance in a single session. This is particularly valuable in patients with a history of prior renal interventions, where scarring and anatomical distortion may limit the efficacy of traditional approaches. This case report describes the use of ECIRS in a 71-year-old male with a history of nephrolithotomy and extracorporeal shock wave lithotripsy (ESWL), who presented with recurrent staghorn calculi. The case underscores the safety, feasibility, and efficacy of ECIRS in complex, recurrent nephrolithiasis.

Patient History and Clinical Evaluation A 71-year-old male presented with intermittent left flank discomfort of several weeks’ duration. He had no fever, dysuria, or gross hematuria. His medical history was significant for nephrolithiasis, with previous treatments including a left open nephrolithotomy in 1989 and ESWL in 2004. He had no significant comorbidities or contraindications to surgical intervention. On physical examination, the patient was afebrile, hemodynamically stable, and had mild left costovertebral angle tenderness. Laboratory investigations revealed normal serum creatinine and estimated glomerular filtration rate (eGFR), and urinalysis showed microscopic hematuria without pyuria. Urine culture was negative. Non-contrast CT of the abdomen and pelvis revealed a large staghorn calculus in the left kidney occupying the renal pelvis and extending into the upper and middle calyces. There was preserved cortical thickness and no evidence of hydronephrosis. The anatomy appeared distorted, consistent with prior surgery. Preoperative Workup The patient underwent a thorough preoperative assessment including: Complete blood count, coagulation profile, and metabolic panel Preoperative urine culture and prophylactic antibiotics CT urography for anatomical mapping Multidisciplinary evaluation to assess operative risk The decision was made to proceed with ECIRS due to the complexity of the stone, previous renal surgery, and the need for comprehensive calyceal access. Surgical Technique The ECIRS procedure was conducted under general anesthesia. The patient was positioned in the Galdakao-modified supine Valdivia position to facilitate both percutaneous and retrograde access simultaneously. 1. Retrograde Access: A flexible ureteroscope was advanced through the urethra and up the left ureter to the renal pelvis. Retrograde pyelography was performed to visualize the anatomy and guide percutaneous access. A guidewire was placed in the renal collecting system under direct vision. 2. Percutaneous Access: Fluoroscopic and ultrasound guidance was used to access the upper pole calyx. A single puncture was made, and the tract was dilated up to 24 Fr using serial fascial dilators. A nephroscope was introduced through the percutaneous tract. 3. Lithotripsy and Stone Clearance: The stone was visualized and fragmented using a combination of ultrasonic lithotripsy and Holmium:YAG laser. The laser provided effective fragmentation of harder stone components, while ultrasonic energy helped debulk softer material. Fragments were retrieved through both percutaneous and ureteroscopic routes using graspers and baskets. Continuous irrigation was maintained to facilitate vision and fragment evacuation. 4. Drainage and Postoperative Management: A nephrostomy tube and a double-J stent were placed at the end of the procedure. Hemostasis was confirmed, and the patient was transferred to the postoperative recovery unit. He received IV fluids, analgesics, and prophylactic antibiotics as per protocol.

The procedure was completed successfully, with no significant intraoperative complications. The total operative time was approximately 90 minutes, which is within the expected range for ECIRS procedures. The patient experienced minimal intraoperative bleeding, and hemodynamic stability was maintained throughout the procedure. Postoperatively, the patient was monitored in the recovery room before being transferred to the surgical ward. The nephrostomy tube was removed on postoperative day 2, and the patient was discharged home on day 3, following an uncomplicated recovery. Follow-up imaging at 1 month confirmed that the stone burden had been completely cleared, and renal function remained intact. No residual stone fragments were present, and the patient reported no recurrence of symptoms. His renal function, as measured by serum creatinine and eGFR, remained stable throughout the follow-up period, indicating that his kidney function had been preserved after the procedure.

ECIRS is a safe and effective approach for the treatment of recurrent staghorn calculi, particularly in patients with a history of previous renal surgeries. This technique combines the benefits of both percutaneous nephroscopy and flexible ureteroscopy, offering enhanced stone clearance and reduced morbidity compared to traditional surgical methods. The case highlights the advantages of ECIRS, particularly in complex cases where altered renal anatomy or previous surgical interventions may complicate the use of standard techniques like PCNL. As minimally invasive techniques continue to evolve, ECIRS stands as a valuable addition to the urologic armamentarium for managing complex renal stones.