Endoscopic combined intrarenal surgery (ECIRS) was initially introduced by Scofone et al. in 2008. ECIRS involves the integration of percutaneous nephrolithotomy (PCNL) with retrograde flexible ureterorenoscopy (fURS). The primary goal of this dual approach is to enhance the success rates of achieving a stone-free status (SFR) following a single surgical procedure. ECIRS is a minimally invasive approach that combines percutaneous nephrolithotomy (PCNL) with retrograde intrarenal surgery (RIRS) for the treatment of complex upper urinary tract calculi. This combination offers several benefits, such as reducing the need for repeat procedures and minimizing the number of puncture channels required to manage complex upper urinary tract stones. Furthermore, ECIRS is advantageous in improving the stone clearance rate during a single surgical procedure. Proper positioning is crucial for achieving a successful integration of PCNL and RIRS, with the Galdakao-modified supine Valdivia (GMSV) position being the most widely adopted approach. In this case series we report the experiences and outcomes of performing ECIRS in the prone position.

This paper reports three cases of prone ECIRS for large-burden and complex urolithiases, discussing and documenting pre-operative decisions, intraoperative considerations, and post-operative outcomes at JRRMMC in Manila, Philippines.

All three patients were either rendered stone-free, or stone burden was considerably decreased after the procedure. The patients experienced little to no complications and are on close follow-up with periodic surveillance CT sonogram.

Prone ECIRS demonstrates effective stone-free rates in patients with large stone burdens, including those with obesity, advanced age, co-morbidities, and prior surgeries, showing minimal complications and benefiting from the familiarity of the prone position among urologists, which also supports a lower learning curve and broader applicability across patient demographics.