Laser Stone Removal (RIRC) in Turkey

Laser stone fragmentation (RIRC) is a minimally invasive endourological treatment based on entering kidney and ureteral stones through a flexible ureteroscope and fragmenting them with holmium laser energy. The procedure is widely preferred in clinical practice due to its high success rate and low complication profile.

Kidney stone treatment with the RIRC method is a procedure performed under general or spinal anesthesia and does not require a surgical incision, as natural urinary pathways are used. Thanks to flexible devices, access is provided to all calyces of the kidney and the stones are pulverized to facilitate spontaneous passage.

The advantages of stone fragmentation with holmium laser include a low risk of bleeding, a short hospital stay, and a rapid recovery process. It is especially effective for stones smaller than 2 cm and is considered a safe option in patients with recurrent stones.

As part of the recovery process after RIRC and the points that should be considered, patients are advised to consume plenty of fluids, be monitored for signs of infection, and use the medications recommended by the physician regularly. In necessary cases, a temporary DJ stent is placed to ensure urine flow.

What Is a Kidney Stone and Why Is Laser Stone Fragmentation (RIRC) Treatment Needed?

The kidneys function as the body’s main purification facilities. While constantly filtering the blood, they excrete harmful waste substances and excess minerals through urine. Sometimes, when enough water is not consumed during the day, when dietary habits are faulty, or when genetic predispositions come into play, these waste substances cannot dissolve in the urine. Just as sugar settles at the bottom when too much is added to a glass of water, these excess minerals also begin to precipitate in the small chambers inside the kidney. Over time, these microscopic precipitates stick together, harden, and form kidney stones, which can range from grains of sand to pebbles and sometimes to much larger sizes.

As long as these stones remain fixed inside the kidney, they may sometimes cause no symptoms at all. However, when they move from their place and progress into the urinary canal or block the kidney outlet, the downward flow of urine is obstructed. This blockage causes a serious increase in pressure inside the kidney, swelling of the organ, and the extremely severe kidney pain well known among the public. If this condition is not treated for a long time, urine accumulation prepares the ground for infections and permanent loss may occur in the kidney’s filtering functions. At this point, the stone must be removed in order to open the blockage, relieve the kidney, and protect the health of the organ.

Why Is the Laser Stone Fragmentation (RIRC) Method Superior to Traditional Surgeries?

In past years, open surgeries involving large incisions in the patient’s back or waist area were generally performed to treat kidney stones. Since these traditional surgical methods required cutting the kidney tissue, the patient’s recovery process lasted for weeks, severe postoperative pain was experienced, and there was a risk of permanent damage to the kidney tissue. Thanks to the tremendous advances in medical technology, open surgeries have now been almost completely abandoned.

The greatest advantage of the laser stone fragmentation method is that it uses the body’s completely natural structure. In the human body, there are natural tubes extending from the bladder to the kidney and carrying urine. In this procedure, no external hole is opened in the body and no incision is made. With extremely thin and flexible instruments, entry is made directly through the canal through which urine exits, the bladder is passed, and the kidney is reached entirely through these natural pathways. From the outside, there is no sign on the patient’s body indicating that they have undergone surgery. The absence of an incision eliminates the risk of wound infection, minimizes the pain felt after surgery, and reduces the time for patients to return to their daily lives, work, or social life from weeks to just a few days. This philosophy of minimal intervention is one of the greatest achievements of modern medicine that respects tissues.

For Stones of What Size and Characteristics Is Laser Stone Fragmentation (RIRC) the Most Suitable Option?

When deciding on the treatment of kidney stones, the size of the stone is one of the most determining factors. In today’s urology standards, the laser stone fragmentation method is accepted as the primary and most ideal treatment option especially for stones up to two centimeters in size. Stones smaller than two centimeters can be completely pulverized and cleared from the kidney in a short time with laser energy.

In addition, this method is also used in cases where the method called extracorporeal shock wave lithotripsy (ESWL) is applied but the stone cannot be broken because it is too hard. Sometimes the stone is broken from the outside into fragments, but these fragments cannot pass spontaneously due to anatomical narrowness or blockages in the patient’s kidney structure. In cases where the structure of the chambers inside the kidney does not allow this passage, the laser method is used to enter directly into that chamber and pulverize the stone in place. In other words, not only the size of the stone but also the anatomical obstacles of the kidney and the stubbornness of the stone play an important role in choosing the laser stone fragmentation method.

Why Is the Hardness of the Stone So Important Before Laser Stone Fragmentation (RIRC)?

The evaluations made before surgery are not limited to measuring only the size of the stone. How hard the stone is directly affects the course of the surgery, how the laser will be used, and how long the procedure will take. In order to measure this hardness, non-contrast computed tomography (CT) is definitely performed before the operation. Through the tomography images, the density of the stone is calculated millimetrically with a special unit called the “Hounsfield Unit.”

Stones of medium hardness dissolve and disperse very quickly with the energy of the laser. However, extremely hard structures known in medical language as calcium oxalate monohydrate or cystine stones resemble a marble or concrete block. When such hard stones are encountered, the settings of the laser are changed. Instead of trying to divide the stone into large pieces, the laser makes much faster and finer shots and gradually begins to abrade the stone from its surface, that is, to pulverize it. Naturally, this pulverization process takes longer in very hard stones. Knowing this hardness value before surgery ensures the correct selection of the devices to be used and that the duration of the surgery is accurately conveyed to the patient.

How Do the Cameras Used in Laser Stone Fragmentation (RIRC) Surgery Work?

The medical devices used to perform this delicate surgery are a perfect combination of engineering and medicine. Devices called “flexible ureterorenoscopes” are used in the procedure. These devices roughly resemble a long, thin cable. Their diameter is almost like the thin ink tube inside a ballpoint pen. At the very tip of the device, there is a very powerful cold light source that illuminates the surgical field and a miniature digital camera that transmits the image inside to high-resolution screens:

The most miraculous feature of these devices is their flexibility. The collecting system of the kidney is not like a straight pipe; like the branches of a tree, it consists of blind spots, recesses, and protrusions diverging in many different directions. It is impossible to enter these chambers with straight and rigid instruments. However, after reaching the kidney, these flexible devices can bend at high angles to the right, left, and backward just like a snake. Their tip can even fold completely backward and easily find stones in the chambers located at the very bottom of the kidney, which are the hardest to reach, and bring them into the field of view of the camera. In this way, no blind spot remains inside the kidney.

Which Types of Laser Are Used in the Laser Stone Fragmentation (RIRC) Procedure?

After the location of the stone is identified with the camera, the stage of destroying the stone begins. At this stage, laser fibers extended into the kidney through a channel inside the camera, as thin as a strand of hair, are used. Today, two different laser technologies stand out worldwide for this procedure. The first is the Holmium laser systems, which have been used safely for many years. The other is the Thulium Fiber Laser (TFL) technology, developed in recent years and providing much more precise results.

Laser devices do not crush the stone with mechanical force or break it with a sledgehammer effect. Instead, they use highly focused light energy to disrupt the structure of the stone at the molecular level. In particular, next-generation systems have the capacity to make hundreds of very fine shots per second. Thanks to these rapid and fine shots, the stone is completely turned into dust like a cloud rather than being broken into pieces. This pulverization method, known in medical language as “dusting,” increases the quality of the surgery. Because if the stone remains in large pieces, these pieces may again cause pain while passing through the urinary canal. However, stone dust that reaches the consistency of fine sea sand silently flows out of the body with the urine after surgery without causing the patient any pain.

Why Is the Urinary Canal Sheath Important in Laser Stone Fragmentation (RIRC) Surgery?

Another important instrument that works in the background of the laser stone fragmentation operation and is one of the cornerstones of success is the “Ureteral Access Sheath.” This sheath is a thin, smooth, and hollow tube placed into the urinary tract leading to the kidney at the beginning of the surgery. The entire surgery is performed by passing the camera through this tube.

The main purpose of using the sheath is to balance the fluid pressure inside the kidney. In order to keep the camera’s view clear and wash the inside of the kidney, a continuous flow of fluid is given throughout the surgery. If this fluid cannot exit easily, the kidney swells like a balloon, internal pressure increases, and the risk of infection arises. This hollow sheath ensures the rapid evacuation of the administered fluid and the stone dust fragmented by the laser from the kidney. In addition, sometimes during surgery the camera may need to be removed and inserted several times. Thanks to the sheath, the camera does not rub against the walls of the urinary canal, the delicate surface of the canal is not scratched, and tissue irritation that may occur after surgery is completely prevented.

How Is Laser Stone Fragmentation (RIRC) Surgery Performed Step by Step?

When the decision for the operation is made and the necessary tests are completed, the process proceeds in a highly planned manner. Since laser stone fragmentation surgery is an extremely delicate procedure requiring millimetric precision, it is always performed under general anesthesia, known as full anesthesia. The patient’s complete sleep allows their breathing to be tied to a standard rhythm with a ventilator. Thus, the kidney remains stable during the operation and the laser shots can be focused directly on the stone much more safely.

When the surgery begins, the structure of the urinary canal is first examined and the safety sheath is placed. The inside of the kidney is reached with the flexible camera. The chambers are scanned one by one and the exact location of the stone is identified. The laser fiber, as thin as a strand of hair, is used until the stone is completely turned into dust. The stone dust is washed out with fluid. After the inside of the kidney is completely cleaned, a thin silicone stent is left inside the urinary canal to support healing, and the operation is ended. When the patient wakes up, the procedure is already over and there is no surgical mark on their body.

Why Does the Location of the Stone Matter in the Laser Stone Fragmentation (RIRC) Procedure?

The location of the stone inside the kidney is the main factor determining the difficulty level of the surgery to be performed. The kidney consists of three main sections—upper, middle, and lower—and many small chambers opening into these sections. If the stone is in the upper or middle sections, it is quite easy for the flexible camera to reach these areas and work at a straight angle.

However, if the stone is located in the chambers at the very bottom of the kidney, the region called the “lower pole,” the procedure becomes somewhat more complicated. In order to reach the stone in the lower pole, the tip of the device has to bend almost in a full turn. While the device is so bent, passing the laser fiber through it and firing at the stone may reduce efficiency. In such difficult situations, surgeons use an intelligent maneuver called “repositioning.” With fine instruments that have a very delicate mesh at the tip, the stone in the lower chamber is gently grasped and moved to the much wider and straighter upper regions of the kidney. After the stone is brought to a more spacious and accessible area, it is turned into dust much more quickly and effectively with the laser.

How Is Laser Stone Fragmentation (RIRC) Compared With Other Methods in Large Stones?

When the size of the kidney stone exceeds two centimeters, the duration of the laser procedure performed only by entering through the urinary tract may become very long. At this point, depending on the patient’s condition, a different closed surgery technique called “Mini-Percutaneous Nephrolithotomy” may come to the agenda. In this method, instead of natural pathways, entry is made directly into the kidney by opening a small hole from the patient’s back only as thick as a ballpoint pen, and the stone is broken and removed.

The advantage of this method in large stones is that the stone mass can be removed from the kidney quickly. However, since this method requires puncturing through the kidney tissue, it carries a slight risk of bleeding and the patient’s hospital stay is prolonged by one or two days. On the other hand, the procedure performed through natural pathways with a laser (RIRC) offers tremendous advantages such as almost no risk of bleeding and the patient getting back on their feet very quickly. Therefore, in very large stones, the advantages and disadvantages of both methods are evaluated in detail, taking into account the patient’s general health and kidney anatomy.

What Can Be Expected During the Recovery Process After Laser Stone Fragmentation (RIRC)?

The most satisfying aspect of laser stone fragmentation surgery for patients is that the recovery process is extremely fast and comfortable. Since there are no stitches, wounds, or dressings in the operated area, patients can start consuming liquids and walking in their rooms a few hours after waking up from surgery. In cases where the clinical course progresses normally, patients are generally discharged from the hospital on the evening of the same day or the next morning.

The silicone tube called the “Double-J Stent,” placed in the urinary canal between the kidney and the bladder at the end of the surgery, is the silent helper of this process. This stent prevents very mild swellings that may occur in the urinary canal after surgery from cutting off urine flow. At the same time, it allows the stone residues that have turned into dust to drain out without blocking the canal. Patients can usually return to desk jobs and daily routines within a few days. The inserted silicone stent is removed painlessly with a simple outpatient clinic procedure approximately two to four weeks after the surgery, once it is ensured that the kidney has completely healed.

In Which Situations Should Care Be Taken After the Laser Stone Fragmentation (RIRC) Procedure?

It is completely natural for some temporary and mild symptoms to occur after the procedure due to the presence of a stent in the urinary tract and the effect of the laser intervention. However, in some cases these symptoms should be monitored closely. The conditions that patients may experience after surgery and that are generally accepted as normal are as follows:

• Mild pink discoloration in the urine
• Burning while urinating
• Frequent need to go to the toilet
• Mild pressure in the lower back while urinating
• Mild fatigue

These symptoms are usually related to the presence of the stent or the passage of small stone dust. However, if high fever, chills, or clotted, heavy bleeding in the urine is seen, it is absolutely necessary to apply to a healthcare institution.

What Should Be Consumed to Prevent Stone Formation After Laser Stone Fragmentation (RIRC)?

Stone disease is a metabolic problem and tends to recur over the years if lifestyle is not changed even if it is treated. The most effective way to prevent this is to create a nutrition and fluid consumption plan that protects the kidneys. The basic elements that should be added to the daily routine to support kidney health and prevent stone crystals from combining are as follows:

• Water
• Freshly squeezed lemonade
• Orange
• High-fiber foods
• Olive oil

Water consumption in particular physically washes the kidneys and prevents the accumulation of sediment. Citrus fruits such as lemon and orange, thanks to the natural citrate they contain, protect the acid balance of the urine and prevent the crystallization of new stones.

Which Foods Should Be Avoided After Laser Stone Fragmentation (RIRC)?

While protecting kidney health, it is not enough only to consume beneficial foods; it is also necessary to avoid harmful habits that prepare the ground for stone formation. Some substances frequently consumed in modern diets seriously tire the kidneys. The foods that individuals with a history of stone disease should absolutely remove from their daily diet or seriously limit in quantity are as follows:

• Excessive salt
• Processed sausage
• Salami
• Sugary carbonated drinks
• Ready-packaged foods

Especially high salt consumption directly accelerates stone formation by increasing the amount of calcium excreted in the urine. By staying away from these foods, living an active life, and maintaining an ideal weight, it is the most guaranteed way to keep the risk of kidney stones at the lowest level for a lifetime. Although laser technology provides excellent results in eliminating the existing stone, preventing the formation of new stones depends entirely on the patient’s new and healthy lifestyle habits. When these simple but effective rules are followed, the kidneys will continue to function smoothly for many years.