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Background: Renal stones are conventionally treated with percutaneous lithotomy (PCNL), with miniPCNL and endoscopic combined intrarenal surgery (ECIRS) as preferred choices to reduce morbidity associated with bigger tracts. MicroPCNL is not recommended for larger stones as fragments obscure intraoperative vision and high intrarenal pressure with prolonged operative time increases the risk of sepsis. MicroECIRS overcomes these disadvantages with simultaneous antegrade and retrograde lithotripsy and drainage. Objectives: To provide a step-by-step illustration on how to perform microECIRS. Materials and methods: 1. Patient in supine Barts flank-free with French split leg or Galdakao-modified supine Valdivia (GMSV) position. 2. MicroPCNL with 4.8Fr “All Seeing Optical Needle” (Polydiagnost, Germany). 3. Placement of access sheath with/without suction. 4. Retrograde intrarenal surgery (RIRS) with Boston Scientific Lithovue or Olympus URF-V ureteroscope. 5. Lithotripsy using Lumenis 120-watt high-power 200-micron laser with/without Moses fibre. Results: MicroECIRS has multiple advantages. Direct ureteroscope-guided puncture, antegrade visualisation of the tract via the ''all seeing needle'', and miniaturization, ensures safe and accurate percutaneous access even in challenging renal anatomy, hence reducing the risk of bleeding and need for post-operative nephrostomy. Low intrarenal pressure with good active and passive drainage bidirectionally prevents pyelovenous reflux and sepsis, and maintains clear vision to allow precision laser lithotripsy. MicroECIRS is also ergonomic for both antegrade and retrograde surgeons as they can remain seated throughout the operation, avoiding muscle fatigue. Additionally, as the camera head of the microPCNL set is mounted on a separate rod, weight is taken off the handheld part such that the surgeon only maneuvers the lightweight needle. Conclusion: MicroECIRS is a safe, easy, and ergonomic option for larger stone volumes. Achieving single-stage stone clearance with no morbidity translates into shorter hospital stays and a faster return to daily activities, hence making this economically viable.

Objective: Retrograde intrarenal surgery (RIRS) is a well-established treatment option for renal calculi. Stone dusting has drastically improved with the advent of high-power LASERs, but the challenge remains in clearing the fine dust and fragments which may become niduses for future stone recurrence. The aim of this article is to demonstrate the use of the Flexible And Navigable ureteric access Sheath (FANS), a novel invention which improves the aspiration of stone dust and fragments, and assess its safety and outcomes. Patients and Surgical Procedure: In this video, Clearpetra 12/14 Fr FANS was used with a TFL LASER for RIRS of the renal pelvic calculus. Data regarding intra-operative outcomes, immediate post-operative (within 24 h) and 3-month stone-free rate (SFR), and post-operative complications, was collected. Retrospective analysis was carried out on 45 patients who underwent RIRS between September 2022 and March 2023 across 3 centres. Results: RIRS was successful in all patients (median operating time=65 min). Immediate CT scan within 24 h showed no evidence of pelvicalyceal injury or perinephric fluid collection. 71.1% (n = 32) had 100% SFR immediately post-operation, and this improved to 93.3% (n = 42) at 3-month follow-up. 11 of these 45 patients have been followed up for 6 months – all have 100% SFR and no complications. 35.6% (n = 16) had transient fever which resolved with antibiotics; none had sepsis. A double J stent was placed in 62.6% (n = 28), while 26.6% (n = 12) had an overnight ureteric catheter only. Conclusion: FANS improves single-session SFR and reduces the need for a ureteric stent or catheter. It is safe with minimal complications, reduces the need for ancillary treatment and post-operative follow-up, therefore resulting in cost savings for the hospital and patient.

Percutaneous Nephrolithotomy (PCNL) has evolved over the decades from Standard to Mini to Ultramini PCNL to Micro-perc, with miniaturisation being the dominant theme and supine approach gaining momentum world over.Aim: In literature, miniaturised PCNL with microperc needle access system has raised concerns of intrarenal pressure and has some limitations with its success for larger stones. Our tips and tricks explain how to overcome these pitfalls by utilising the full construct of the needle system to its maximum potential. These will in turn help make the procedure versatile, precise, ergonomical, and enhance a surgeon's experience with improved outcomes for patients especially in large renal stones.Materials and Methods: We describe the limitations of microperc needle access as stated in literature and proposals by the co-authors using microperc for miniaturised access on how to overcome the same.Results: A simplified table describing the limitations and tips and tricks on overcoming these is provided for quick reference.Conclusion: As Technological advancements and techniques for miniaturised access in urolithiasis improve, we believe our suggestions will help surgeons overcome the quoted limitations of microperc needle access for miniaturised PCNL, making this a versatile, safe and efficacious technique even in large and complex stones. A multi centre trial will be the best way to validate the suggestions proposed in this article.