Role and Importance of Ergonomics in Retrograde Intrarenal Surgery (RIRS): Outcomes of a Narrative Review - Beyond the Abstract

With recent technological advancement, new and improved endoscopic instruments and laser devices have catapulted flexible ureteroscopy (FURS) to the forefront, hence making retrograde intrarenal surgery (RIRS) a popular choice for the management of renal stones. The singular advantage of RIRS procedure is its reproducibility world over in any set up by all urologists, consultants, and trainees alike. There has been no consensus on what the ideal ergonomic position is to perform this surgery as traditionally urologists perform this in standing and many have adopted the sitting position The latter being advocated after the RoboflexTM Avicenna was popularised by Geavlete et al.1 Improvising the RIRS outcomes in a sitting position with ergonomic benefits were seen by MEL position2 and the two-surgeon technique3 and even a prototype endo-chair with adjustable back support and armrests was assessed.4

The limitations of available literature were that no definitive trial or study was ever performed outside the centre to verify these results. Whilst many suggestions in conference papers are available a paucity of data necessitated the collective need to perform a literature review. Endourologists constantly try to find the most comfortable position when performing RIRS to avoid physical fatigue and future problems like lower back, neck, wrist, or finger pain.5

The premise of the study being: Does the sitting position offer distinct ergonomic advantages in RIRS which translates into better clinical outcomes for the patient whilst ergonomically beneficial to the operator. When the idea was discussed with the remaining co-authors, we concurred that at this point a consensus statement may not be possible, and hence the aim of our review was to examine the impact and feasibility of ergonomic adjustments and outline future directions and recommendations in order to improve the awareness of and reduce the prevalence of musculoskeletal injuries among urologists. A summary of these recommendations is available in table1.

Table 1: Summary of changes to conventional RIRS for a more ergonomic approach
Conventional RIRS

Ergonomic RIRS

Position of surgeon


Sitting (with endo-chair) or standing

Position of monitors

In line of sight at eye level or slightly below

In line of sight at eye level or slightly below

Position of scope

Arms by the side

Shoulders and elbows relaxed, scope held close to chest

Robotic platform

Not applicable

Seated at console

Muscle fatigue in large/multiple stones or multiple operations



Operative time

Dependent on stone size

Dependent on stone size

(Theoretically, faster and more precise with more comfortable position)

Scope longevity

Dependent on user and usage

Dependent on user and usage

(Theoretically, longer lifespan with less stress and torque on scope)

Surgical volume

Dependent on individual

Dependent on individual

(Theoretically, less fatigue allows surgeons to operate more)

Our narrative review has shown that ergonomics in RIRS is poorly understood and there are currently no standardized recommendations to measure or improve surgeon-associated morbidity in RIRS. While modern endourology armamentarium seems to help with procedural ergonomics, a multi-centre randomized controlled trial using validated scoring systems is needed to develop recommendations to enhance surgeon comfort and longevity and prioritize the health and safety of endourologists.

I would like to acknowledge my trainee and 1st author Ms. Chloe Ong SH for the hard work that has gone into this article and the support of each of my co-authors who equally contributed to the construct of this article.

Written by: Dr. Vineet Gauhar MS, MCh Uro, Dip MIS Uro (France and Singapore) Division of Urology, Ng Teng Fong General Hospital, National University Health System, Singapore


  1. Geavlete P, Saglam R, Georgescu D, et al. Robotic flexible ureteroscopy versus classic flexible ureteroscopy in renal stones: Initial experience. European Urology, Supplements. 2016;15(11):e1444.
  2. Goh R, Biligere S, Heng C, Gauhar V. Retrograde intra renal surgery by a modified ergonomic position in calculi 1.5 cm and above: A prospective outcome analysis in Asian ureter in a single institution. Journal of Endourology. 2016;30 (Supplement 2):A317.
  3. Hui S, Qingya Y, Xinbao Y, Ming L, Gonghui L, Jun C. Two-shift operation mode can improve the efficiency and comfort of flexible ureteroscopic holmium laser lithotripsy for the treatment of renal calculi larger than 1.5cm. International braz j urol : official journal of the Brazilian Society of Urology. 2019;45(6):1161-1166.
  4. Unsal A, Tepeler A, Resorlu B. A new designed ergonomic operator chair (endo-chair) for retrograde intrarenal surgery. Journal of Endourology. 2012;26(SUPPL.1):A409.\
  5. Klein J, Charalampogiannis N, Fiedler M, Wakileh G, Gozen A, Rassweiler J. Analysis of performance factors in 240 consecutive cases of robot-assisted flexible ureteroscopic stone treatment. Journal of Robotic Surgery. 2020((Klein, Wakileh) Department of Urology, Medical School Ulm, University of Ulm, Ulm 89075, Germany(Charalampogiannis, Fiedler, Gozen, Rassweiler) Department of Urology, SLK-Kliniken Heilbronn, University of Heidelberg, Heilbronn 74078, Germany).

Read the Abstract