RIRS is being used in the management of renal calculus in multiple clinical scenarios. It is safe and effective procedure with minimal morbidity to the patient. In patients with AML it is extremely useful as other procedures like percutaneous nephrolithotomy (PCNL) and extracorporeal shock wave lithotripsy (ESWL) have high complication rates of bleeding [5]. RIRS is now increasingly being used in management lower calyceal calculus [6]. Basketing the calculus out of lower pole calyces is a commonly used technique which allows the surgeon to place the calculus at a more favorable position in the kidney which is usually renal pelvis or upper calyx. It facilitates effective fragmentation and minimizes trauma to the flexible ureterorenoscope [2].
Stone basketing has a few known complications. Important intraoperative complications include entrapped and broken basket [7]. Although tipless baskets assume safer configurations, they break easiest [8]. In case of broken basket, there have been reports of performing PCNL to retrieve the broken basket tip [9]. But ours was a scenario complicated by the presence of concomitant renal angiomyolipoma.
If a basket is broken and entrapped, there has been suggestion in the literature, to deal with the calculus first before attempting to remove the broken basket tip [7]. In our case, also we fragmented the calculus, thereby freeing the entrapped basket fragment from the calculus, instead of making too many premature attempts to retrieve the broken basket fragment. We also felt too many attempts to retrieve the broken basket without fragmenting the calculus may result in more trauma or worse, another broken basket.
While retrieving the broken basket fragment, we recommend to identify the broken tip of the basket fragment that can be firmly grasped by another tipless nitinol basket or by any other suitable stone extraction devices. Holding the basket at the broken tip has multiple advantages. It is easy to locate the broken tip; the grasp is firm and allows removal under vision with less chances of slippage. It thus facilitates basket extraction with minimal attempts, without causing much trauma. We did not cut the basket with laser into multiple parts, as this could be tedious and time-consuming with additional risk of leaving retained fragments [7].
Retrospectively looking we feel we could have avoided this complication altogether by at least partial fragmentation of easily accessible part of the calculus first, thereby making the calculus smaller and then attempting to basket the calculus. Further, once the basket got entrapped around the calculus, we could have avoided pulling the basket forcefully. Instead it would have been prudent to have the basket wire cut proximally near the handle after the basket got entrapped (Fig. 3). It could have given two advantages. A gentle traction could have been maintained by an assistant from outside by holding of the basket wire proximally by hand, thereby easing lower calyceal stone fragmentation. Also, after stone clearance the basket wire could have been retrieved out by gentle hand traction obviating the need for basketing the basket (Fig. 4).