In an adult with autosomal‑dominant polycystic kidney disease, preserved renal function, no active urinary infection, and a ≤2 cm stone in an accessible calyx, is retrograde intrarenal surgery (RIRS) contraindicated?

Is Retrograde Intrarenal Surgery Contraindicated for Polycystic Kidney Disease?

Retrograde intrarenal surgery (RIRS) is NOT contraindicated in autosomal dominant polycystic kidney disease (ADPKD) and can be safely performed for accessible stones ≤2 cm when there is no active infection. 1

Clinical Decision Framework

Primary Considerations Before RIRS in ADPKD

Rule out active infection first – this is the critical safety step:

• Obtain both blood and urine cultures before any intervention if the patient is febrile or has elevated inflammatory markers 1, 2
• Check C-reactive protein and white blood cell count; CRP ≥50 mg/L or WBC >11 × 10⁹/L suggests cyst infection rather than simple UTI 1, 2
• Perform renal imaging (ultrasound, CT, or MRI) to differentiate between cyst infection, cyst hemorrhage, and nephrolithiasis, as all three can present with similar symptoms 1, 2
• If cyst infection is confirmed, delay stone intervention until completing 4–6 weeks of lipid-soluble antibiotics (trimethoprim-sulfamethoxazole or fluoroquinolones) 1, 2

When RIRS Is Appropriate in ADPKD

For stones ≤2 cm in accessible calyces with preserved renal function and no infection, RIRS is a valid first-line option:

• The AUA/Endourological Society guidelines recommend ureteroscopy (URS/RIRS) for symptomatic stones ≤10 mm in any location, including lower pole 1
• RIRS has been successfully used in ADPKD patients with complete stone clearance in multiple case series 3
• A single-center study of 19 ADPKD patients with nephrolithiasis reported successful outcomes with URS and RIRS without major complications over 4.2 years mean follow-up 3

Technical Considerations Specific to ADPKD

The distorted anatomy from cysts requires careful technique but does not preclude RIRS:

• Normal saline irrigation must be used (never glycine or water) to prevent hemolysis and electrolyte abnormalities if significant absorption occurs through cyst rupture 1
• Flexible ureteroscopy allows navigation around cysts to reach stone-bearing calyces 4, 5
• RIRS may require staged procedures in ADPKD due to anatomic complexity, but this does not constitute a contraindication 1

Alternative Treatment Selection

When RIRS may not be optimal in ADPKD:

• Stones >20 mm total burden: PCNL becomes first-line therapy per AUA guidelines, though PCNL in ADPKD carries theoretical bleeding risk from cyst puncture 1
• Lower pole stones >10 mm: SWL should not be first-line (58% success rate vs 81% for URS); RIRS or PCNL are preferred 1
• Complicated nephrolithiasis with recurrent infection: Consider nephrectomy only if the kidney has negligible function 1

Common Pitfalls to Avoid

Do not confuse cyst infection with UTI – this is the most critical error in ADPKD stone management:

• Standard UTIs in ADPKD require only ≤7 days of antibiotics (nitrofurantoin, TMP-SMX, or fosfomycin) 1, 2
• Cyst infections require 4–6 weeks of lipid-soluble antibiotics and may need percutaneous drainage if unresponsive 1, 2
• Performing RIRS during active cyst infection risks sepsis; always obtain cultures and inflammatory markers first 1, 2

Avoid fluoroquinolone overuse – while these agents penetrate cysts well, the KDIGO 2025 guideline specifically warns that fluoroquinolones increase risk of tendinopathy and aortic aneurysm/dissection in ADPKD patients who already have underlying vascular abnormalities 1, 2

Do not use chronic NSAIDs for pain control in ADPKD patients undergoing stone management, as they cause renal adverse effects 2

Practical Algorithm for Stone Management in ADPKD

1. Assess for infection: Check CRP, WBC, blood and urine cultures 1, 2
2. Image the kidneys: Rule out cyst hemorrhage and localize stones 1, 2
3. If infection present: Treat with appropriate antibiotics for 4–6 weeks before stone intervention 1, 2
4. If no infection and stone ≤2 cm in accessible calyx: RIRS is appropriate first-line therapy 1, 3
5. If stone >20 mm or complex anatomy: Consider PCNL with awareness of bleeding risk from cyst puncture 1
6. Use normal saline irrigation only during any endoscopic procedure 1