The Storz HD camera heads (H3-Z and the latest pendulum version) (Fig. 12.1, 12.2) have an optimized weight and ergonomic handling, reducing fatigue and improving control during procedures. The integrated 3-chip camera head with the latest CCD (charge-coupled device) sensor technology assures detailed, high-contrast, quasi-3D, and noise-free images, with natural color reproduction across the entire zoom range. Ergonomically located buttons allow to program the camera head features according to the endoscope in use. HD camera heads have a 16:9 aspect ratio versus the 4:3 of the SD camera heads, increasing by more than 35 % the amplitude of the endoscopic field and by five times more the image resolution.

Since these camera heads have been conceived for laparoscopic procedures, thus for vision in wide-body hollows and to be coupled with big optics, the transposition of their use in ureteroscopy and nephroscopy requires a particular setting, in order to obtain an optimal vision.

Rigid, semirigid, and flexible ureteroscopes and nephroscopes require preliminary white balance, with the exception of the digital CMOS flexible nephroscope. Enhancement and brightness are set up according to the instrument to be used and the size/color of the working space (ureter versus renal pelvis and calyces):

Optic cables with different diameters (2.5 mm for all flexible endoscopes and the semirigid ureteroscope, 3.5 mm for the rigid nephroscope) (Fig. 12.3) differ in the amount of light transmitted. The Xenon light source should also be regulated in order to avoid bad vision due to too much light and tissue reflection. In addition, injecting too much light into the cable does not improve luminosity, but light transforms into heat and burns the optical fibers of the endoscope.

The flexible digital CMOS (Complementary Metal-Oxide Semiconductor) nephroscope has a distal chip directly transforming the image into a digital signal on the tip of the instrument and needs no light source nor optic cable or white balance, having an integrated LED (light-emitting diode) technology in the handle (enhancement off, zoom × 2).

The operating table for RIRS/PNL has to be radiolucent, with the possibility to translate it for housing the C-arm and to avoid radiopaque transverse bars underneath. Furthermore, the patient must have the chance to be put in lithotomic position (see also Chaps.​ 11 and 19). For a supine PNL, it is better to use an independent C-arm rather than an X-ray device integrated to an endourology table, requiring two different tables for the right and left side, or to change the position of the patient upside down (putting the head in the place of the feet) (see also Chap.​ 3). The individual C-arm (Fig. 12.7) can be placed as required either on the right or on the left side of the patient, leaving all the needed space to the surgeon. If fluoroscopy-only guidance is used, it is also important to be able to tilt the C-arm towards head or legs of the patient. This allows to target the kidney first in the anteroposterior incidence, then with a 30° tilt of the C-arm cephalad, to obtain information about the depth of the needle trajectory (see also Chap.​ 11) [1]. In order to maximally decrease radiation exposure of both patient and surgical staff and also to improve safety of the puncture, the combined use of ultrasound (Fig. 12.8) is crucial.

The choice of the nephroscope is of utmost importance. Rigid nephroscopes have the advantage of a superior optical quality due to the rod lens system. The optimal nephroscope should have a sufficient working length, a large working channel, a reduced outer diameter, and a watertight entry site for instruments and accessories.

In older nephroscopes the cranked (Fig. 12.9) or 45° offset optics and the light cable were located on opposite sides of the shaft. Therefore, in supine position, collision with the border of the surgical table of this type of nephroscope could occur, resulting in limited maneuverability. For this reason, when we started with ECIRS years ago, we changed the kind of support under thorax and ankle of the patient, in order to enlarge the space of movement of the instrument.

Presently, all major manufacturers produce models in which the optical and light cables and the irrigation lines are all located on the same side of the shaft (Fig. 12.10a, b). With such nephroscopes, problems due to a conflict with the surgical table are only exceptionally encountered. Most nephroscopes have a continuous flow design, with an inflow and an outflow valve. However, when using a plastic Amplatz sheath, the outer shaft with the outflow valve loses its role; in fact, the irrigation fluid can flow out between nephroscope and Amplatz sheath. Furthermore, the shaft additionally increases the diameter of the scope, and this can be a disadvantage when accessing a calyx with a narrow infundibulum. Therefore, it is preferable to choose a nephroscope that can also be used without the outer shaft.

In the market there are also midi (Fig. 12.11) and mini-nephroscopes (Fig. 12.12a, b, c).

A flexible cystoscope is crucial during a contemporary PNL/ECIRS. It allows to access peripheral calyces that are not reachable with a rigid instrument. This allows to avoid the need for multiple tracts, especially in case of staghorn stones. The limitation of analogic flexible instruments (Fig. 12.13a) is the small diameter of the working channel and their perceived inferior optical quality, because of the “honeycomb” effect produced by the fiber-optic bundles. Actually this can be adequately corrected by the right set up of the filters. Digital nephroscopes (Fig. 12.13b) have a very high quality of imaging. Usually the lithotripsy energy source for any flexible instrument is the laser, because of the reduced diameter and significant flexibility of the fibers employed.

One of the major advantages of the supine position is its ability to use two endoscopes simultaneously, one through the Amplatz sheath and the other transurethrally. In case of simultaneous renal and ureteral stone, the latter can be treated with a rigid ureteroscope (Fig. 12.14a, b, c) and holmium laser. The use of a ureteroscope has also the advantage of preventing the migration of small fragments into the ureter during fragmentation. In addition, through the ureteroscope it is possible to maintain a continuous and abundant irrigation which helps washing out small fragments through the Amplatz throughout the fragmentation process.

The use of flexible ureterorenoscope (Fig. 12.15) retrogradely together with a rigid or flexible nephroscope anterogradely allows to reach any district of the renal cavities. For this reason among the instruments semirigid and flexible ureteroscopes must be at disposition.

In summary, in order to achieve maximal efficiency during ECIRS, the optimal set of endoscopes includes rigid and flexible nephroscopes and rigid and flexible ureteroscopes.