Introduction: Although metallic and Hem-O-Lok™ clips have consistently shown their safety and efficacy, especially in laparoscopic surgery, some rare complications may arise, oftentimes requiring complex surgical procedures. This video describes the utilization of miniaturized endoscopic combined intrarenal surgery (mini-ECIRS) to remove Hem-O-Lok™ clips that eroded into the collecting system as a late complication of robotic partial nephrectomy. Methods: We present a 68-year-old male patient that underwent a robotic-assisted laparoscopic partial nephrectomy in 2015 to address a small renal mass (2.0 x 1.9cm) on the right side. Pathology revealed the tumor to be an oncocytoma. Then, the patient was lost to follow-up but returned to the urologic clinic 7 years later due to gross hematuria and right-sided flank pain. Cystoscopy was negative for lesions or tumors, and a CT scan demonstrated a right-sided calculus (1.3 x 1.4cm) in the renal pelvis. Results: Considering the size and location of the stone (=2cm), the patient underwent a flexible ureteroscopy. However, a calcified Hem-O-Lok clip was found to be free-floating in the right renal pelvis. As the size of the clip precluded its prompt removal through the ureter, we decided to perform right-side mini-percutaneous nephrolithotomy by gaining access through the mid pole with a 15/16Fr access sheath. The clip was then removed with a grasper in one piece. During the routine final endoscopic survey, we found another clip in the process of erosion. This time, we first utilized a holmium-YAG laser to dissect it from the surrounding urothelium to subsequently remove it through the renal tract. The total operative time was 81min and the laser pedal time 1min. No complications were noted, and the patient was discharged on the first postoperative day. Conclusions: Erosion of surgical clips is a rare complication in modern-era surgery, although it may require complex surgical procedures to address it. This case demonstrates the safety and feasibility of mini-ECIRS to remove surgical clips after partial nephrectomy. SOURCE OF Funding: None.
