Urolithiasis is a common problem in a current era

1. SURGICAL MANAGEMENT OF
UROLITHIASIS
By Dr. Fayera (GSR IV)
Moderators: Dr. Tadele (Urologist)
Dr. Mathias (Urologist)
Dr. Mekbib (Urologist)
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2. Outline
Introduction
Applied Anatomy
Epidemiology
Classifications of stone
 Surgical options of management
Complications
Summary
References
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3. Anatomy
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4. INTRODUCTION
• Urinary stone disease has been there since ancient times
• the site of stone formation has migrated from LUT to Upper UT
• the disease once limited to men is increasingly gender blind
• Medical management is desirable to prevent recurrence
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5. EPIDEMIOLOGY
• The average lifetime risk of stone formation is 1-15%
 expected recurrence rate … 50%
- 10% - at 1 year
- 35% - at 5 year
- 50% - at 10 year
• The incidence and prevalence of stone is rising worldwide
• attributed to an increase in the detection of asymptomatic calculi
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6. RISK FACTORS
Gender
Race/Ethnicity
Age
Geography
Climate
Water intake
Diet
Occupation
Obesity
Medication
Anatomical abnormalities
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7. Compositions of Nephrolithiasis
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8. Diagnostic Evaluation
• Clinical evaluation
• Investigations
– Base line investigations
– Radiological evaluation
– Metabolic evaluation
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9. Clinical Evaluation
• Pain – commonest
• Hematuria
• Fever, UTI
• Urosepsis
– Pyonephrosis
– Infected hydronephrosis
• Uremia
– Bilateral obstruction
– Obstruction in solitary kidney
• Asymptomatic
• Immediate evaluation in patients with
– Solitary kidney
– Fever or when there is doubt
regarding a diagnosis of renal
colic
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10. Radiological Evaluation
• Cornerstone in the evaluation of stone disease
• Includes
– Plain X ray KUB + USG of KUB region
– NCCT ( Non Contrast CT)
– IVU ( Intravenous Urogram)
– Renal Scintigraphy
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11. Ultrasound (US)
• Primary diagnostic imaging tool
• Safe ,reproducible and inexpensive
• Higher potential for misinterpretation of
size
 improved with measuring the
acoustic shadow
• Sensitivity (61%) and specificity
(97%)
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12. Radiography(KUB and IVP)
• KUB
– Oldest method of
identifying stones
– Sensitivity of 57% and a
specificity of 76%
– Inability to visualize all stone
types
• IVP
– Better delineation of the pelvicalyceal and
ureteral anatomy
– Sensitivity 70% and specificity 95%
– Radiolucent stones detected as filling defects
– Detect Underlying anatomic abnormalities
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13. Non-contrast-enhanced CT (NCCT)
• The gold standard imaging with sensitivity of
98% and specificity of 97%
• Can determine
– Stone density
– Inner structure of the stone
– Skin-to-stone distance and surrounding
anatomy
• Able to visualize extraurinary
tract abnormalities
• Radiation risk can be reduced by low-dose
CT
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14. Management
• Acute colic management
– NSAID
– OPIOIDS
• Management of sepsis and/or anuria in obstructed kidney: two options
– Placement of an indwelling ureteral stent
– Percutaneous placement of a nephrostomy tube
• Medical expulsive therapy (MET)
– Percutaneous irrigation chemolysis
– Oral chemolysis
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15. Surgical management of urolithiasis
 Minimally invasive technique
1.Percutaneous nephrolithotomy (PNL)
2. Rigid and flexible ureterorenoscopy (URS)
3.Shock wave lithotripsy (SWL)
 Open surgery
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16. SWL
• ESWL involves
the administration of a series of
shock waves generated by a
machine called a lithotripter.
• The shock waves are focused by
x-ray onto the kidney stone and
travel into the body through skin
and tissue, reaching the stone
where they break it into small
fragment
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17. Workflow of the ESWL Treatment
• Proper patient selection
• Device preparation,
• Pain therapy,
• Patient preparation,
• Positioning ,
• Stone targeting,
• Coupling and
• Shock wave application
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18. Preoperative evaluation
• Thorough Hx and PE
• U/A, urine culture
• Pregnancy test when appropriate
• Coagulation studies in pts with hx of coagulopathy
• Imaging: NCCT is preferred
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19. Proper patient selection based on -
• Stone size,
• Composition,
• Skin-to-stone distance,
• Stone location,
• Hounsfield units, and
• Triple D score
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20. Complications Following SWL
• Cutaneous hemorrhage at the area of generator contact
• Parenchymal or capsular hematoma of the kidney
• Hematuria (common).
• Cardiac arrhythmia.
• Renal colic- fragments passing down the ureter
• Urosepsis
• Stein Strasse(‘’stone street’’)
• Deterioration of renal function- transient tubular dysfunction for up to
7-9days
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21. Follow‐up after ESWL
• plain abdominal radiography (i.e. KUB) 1–4 weeks
• Stone fragments less than or equal to 4–5 mm can be observed if
asymptomatic but may lead to future colic events or serve as a nidus
for stone recurrence
• Repeat SWL
• Timing- no consensus (3days -4week)
• Failure
• After 3 sessions
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22. Percutaneous Nephrolithotomy
• The standard procedure for large renal calculi
• Standard access tracts are 24-30 F or Smaller access sheaths, < 18 F
• Contraindications
 Uncorrected coagulopathy
 Untreated UTI
 Tumour in the presumptive access tract area
 Potential malignant kidney tumour
 Pregnancy
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23. • Best clinical practice
– Antibiotics
– Anesthesia
– Pre-operative imaging
– Positioning of the
patient
– Puncture
– Intracorporeal lithotripsy
– Dilatation
– Choice of instruments
– Nephrostomy and stents
PCNL
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24. • Nephrostomy and stents: decision depends on several factors including
– Presence of residual stones
– Likelihood of a second-look procedure
– Significant intra-operative blood loss
– Urine extravasation
– Ureteral obstruction
– Potential persistent bacteriuria due to infected stones
– Solitary kidney
– Bleeding diathesis
– Planned percutaneous chemolitholysis.
PCNL
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25. • Post-op
– Keep transurethral catheter
for 6-24 hrs and nephrostomy
for 3 days
– Nephro-uretero-tomography is
performed prior to removal
 Complications of PCNL
• Fever - 10.8%
• Need transfusion - 7%
• Thoracic complication -1.5%
• Sepsis - 0.5%
• Organ injury -0.4%
• Embolisation -0.4%,
• Urinoma -0.2%, and
• death - 0.05%
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26. Management of renal stone
1 26

27. Indications for active removal of renal stone
• Stone growth
• Stones in high-risk patients for stone formation
• Obstruction caused by stones
• Infection
• Symptomatic stones (e.g., pain or haematuria)
• Stones > 15 mm
• Stones < 15 mm if observation is not the option of choice
• Patient preference
• Comorbidity
• Proximal Ureteral Stone
• Social situation of the patient (e.g., profession or travelling)
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28. • Most are struvite but can also be cystine, calcium oxalate monohydrate, and uric acid
• Ideal management is composed of 3 stages
– Complete surgical removal of the entire stone burden
– Any metabolic abnormalities must be identified and appropriately treated
– Assess for anatomic abnormalities
• SWL, PNL, combined PNL and SWL, open surgery
• PNL, followed by either SWL or repeated PNL, should be used for most
patients with struvite staghorn calculi
• SWL in small volume stones with normal or near normal anatomy
• Nephrectomy non functioning kidney with staghorn stone
Staghorn stone
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29. Treatment Decisions by Stone Burden
 Non-staghorn stones
• Stone burden (size and number) is the single most important factor
• Calculi are less than 10 mm in diameter
– 50% to 60% of all solitary renal
– SWL is generally satisfactory
– PNL and ureteroscopy for those with anatomic malformationcausing
obstruction, SWL failure
• Calculi between 10 and 20 mm
– SWL as first-line management
– Stone location and composition matters
– Cystine calculi and brushite calculi both respond poorly to SWL
• Stone Greater than 20mm…..PCNL is first line
– URS is an option
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30. Treatment Decisions by Stone Composition
• Patients with such stones (i.e.,brushite, cystine, ca oxalate monohydrate) should be treated
by SWL only when the stone burden is small ( <1.5 cm)
 For matrix caliculi
– Treated with PNL
– SWL is ineffective b/c the stone is gelatinous
– Ureteroscope is not also preferred b/c of large volume of the stone
 Indinavir stones
– Hydration and analgesic therapy
– discontinuing the drug : temporarily or permanently
– intervention for prolonged renal obstruction, signs of sepsis, or unremitting symptoms
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31. Renal Anatomic Factors
 Ureteropelvic Junction Obstruction(UPJO)
• Options of management are
– Open pyeloplasty and stone extraction
– PNL+ endpyelotomy
– laparascopic pyeloplasty + pyelolitotomy
 calyceal diverticula
– Percutaneous approach
– Retrograde ureteroscope for upper and middle calyceal
diverticula (stone <2cm)
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32.  15-20% have stone disease
 Most are Ca oxalate stones
 Commonly located at renal pelvis and posterior lower pole calyces
 SWL,URS, PCNL, Laparascopy
Horseshoe kidney and Renal ectopia
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33. Factors Affecting Management of Ureteral Stones
• Stone-Related Factors
– Location
– Size
– Composition
– Degree of obstruction
• Technical Factors
– Available equipment
– Cost
• Clinical Factors
– Symptom severity
– Patient's expectations
– Associated infection
– Solitary kidney
– Abnormal ureteral anatomy
– Coagulopathy
– Obesity
Management of ureteric stone
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34. Over all passage rate of ureteral stone
– Mid ureteral stone : 45%
– Distal ureteral stone: 70%
– Ureterovesical junction : 79%
• By size
– < or = 2mm : 95%
– 2-4mm : 83%
– > 4mm : 50%
– 4-6mm : 59%
– > 6mm : 21%
• > or = 7mm : chance of passage is very low
• Spontaneous passage by location •
– Proximal ureteral stone: 25%
Average interval to
stone passage
– < or = 2mm : 31days
– 2-4mm : 40 days
– 4-6mm : 39 days
• Majority of stone pass
with in 4-6wks
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35. 35

36. Option of management ureteral stone
• Expectant or Medical expulsive therapy
• SWL
• URS
• Percutaneous renal access with antegrade URS
• Laparoscopic or robotic ureterolithotomy
• Open ureterolithotomy
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37. Endoscopic stone removal
• A ureteroscope is a long thin endoscope passed transurethrally
across the bladder into the ureter.
• The ureteroscope is used to remove stones that are impacted
in the ureter.
• Stones that cannot be caught in baskets or endoscopic forceps
under direct vision are fragmented by a lithotripter.
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38.  Expectant management
• Candidate
– Stone < 6mm
– Normal renal function
– Well controlled pain
– Non obstructed
– Non infected
• Observation period 2- 4 weeks
• Weekly KUB to see progression of stone
• Medical expulsive therapy
– First line therapeutic
option for stone < 10mm
– Agents are: alpha blockers, ca++
channel blocker & corticosteroid
– Mechanism of action is it relax
ureteral smooth muscle to restore
normal peristalsis
– Nefidipine - increase stone passage
rate by 9%
– Alpha-blockers- increase stone
passage rate by 20%
Treatment algorithm of ureteral stones
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39. Stone Factors
 Treatment Decision by Localization
 Proximal and mid ureteric
– Primary options include SWL and URS, although PCNL and antegrade nephroscopy
may be indicated for select cases
– A percutaneous and antegrade  for very large proximal ureteral calculi not amenable
to either SWL or URS
 Distal utereric
• SWL and URS both remain the mainstays of treatment of distal ureteral stones.
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40.  Treatment Decision by Stone Burden
• In cases of high stone burden SWL is less effective and needs adjuvant therapy
 Treatment by Stone Composition
• Brushite (calcium phosphate) stones, calcium oxalate monohydrate, and cysteine stones
are all more resistant to SWL therapy and can be expected to have better rates at all sizes
and locations with URS
Stone Factors
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41. Ureteral Anatomic Factors
• Megaureter
– nonobstructed megaureter: MET, SWL, and URS
– obstructed megaureter: manage both the stone and the underlying pathology have included the
following:
• Retropulsion of the stones then PCNL + ureteroneocystostomy
• Ureterolithotomy with ureteroneocystostomy
• Ureteroscopy with endoureterotomy (in short-segment cases <3 cm
• Duplicated Collecting System
– Retrograde pyleography
– URS
• Ureteric stricture and stenosis
– Endoureterotomy followed by URS
– Open, laparoscopic, or robotic-assisted laparoscopic treatment
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42. Treatment decision based on
Clinical Factors
 UTI
• PCNL and URS, when active stone extraction is possible
• UTI associated with an obstructing upper tract stone (ureteral or renal) requires
emergent urinary tract drainage
– ureteral stenting or percutaneous nephrostomy
 Renal function test
• Nephrectomy : symptomatic upper tract stones located in renal units with approximately
15% or less split function
 Solitary kidney
• Asymptomatic stones are managed actively

43.  Morbid obesity
– Ureterorenoscopy and PCNL
 Old age and frailty
– PCNL , more blood transfusions
– SWL, perirenal hematoma
 Spinal Deformity or Limb Contractures
– PCNL and URS are preferred than SWL
 Uncorrected coagulopathy is a contraindication to
– URS with little to no increase in surgical morbidity
Treatment decision based on Clinical Factors
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44. Open surgery
• PRINCIPLES
– To preserve as much as possible of the functioning renal tissue and to prevent
complications.
– There is no place for hypotensive anaesthesia in renal surgery
• Special considerations
– In bilateral kidney stones, operate on the most painful side first then on the other side.
– In bilateral kidney stones with one non-functioning (bad) kidney, operate on the
healthy side first then perform nephrectomy on the bad kidney
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45. Indication for open renal surgery
• Failure of , or C/I to SWL or PNL
• Associated anatomic abnormalities
• Stone so large & complex
 Open surgery should be considered as the
last treatment option, after all other
possibilities have been explored.
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46. Types of surgery
 Anatrophic nephrolitothomy
– Massively sized , complete , fully branched staghorn stone
 with infundibular stenosis

 Radial nephrotomy: indicated for removal of solitary caliceal stone or caliceal stone
associated with larger intrapelvic stone
 Simple pyelolithotomy: renal stone + PUJ obstruction

 Extended pyelolithotomy : indicated for trapped caliceal & branched stones.
 Pyelonephrolithotomy: removal of branched calculi located with in the lower pole
infundibulum.
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47.  Partial nephrectomy: lower pole stone + infective destruction of parenchyma
 Nephrectomy: kidney destroyed by ; obstruction + infection ( xanthogranulomatous
pyelonephritis
 Calyceal diverticulolithotomy: calyceal diverticular stone
Types of surgery….
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48. APPROACH
• RENAL STONE
• Flank approach is preferred
• Position-Lateral decubitus
• Incisions
• Subcostal,
• 11th or 12th rib intercostal –better access to renal hilum and upper pole
mobilization
• Transperitoneal
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49. Approach
• URETERIC STONES
• Depends on location of stone
• Proximal ureter
• Supracostal
• Subcostal
• Dorsal lumbotomy
• Distal ureter:
• Low midline
• Pfannenstiel,
• Gibson incision.
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50. Pyelolithotomy
• Indication-Renal Pelvic Stone
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51. Radial Nephrolithotomy
• Indication-Caliceal Stones or Diverticulum Stones Not Extractable Via
a Pyelotomy. Large Staghorn Stones with Multiple Caliceal Extensions
that Require Several Radial Nephrotomies in Addition to an Extended
Pyelolithotomy
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52. Anatrophic Nephrolithotomy
• Indications-Staghorn Stones or Large Stone Mass Located in
• Multiple Peripheral Calices with Narrow Infundibula
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53. Anatrophic Nephrolithotomy
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54. Anatrophic Nephrolithotomy
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55. Ureterolithotomy
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56. Results
• Stone free rates:
• Anatrophic nephrolithotomy 80–100%
• pyelolithotomy
• single stone ~ 100%
• staghorn stone or multiple calyceal stones ~90%
• ureterolithotomy 84–100%
• recurrence rates following anatrophic nephrolithotomy 5-30%
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57. Postoperative management
• Intravenous fluids
• Postoperative antibiotics for 5–7days guided by preoperative urine culture and sensitivity
findings
• The ureteral stent is removed cystoscopically at approx 7 d postoperatively in uncomplicated
cases
•
• A urine culture is checked for persistence of infection
• At 1–2 mo a follow-up intravenous pyelogram (IVP) is obtained
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58. Complications
 Pneumothorax
 Renal hemorrhage
 Renal arteriovenous fistula formation or a false aneurysm
 Renal injury and hypertension.
 Urinary extravasation
 Flank absess
 Loss of the stone intraoperatively, fistulas, and strictures
58

59. Bladder Stone
• 5% of all the urinary stone
diseases
• Classified as
– Migrant : 3% to 17% of bladder
calculi
– primary idiopathic- nutritional
deficiency, most common in children <
10 yrs, peak at 2 to 4 years
– secondary: associated with an
underlying bladder pathology
• Clinical presentation
– Terminal hematuria : most common
presentation
– lower urinary tract symptoms
– Pulling the penis  pathognomonic of
bladder stone in children
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60. Management
• Medical Management
– Chemo dissolution: time
consuming and not completely
efficient
• ESWL: option in
– Pts with artificial urinary
sphincters or a penile prosthesis
– Stones in neobladders
– factors affecting the outcome
include the amount of post void
residue, the stone composition, and
the stone size
• Endourologic Approach
– Cystolithotomy: intact
removal of stone
– Cystolithotripsy: fragmenting the
stone with energy source
– Cystolitholapaxy: mechanical
breakage of the stone
– Rout transurethral with
laser lithotripsy
• Percutaneous approach
• patients who have undergone previous
bladder neck reconstruction or closures
• Open cystolithotomy
- Associated with the need for prolonged
catherization and hospital stay
- If transurethral or percutaneous access to
the bladder is contraindicated 60

61. Lower Tract Calculi in Special Situations
• BOO With Bladder Lithiasis
• The presence of urolithiasis secondary to
BOO forms the absolute indication for
treatment of BPH
• Bladder Calculi in Patients With Spinal
Cord Injury
– Stone formation peaks at 3 months
after injury
– Managed as general population
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62. Urethral Calculi
• 0.3 - 1% of all stone disease
• Obstructing urethral calculus is very rare
• More common in males
• Bimodal age distribution (early childhood and fourth or
fifth decades of life)
• Majority are migratory from bladder and calcium oxalate
(85%–90%) of cases
• Common on prostaticand bulbar urethra
• Clinical Presentation
– acute painful retention of
• urine
– weak stream, interrupted stream,
or splaying, gross hematuria, and
dysuria
• Treatment
– Location within the urethra
– Distance from the internal or the
external urethral meatus
– Stone characteristics
– The ability of the stone to get
• pushed into the bladder, and
– Associated structural abnormalities
of the urethra
62

63. • Posterior urethra stones
– Pushed back into the bladder for ESWL(success rate of only 60%) or intracorporal
lithotripsy (success rate of 85% to 90% )
• Anterior urethra stones
– Milking the stone : for small and smooth-surfaced stones and near to external
meatus
– For larger and more proximal anterior urethral stones urethrotomy and stone
extraction
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64. Summary
 Clinicians should obtain a non-contrast CT scan on patients prior to performing PCNL.
 Clinicians may obtain a functional imaging study (DTPA or MAG‐3) if clinically significant
loss of renal function in the involved kidney or kidneys is suspected
 Patients with uncomplicated ureteral stones <10 mm should be offered observation, and
those with distal stones of similar size should be offered MET with α-blockers
 In patients with obstructing stones and suspected infection, clinicians must urgently drain
the collecting system with a stent or nephrostomy tube and delay stone treatment.
 For patients with asymptomatic, non-obstructing caliceal stones, clinicians may offer active
surveillance 64

65. REFERENCES
- AUA Guideline
-EUROPEAN UROLOGICAL ASSOCIATIAN Guideline 2020
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66. THANK YOU!
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