This document discusses the management of renal, ureteric, and bladder stones. For renal stones, conservative management is recommended for small stones less than 5mm. Surgical interventions include ESWL, PCNL, URS, and open surgery depending on stone size and location. For ureteric stones, conservative management or URS are options, with open surgery for larger or impacted stones. Bladder stones can be treated with cystoscopic litholapaxy or open cystolithotomy depending on stone factors and patient condition. The goal is to remove stones while minimizing complications through appropriate surgical procedures.

1. Management of Urinary calculus
(Renal,ureteric and bladder calculus)
Dr Uvaish Parmar
1st Year reasident
DNB(General surgery)
Apollo hospital international limited
Ahmedabad

2. Management of Renal stones
Renal stone
Medical
management
Surgical
management

3. Medical management
• Conservative Treatment(4-6 weeks):
Indication
• Single stone < 5 mm.
• Ureter is undilated.
• Evidence of downward movement.

4. Conservative treatment
 Plenty of water orally.
 Diuretic—oral frusemide to flush the stone.
 Suitable antibiotics to control sepsis; antispasmodics to
 relieve pain.
 IVfluids—fastinfusionofabout 1.5to2 litresandinjection
 frusemide 60 to 80 mg. Usually given for 3 to 5 days.
 Surgical intervention for ureteric stones:

5. • For Cystine, Calcium oxalate & Uric acid stone
• Increase fluid Intake
• Alkalization of Urine: Potassium citrate/ Sodium bicarbonate
• Urinary PH: 6.5-7.0
• For Uric Acid: Allopurinol 300 mg QID
• For Cystine: D-Penicillamine & Alpha – Mercaptopropionyleglycine

6. RENAL CALCULUS
• Avoid animal protein: Meat, chicken & Egg
• Take low salt diet.
• High Fibre diet
• Weight Reduction.
• Tamsulosin- alpha -1 blockers ( Flowmax) : 0.4 mg for 7-10 days:
• Nifedipine: CCB:May be beneficial.

8. Surgical interventions for Renal
calculus
• ESWL( Extracorporeal Shock Wave
Lithotripsy)
• PCNL( PercutaneousNephrolithotomy)
• URS( Ureteroscopy)
• Lap Stone Removal
• OSS( Open Stone Surgery)

10. STONE& SURGERYOFCHOICE
• Stone < 2 cm:
• Stone > 2 cm :
ESWL
PCNL
• Staghorn Calculi: PCNL+ ESWL
• Initial approach is PCNL, followed by ESWL.
• 80-85% of simple renal calculi :Treated satisfactorily with ESWL.

11. ESWL:
• Principle: Bombarding of stones with High energy shock waves to disintegrate the
stones into fragments- small fragments pass down to ureter.
• Localization of stone for bombarding – Fluoroscopy or USG
• Physics of ESWL:The change in density b/w the soft renal tissue & hard stone
causes release of energy at the stone surface which causes “ Compression induced
tensile cracking of stone“.
• Incoming Shock waves – causes fragmentation of stones-Erosion & Shattering
• Gold standard / strongest Lithotripter for ESWL-Dornier Unmodified HM-3

12. SHOCKWAVESOFESWL:
Small fragmented stones:
Shock waves breaking the stone

13. ESWL

14. CONDITIONS WHERE ESWL MAY
FAIL :-
• Stone size > 2 cm, Multiple stone or Staghorn stone.
• Lower Calyceal location
• Marked hydronephrosis or scarring
• Calyceal diverticulum
• Horseshoe kidney
• Difficult stone : Brushite, Hydroxyapatite, Cystine & Calcium oxalate monohydrate (
BHC-2)

15. CONTRAINDICATION OF ESWL:
Absolute Relative Relative
Pregnancy UTI Obesity
Bleeding Disorder Unrelieved distal obstruction Severe Renal failure
Cardiac Pacemakers Aneurysm
Uncontrolled Hypertension
Severe orthopedic deformity

16. COMPLICATIONS OF ESWL:
• Infection – Main complication.
• Acute injury to the renal parenchyma: Hematuria & edema around thekidney.
• Chronic renal injury: Hypertension, Decrease renal function & Increase in rate of
stone recurrence.
• Lung Parenchymal Injury
• Steinstrasse ( street of stones gravel in ureter)

17. PCNL: PERCUTANEOUSNEPHROLITHOTOMY
• Indication:
(a) Size of stone > 2.5cm
( b) Multiple stones
(c) Stones not responding to ESWL( BHC-2)
(d) Central part of staghorn stone.

18. COMPLICATION OF PCNL
• Hemorrhage
• Perforation of the collecting system
• Perforation of the colon
• Perforation of the pleura
• Infections

19. Open Stone surgery :
Indication:
1.Anatomical abnormality(PUJO)
2. Non functioning kidney with stone
1.Pyelolithotomy
2.Extended pyelolithotomy
3.Nephrolithotomy
4.Partial nephrectomy

20. PYELOLITHOTOMY
Kidney –Mobilized &
Vascular Pedicle control
On the Pelvis: Give
Longitudinal incision over
the stone

21. EXTENDED PYELOLITHOTOMY
Indication:
Large Staghorn
Calculi & Calyceal
Stone

22. NEPHROLITHOTOMY:
• Indication: Complex calculus branching into the most peripheral calyces.
• Mobilized the kidney.
• Cross-clamp the renal pedicle to control the bleeding.
• Cool the kidney with ice pack( to increase the ischemic time)
• Incision given on Brodel’s Line: Posterior & parallel to the most convex part of the
kidney , where territories of the anterior and posterior branches of the renal artery
meet.

23. NEPHROLITHOTOMY
Stone
Brodel’s line

24. PARTIAL NEPHRECTOMY:
Indication:
• Stone in lowermost calyx
• Kidney containing stone area:
Nonfunctional.
• Xanthogranulomatous pyelonephritis.

25. Laparoscopic stone Removal
l

27. Management of Ureteric Calculus
Ureteric
calculus
Medical
Management
Surgical
Interventions

28. Indications for conservative treatment
􏰀 Size of the stone more than 5 to 8 mm
􏰀 IVU showing deterioration of function
􏰀 Co-existing infection
􏰀 If stone is impacted in the ureter with persistent
symptoms

29. Conservative management
 Plenty of water orally.
 Diuretic—oral frusemide to flush the stone.
 Suitable antibiotics to control sepsis; antispasmodics to
 relieve pain.
FLUSH THERAPY
 IVfluids—fast infusion of about 1.5 to 2 litres and
injection
 frusemide 60 to 80 mg. Usually given for 3 to 5 days.

30. o ureteric stones are always of renal origin.
o Nature of stones are same as that of renal stones.
So the medical management is same as renal stones

31. Surgical interventions for ureteric calculus
Siteofstone
Upper 1/3
Middle1/3
Lower 1/3

32. Upper 1/3 ureteric stone
1. ESWL for stone in upper third ureter.
The stone is pushed into the renal pelvis and then PCNL.is done.
2. URS—Ureterorenoscopic stone removal:
Through ureteroscope,stone is visualised and often fragmented using pneumatic
bombarder. It is then extracted by ureteroscope.
Complications :- perforation of ureter and extraperitoneal leakage of urine, bleeding.
3.Open ureterolithotomy through loin incision.

33. Middle 1/3 Ureteric stone
o URS.
o Open ureterolithotomy.

34. Lower 1/3 ureteric stone
oURS.
o Dormia basketing:
 Dormia basket is used to remove the
stone in the lower ureter. Single stone
less than 1 cm can be removed.

35. Dormia basketing
Indication
􏰀 Stone in lower third ureter
􏰀 Stone below pelvic brim
􏰀 Stone less than 10 mm size
􏰀 Single stone
Complications
􏰀 Stone dislodgement
􏰀 Urethral injury
􏰀 Avulsion of ureter
􏰀 Stricture ureter

36. Open ureterolithotomy
 Using cystoscope under general anaesthesia,
 ureteric meatotomy is done for stones impacted at the
ureteric orifice. It is released by cutting the orifice at upper
and lateral aspects.
 Note:
 All ureteric stones can be removed through laparoscopy or
retro- peritoneoscopy.

37. Management of Bladder stone
1. Cystoscopic litholapaxy
Under GA, cystoscope is passed and the stone is visualised. It is fragmented by pneumatic, laser, electromagnetic waves or mechanohydraulic
lithotripsy. The bladder is flushed using an irrigator (Freyer’s evacuator or irrigator or Ellik’s evacuator).
Contraindications
􏰀 Too large stone
􏰀 Too small stone. Too soft stone. Too many stones
􏰀 Stone in bladder diverticula
􏰀 Bladder tumour
􏰀 Contracted bladder
􏰀 Patient’s age below 10 years
􏰀 When patients general condition is poor, as the procedure
takes a longer duration it is avoided and open removal is advised

38. 2. Suprapubic open cystolithotomy
Through pfannenstiel incision, bladder is approached extra- peritoneally. Bladder is identified by its detrusor muscle
pattern, which is criss-cross and also its venous pattern.
Bladder is opened near the fundus and stone is removed.
Bladder is closed often with SPC using Malecot’s catheter and Foley’s catheter is passed per urethera.
Wound is closed in layers with a drain
3.Suprapubic percutaneous litholapaxy
This procedure is becoming popular. When cystoscope cannot be passed per urethra, bladder is approached
suprapubically.
Through a needle, guidewire and dilators, a track is created through which a nephroscope is passed to remove the
stone after fragmenting.
The cause is treated.