Surgical management of urolithiasis

1. SURGICAL MANAGEMENT OF
UROLITHIASIS
By Dr Mengistu.K (GSR IV)
Moderator Dr Getachew( Urosurgeon)
May, 2021
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2. Outlines
• Objective
• Introduction
• Diagnostic evaluation
• Management
• Summery
• Referance
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3. Objective
• To discuss on management of urolithiasis
focusing on surgical managements
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4. Introduction
• Urinary stones are polycrystalline aggregates
composed of varying amounts of crystalloid
and organic matrix.
• Third most common affliction of the urinary
tract, exceeded only by UTI and pathologic
conditions of the prostate.
• Site of stone formation has migrated from the
lower to the upper urinary tract.
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5. • Epidemiology
– Prevalence rates for urinary stones vary from 1%
to 20%.
– Rise in stone incidence and prevalence due to rise
in the detection of asymptomatic calculi.
• Risk factors
– Gender, age, geography, climate, occupation, BMI
and water
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6. Types of stones
• Calcium Nephrolithiasis (75%)
– Calcium oxalate (70%)
– Calcium Phosphate (5-10%)
• Uric Acid Nephrolithiasis(10-15%)
• Struvite (15-20%)
• Cystine (1%)
• Drug-Induced (1%) [Triamterene, Indinavir
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7. • Predictors of stone recurrence
– younger age
– male sex
– family history
– prior stone event
– non obstructing renal stones
– Symptomatic renal pelvis/lower pole stones and
uric acid composition.
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8. Stone Formation
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9. Compositions of nephrolithiasis
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10. Diagnostic evaluation
• Clinical evaluation
• Investigations
– Base line investigations
– Radiological evaluation
– Metabolic evaluation
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11. 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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12. 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)
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13. Basic laboratory analysis
• Analysis of stone compossion
• Urine analysis
– PH- acidic urine- uric acid & cystine stone
– Alkaline urine- struvites , calcium phosphate
• Specific gravity- concentrated urine-↑se risk
• Microscopic Urine crystals analysis
– Hexagon shape crystal : Cystine
– Coffin-lid shape crystal : Struvite
– Diamond shape crystal : Uric Acid
– Envelope shape crystal : Calcium oxalate
• Urine culture
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14. Analysis of stone composition
• Should be performed in all first-time stone
formers
• Repeat stone analysis is needed in the case of:
– Recurrence under pharmacological prevention
– Early recurrence after interventional therapy with
complete stone clearance
– Late recurrence after a prolonged stone-free
period
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15. • Diagnosis in special groups and conditions
– Diagnostic imaging during pregnancy
– Diagnostic imaging in children
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16. 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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17. 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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18. Non-contrast-enhanced CT
• The goldstandard 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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19. Metabolic evaluation
• Blood Biochemistry
• Urine examination
• 24-hours urine
examination
Common metabolic
abnormalities
• Hypercalciuria
– Absorptive
– Renal
– Resorptive
• Hyperparathyroidism
• Hyperoxaluria
• Hyperuricosuria
• Hypocitraturia
• Hypercalcemia
• Hyperuricemia
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20. 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
– Percutaneous irrigation chemolysis
– Oral chemolysis
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21. • General recommendations and precautions
for stone removal
– Antibiotic therapy
– Antithrombotic therapy
– Obesity
– Stone composition
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22. • Surgical management options
• Minimally invasive
– ESWL
– Percutaneous Nephrolithotomy
– Ureterorenoscopy
– Laparoscopic Approach to stones
• Open surgery
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23. Extracorporeal shock wave lithotripsy
(SWL)
• Shock waves generation
– Electromagnetic
– Electrohydraulic
– Piezoelectric
• Focused at stone
• Fragmentation
– Spall fracture
– Squeezing-splitting or
circumferential
compression
– Shear stress
– Superfocusing
– Cavitation
• Four main elements
– Energy source
– Focusing device
– Coupling device
– Localization device
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24. • The success of SWL
depends
– The efficacy of the
lithotripter
– size, location (ureteral,
pelvic or calyceal), and
composition (hardness) of
the stones and patient’s
habitus
– performance of SW
• Best clinical practice
– Stenting
– Pacemaker
– Shock wave rate
– Number of shock waves,
energy setting and repeat
treatment sessions
– Improvement of acoustic
coupling
– Pain control
– Antibiotic prophylaxis
– Medical therapy after SWL
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26. • Contraindications of extracorporeal SWL:
– Pregnancy, due to the potential effects on the
fetus
– Bleeding diatheses
– Uncontrolled UTIs
– Severe skeletal malformations and severe obesity,
which prevent targeting of the stone;
– Arterial aneurysm in the vicinity of the stone
– Anatomical obstruction distal to the stone.
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27. Shock wave lithotripsy-related complications
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28. 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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30. • Best clinical practice
– Antibiotics
– Anesthesia
– Pre-operative imaging
– Positioning of the
patient
– Puncture
– Intracorporeal lithotripsy
– Dilatation
– Choice of instruments
– Nephrostomy and stents
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31. • 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.
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32. • Post op
– Keep transurethral catheter for 6-24 hrs and
nephrostomy for 3 days
– Nephro-uretero-tomography is performed prior to
removal
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33. Complications
• Fever 10.8%
• 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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34. Ureteroscopic Stone Management
• Rigid ureteroscope: tip
diameter of < 8 French
(F)
– Lower ureteric stone
– Mid ureteric stone
– Upper ureteric stone – in
some cases
• Flexible ureteroscope –
very costly
– Upper ureteric stone
– Small renal stone
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35. • Best clinical practice in
ureteroscopy
– Access to the upper urinary
tract(retrograde and
antegrade
– Safety aspects
– Ureteral access sheaths
– Intracorporeal extraction
lithotripsy
– Stenting before and after URS
– Medical expulsive therapy
after ureteroscopy
• Complications
• Intraoperative
– Stone migration into the ureteral wall
– Mucosal trauma
– Ureteral perforation
– Ureteral avulsion
• Early Postoperative
– Gross hematuria
– Renal colic
– Residual stone
– Pyelonephritis
– Urinoma
– Ureteral stent symptoms
• Late Postoperative
– Ureteral stricture
– “Forgotten” encrusted ureteral stent
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36. Management of renal stone
• Optimal treatment for a given patient is not
always clear and depends on 3 factors
Stone related
factors(the most
important factor )
Anatomic factors Clinical factors
Size
Number
Location
Composition
Obstruction or stasis
Hydronephrosis
Ureteropelvicj unction
obstruction
Calyceal diverticulum
Horseshoe kidney
Renal ectopia or fusion
Lowerpole
Infection
Obesity
Body habitus deformity
Coagulopathy
Juvenile
Elderly
Hypertension
Renal failure or transplant
Solitary kidney
Urinary diversion
Pregnancy
Patient symptoms
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37. 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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38. Treatment algorithm of renal stones
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40. Staghorn stone
• 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
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41. • 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
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42. 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
malformation causing 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
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43. • Stones larger than 20 mm
– PNL
– Ureteroscopy: bleeding diathesis, obesity).
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44. 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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45. Renal Anatomic Factors
 Ureteropelvic Junction Obstruction
• 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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46. Horseshoe kidney and Renal ectopia
– 15-20% have stone disease
– Most are Ca oxalate stones
– Commonly located at renal pelvis and posterior lower pole calyces
– SWL,URS, PCNL, Laparascopy
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47. 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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48. Over all passage rate of ureteral stone
• Spontaneous passage by location
– Proximal ureteral stone: 25%
– 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
• 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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49. 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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50. Treatment algorithm of ureteral stones
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51. Expectant management
• Candidate
– Stone < 6mm
– Normal renal function
– Well controlled pain
– Non obstructed
– Non infected
• Observation period 2-
4weeks
• 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%
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52. 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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53. Treatment Decision by Stone Burden
• In cases of high stone burden SWL is less effective
and needes 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
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54. 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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55. 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
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56. • 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
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57. 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 stone. 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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58. Indication for open renal surgery
• Failure of , or C/I to SWL or PNL
• Associated anatomic abnormalities
• Stone so large & complex
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59. Surgical techniques
 Approaches to the kidney
• Flank Approaches
– Eleventh rib incision (classic flank):
Better access to renal hilum and upper
pole
– Subcostal flank incision
• Anterior Approaches
– Subcostal transperitoneal incision
– Bilateral subcostal transperitoneal
incision
– Thoracoabdominal incision
– Midline Abdominal Incisions
– Infraumblical incision
– Inguinal incision
Posterior approach
• Excellent procedure
for pylolitotomy and
upper third
ureterolitotomy
• Decreased pain and
shorter hospital stay
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60. 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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61. • Partial nephrectomy : lower pole stone +
infective destruction of parenchyma
• Nephrectomy : kidney destroyed by ;
obstruction + infection ( xanthogranulomatous
pyelonephritis
• Calyceal diverticulolithotomy : calyceal
diverticular stone
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62. Anatrophic Nephrolithotomy
• Gerota’s fascia is incised in cephalo-caudal direction
• The kidney is mobilized and the perinephric fat is
dissected of the capsule
• If the capsule is inadvertently incised, it can be
closed by fine catgut suture
• Main renal artery and posterior branch are identified
and dissected
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63. • Renal pelvis and ureter are identified but not
dissected
• Avascular plane is identified
– Clamping the posterior segmental artery and injecting
20ml of methylene blue IV
– Using Doppler to localize area of minimal blood flow
– Using the brodel’s line after clamping the renal pedicle
• Incising the renal capsule at the lateral convexity of
the kidney and parenchyma incision is made 1-3cm
posterior to it
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64. 64

65. 65

66. • 25mg mannitol administered
• Bowl bag and dry packs re placed around the
kidney
• Iced slush applied to core temperature of the
kidney to15-20min
• The renal parenchyma is bluntly dissected with
the back of the scalpel handle
• The ideal location to enter the collecting system
is at the base of the posterior infundibulum
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67. 67

68. • After removal of all stone fragments, the renal
pelvis and calyces are copiously irrigated with
cold saline and the irrigant is aspirated
• Double J stent placed from the renal pelvis to
the bladder
• Reconstruction of the intrarenal collecting
system with correction of coexistent anatomic
abnormalities that may be present
• 5-0 or 6-0 chromic catgut sutures.
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69. • The renal capsule is closed with a running lock stitch of
4-0 chromic catgut suture or mattress sutures over
bolsters can be used.
• After capsule is repaired the renal artery is unclamped
and kidney is seen for hemostasis, color and turgor
• The kidney and proximal ureter are covered by Gerota’s
fascia omentum
• A Penrose or suction-type drain is placed within
Gerota’s fascia and brought out through a separate
stab incision
• Avoide nephrostomy tubes infection risk
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70. Pyelolithotomy
• Mobilization of the kidney after gerota’s fascia is
incised.
• The renal pelvis and upper ureter are identified and the
pelvis is approached posteriorly
• Two stay sutures are placed in the renal pelvis using 4-
0 chromic suture and a longitudinal incision made
• Removal of all stones
• The renal pelvis is closed with a 4-0 chromic
continuous suture.
• Drainage of the system is performed as described
previously
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71. Extended Pyelolithotomy
• The dissection is carried subparenchymally to
expose the renal pelvis and the infundibula.
• A curvilinear pyelotomy incision is made over
the stone and then extended to the superior
and inferior calyces.
• Stone removal
• The collecting system is closed with a
continuous 4-0 chromic catgut suture
• Drainage
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72. Ureterolithotomy
• The flank or posterior lumbotomy incision can be used
for the upper ureter
• An anterior extraperitoneal muscle splitting incision
can adequately expose the mid-ureter
• The lower ureter can be accessed via a Gibson,
Pfannenstiel, or midline suprapubic incision
• Distal ureterolithotomy, exposure of the ureter
requires certain other maneuvers.
– Identifying the iliac vessels
– Dividing the obliterated umbilical vessels can help.
– The bladder is reflected medially and kept decompressed
with a Foley catheter
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73. Upper ureterolithotomy
• Gerota’s fascia is opened and the upper ureter is
identified
• A Babcock forceps or vessel loop is placed on the ureter
above the stone expose the ureter downward
• A vertical ureterotomy and stone extraction
• Carefully irrigate the entire ureter and put double J stent
• Close the incision longitudinally with simple interrupted
5-0 sutures placed 1–2 mm apart.
• A Penrose or suction drain
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74. Postoperative management
• Intravenous fluids
• Postoperative antibiotics for 5–7 d 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-upintravenous
pyelogram is obtained
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75. 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
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76. 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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77. 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
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78. Open Surgery
• Open cystolithotomy
– Associated with the need for prolonged catherization
and hospital stay
– If transurethral or percutaneous access to the bladder is
contraindicaed
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79. 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 Urinary
Diversions
– Causes : infection,
metabolic abnormalities,
and anatomic and
structural factors
– Mgt depends on type of
diversion
• Bladder Calculi in Patients
With Spinal Cord Injury
– Stone formation peaks at 3
months after injury
– Managed as general
population
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80. Urethral Calculi
• 0.3% to 1% of all stone
disease
• Obstructing urethral
calculus is a 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 prostatic and
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
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81. • 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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82. Summery
• Urinary stones are third most common affliction
of the urinary tract, exceeded only by UTI and
pathologic conditions of the prostate.
• Site of stone formation has migrated from the
lower to the upper urinary tract
• Radiographic evaluation Cornerstone in the
evaluation of stone disease
• PCN is the standard procedure for large renal
calculi
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83. Reference
• Campbell-walsh-wein urology twelfth edition
• European Association of Urology 2020 edition
• CURRENT CLINICAL UROLOGY
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