The document discusses different treatment options for renal and ureteric stones, including conservative management, extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy (URS), and open surgery. For renal stones less than 2cm, ESWL is recommended, while PCNL may be used for larger stones or when ESWL fails. URS is recommended for ureteric stones, with an 85-90% success rate in achieving a stone-free state. Complications, prevention strategies, and dietary and medication advice are also summarized.

1. Renal stones endoscopic management Dr sarwar noori mahmood F.I.C.MS(urology), F.E.B.U

2. Indications for treatment Presence of symptoms and /or obstruction in a functioning kidney

3. Treatment of Renal Stones Four Options 1) conservative , 2) non-invasive: ESWL 3) minimal invasive : PCNL, URS 4) open surgery New technology :  morbidity,  hospital stay,  invasiveness

4. Natural history of renal stones

6. Spontaneous clearance of stones takes place ONLY WHEN— 1.There is good flow of urine/function on the affected side & 2.There is no distal obstruction

7. MANAGEMENT OF RENAL CALCULI by ESWL < 2cm in diameter and/or surface area < 500 mm 2 Treatment : ESWL mono-therapy > 2cm in diameter and/or surface area > 500 mm 2 Treatment : PCNL +/- ESWL Combination therapy

8. Treatment of Renal Stones

9. ESWL

10. Generation of shock wave

11. T H E M A G I C W O R D--- LITHOTRIPSY EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY WHAT ARE SHOCK WAVES?

14. There should be a limited amount of gravel , which is expected to be passed out spontaneously within reasonable time limit , without causing much discomfort/colics .

15. IDEAL SITUATION FOR SUCCESSFUL E.S.W.L. Renal calculus of less than 2 cm having hetrogenous calcification/ architecture In X- ray , in a well functioning renal unit with no distal obstruction

19. Percutaneous nephrolithomy PCNL The key-hole surgery

20. Indication of PCNL: >2.5-3.0 cm failure of ESWL (matrix,cystine,ca oxalate monohydrate) cystine stone >1.5 cm lower calyx stone ≥ 2.0cm(narrow, long, acute angel infuldibulopelvic angel) caliceal diverticulum UU stone >1cm not respond to ESWL or difficult with URS.

21. FUCTIONAL ANATOMY OF KIDNEY FOR PERCUTANEOUS TECHNIQUE 1. VASCULAR 2. CALYCEAL 3. ANATOMIC RELATION

23. PERCUTANEOUS RENAL SURGERY PRE – OP WORK UP Urine culture Renal function test Haematological profile Caogulation profile KUB and IVU US .

24. Steps for PCNL Retrograde ureteric catheterization Fluoroscopy-guided percutaneous puncture(B-ultrasound for simple case) Tract dilation Lithotripsy Double-J stent and nephrostomy tube placement

25. ANAESTHESIA Epidural anesthesia (Most cases) G eneral anesthesia (Obesity and lung dysfunction) Local anesthesia （ for second-look ）

26. Body position prone position (most cases) side-lying position （ obesity 、 cardiorespiratory dysfunction ） supine position （ transplanted kidney ）

28. Retrograde ureteric catheterization 6Fr ureteric catheter open end Wash out small stones Prevent small stones moving from pelvis into ureter

30. AMPLATZ SHEATH Metallic Teflon

35. X-ray Ultrasonography Which one is better ？ 2 methods combination better.why?

49. Air pneumatic lithotripter Ho:YAG laser 3th generation EMS Which one is better?

50. Double-J stent and nephrostomy tube placement,Tubeless PCNL NOT common

53. PERCUTANEOUS RENAL SURGERY COMPLICATIONS 1. RENAL PELVIC PERFORATION 2. HAEMORRHAGE 3. INJURY ADJACENT ORGANS 4. UROSEPSIS 5. FLUID ABSORPTION 6. AV MALFORMATION

55. Ureteric stone

56. INDICATIONS FOR INTERVENTION: The classical indications for intervention are well known & include the following: * Presence of infection * Presence of obstruction * Persistent colic with no advancement of the stone * A stone more than 0.5 cm in diameter The classical indications have recently been modified because of the advent of new technology & the high expectations of today's patients. THERAPEUTIC OPTIONS: These include: * Surgery * Percutaneous surgery * Ureteroscopy with Electrohydraulic lithotripsy(EHL), Ultrasound lithotripsy, Laserlithotripsy, Electro-mechanical Impactor lithotripsy, & Lithoclast lithotripsy. * ESWL * Spontaneous passage

57. MANAGEMENT OF URETERIC STONES -Stones < 0.5 cm in diameter doesn’t pass spontaneously 4 to 6 weeks and /or causing symptoms : ESWL monotherapy -Stones > 0.5 cm in diameter & < 1 cm in diameter : ESWL monotherapy

58. MANAGEMENT OF URETERIC STONES Stones > 1 cm in diameter : trial of ESWL monotherapy Patient counselled: 1. Repeat session may be necessary 2. URS/PCNL/ureterolithotomy

59. RESULTS OF URETROSCOPIC LITHOTRIPSY (URS) Achieved stone free status = 85% to 90% Failures: 1. Access problems 2. Stone migration Flexible URS for upper third ureteric calculi especially in the male

60. URS complications: pain ,sepsis ,damage to ureteral mucosa and wall, failure

61. RENAL STONES

62. Nephrolithotomy

63. PREVENTION OF STONES 1. Treatment of causes 2. Dietary manipulations 3. Medications - indication duration

64. DIETARY ADVICE 1. Hydration 2. Avoid oxalate-rich food 3. Avoid calcium-rich food ? 4. Avoid refined carbohydrates 5. Increase crude fibres

65. MEDICATIONS 1. Thiazides 2. Allopurinol 3. Antibiotics 4. Sodium bicarbonate 5. Potassium citrate 6. Magnesium salts 7. Pyridoxine