Indications for active removal of stones:

• Choice of treatment or patient preference
• Comorbidity (eg hypertension, diabetes, obesity, dyslipidemia & gout)
• Infection (eg pyelonephritis)
• Obstruction caused by stones
• Patients who are high-risk stone formers
• Stone size of ≥6 mm after a period of watchful waiting
• Symptomatic stones (eg presence of pain & hematuria)

Special problems encountered in stone removal:

• Presence of caliceal diverticulum stones
• Patient has horseshoe kidneys
• Patients w/ uteropelvic junction (UPJ) obstruction

Extracorporeal Shockwave Lithotripsy (SWL)

• A noninvasive & non aesthetic procedure, & the first choice of treatment for stone <1.5cm
• Success depends on the efficacy of the lithotriper & some factors:
  • Size, composition & location of the stones
  • Patient’s habitus
  • Performance of extracorporeal shockwave lithotripsy (SWL)

• Contraindications include:
  • Arterial aneurysms
  • Anatomical destruction distal to the stones
  • Bleeding diathesis
  • Infection
  • Severe skeletal malformations
  • Severe obesity
  • Uncontrolled urinary tract infections (UTIs)

Percutaneous Nephrolithotomy (PNL)  

• Standard procedure for large renal calculi
• Different rigid & flexible endoscopes are used in this procedure & it depends on the preference of the surgeon
• Contraindications include:
  • Patients on anticoagulant therapy
  • Untreated UTI
  • Tumor in the presumptive access tract area
  • Potential malignant kidney tumor
  • Pregnancy

• Complications associated w/ PNL:
  • Fever
  • Bleeding
  • Urinary leakage
  • Problems due to residual stones
  • Steinstrasse
    • Accumulation of stone fragments or stone gravel in the ureters
    • Major factor for its formation is the size of the stone
    • If asymptomatic, then conservative treatment is the initial option
    • For steinstrasse associated w/ UTI & fever, percutaneous nephrostomy is indicated
    • When large stones fragments are present, shockwave lithotripsy is indicated

Uteroscopic Lithotripsy - Rigid & Flexible (URS)

• A minimally invasive procedure that is used for both ureteric & renal stones as an alternative treatment to extracorporeal shockwave lithotripsy (SWL)
• Can be performed under a local, intravenous or general anesthesia
• URS may be used in patients who had failed previous treatment attempts, stones too large for SWL, strictures, tumors, stones in children, those w/ bleeding disorders & obese
• Stone-free rate status w/ larger stones is achieved earlier w/ URS