Surgical Intervention
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