Palestinian Board of Surgery Residency Training Programme Prepared by :-Dr. Hazem El haddad

Recent management Of Urolithiasis

Treatment of the stone Depends on : Stone location The primary goal of surgical stone management is to achieve maximal stone clearance with minimal morbidity to the Patient. Depends on : Stone location Stone burden Kidney function Availability of man power Availability of instrument

MANAGEMENT (3 Principles) Recognize Emergencies Adequate Analgesia Impact of size and location

Emergencies Sepsis with obstruction (struvite stones?) Anuria ARF Urologic consultation

Hospitalization? Emergencies Refractory Nausea Debilitation Extremes of age Refractory Pain

Renal Colic/Ureter Colic Patent pain colic NSAID Morphine Morphine like drugs : Tramadol Medical expulsion therapy for stone < 5mm Alpha blocker

Manage The Stone After adequate analgesia and ruling out emergencies Principles here are stone size and location

Probability of Stone Passage Stone location and size Probability of passage (%) Proximal ureter > 5 mm 5 mm 57 < 5mm 53 Middle section of ureter 20 38 Distal ureter 25 45 74

Treatment Modalities for Renal and Ureteral Calculi Treatment Indications Advantages Extracorporeal Radiolucent calculi Minimally invasive shock wave Renal stones < 2 cm Outpatient lithotripsy Ureteral stones < 1 cm procedure Limitations Complications Requires spontaneous passage Ureteral obstruction by of fragments stone fragments Less effective in patients with Perinephric hematoma morbid obesity or hard stones

Treatment Modalities for Renal and Ureteral Calculi Treatment Indications Advantages Ureteroscopy Ureteral stones Definitive Outpatient procedure Limitations Complications Invasive Ureteral stricture or Commonly requires injury postoperative ureteral stent

Treatment Modalities for Renal and Ureteral Calculi Treatment Indications Advantages Ureterorenoscopy Renal stones < 2 cm Definitive Outpatient procedure Limitations Complications May be difficult to clear Ureteral stricture or injury fragments Commonly requires postoperative ureteral stent

Treatment Modalities for Renal and Ureteral Calculi Treatment Indications Advantages Percutaneous Renal stones >2 cm Definitive nephrolithotomy Proximal ureteral stones > 1 cm Limitations Complications Invasive Bleeding Injury to collecting system Injury to adjacent structures

Kidney stone With huge hydronephrosis or pyonephrosis : Percutaneous Nephrostomy is mandatory aim to improve kidney function

Kidney stone without enlargement of collecting system < 5mm Watchful waiting ESWL 5mm – 20 mm PcNL if no urologist  open surgery

Kidney stone without enlargement of collecting system > 20 mm ESWL + Double J PcNL Open surgery Staghorn stone ESWL (fractional)

Efficacy of ESWL Stone size Stone free rate (%) < 10 mm 10 – 20 mm ca oxalate monohydrate cystine < 15 mm > 20 mm 84 (40 – 92) 77 (50 – 85) 38 – 81 60 – 63 71 40

Efficacy of PcNL Stone size Stone free rate (%) < 20 mm In lower calyx 10 – 20 mm 84 much better than ESWL

Retreatment of ESWL Maximal 3-5 times depends on : type of the machine For electrohydrolic intent 4-5 days For Piezoelectric ± 2 days

Staghorn stone Open surgery Sandwich PcNL and ESWL

Ureter Anatomy Narrowing of ureter UPJ Crossing with iliac vessel intramural

Treatment of Ureteric stone depends on : Size Location Complication Obstruction Infection Kidney function

Treatment of Ureteric stone Observation : for stone less than 5mm except for : Infection Intractable pain Single kidney Transplant kidney Reduced kidney function M E T Diuresis 2 liter/24 hours NSAID Alpha blocker

Treatment of Ureteric Stone Location Treatment Proximal < 1 cm ESWL URS lithotripsy Ureterolithotomy > 1 cm PcNL URS + Lithotripsy

Treatment of Ureteric Stone Distal < 1 cm URS + Lithotripsy ESWL Ureterolithotomy > 1 cm URS – Lithotripsy Ureterolithotomyy

Bladder stone < 2 cm  lithotripsy > 2 cm  Endoscopic Holmium YAG Pneumatic Electrohidrolyc Ultrasound > 2 cm  Open surgery

Urethral stone Holmium Laser (Endoscopy) Push back  bladder stone

Sources IAUI Guidelines Penatalaksanaan penyakit batu saluran kemih, 2007 Pocket Guidelines EAU 2010

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