1. Stone Diseases in Algeria: URS Replaces Slowly Open Surgery H. KOUICEM, Algeria Algerian Association of Urology

2. In Algeria, urolithiasis is a wide-spread health problem. Until recently, stone diseases were almost exclusively treated via open surgery, due to financial restrictions leading to a lack of minimally invasive technological infrastructure. Only recently, ureterorenoscopy and LASER stone fragmentation are introduced. Introduction Open Surgery Ureteroscopy

3. OPEN SURGERY T herapeutic Options available Until 2014 Roboflex Avicenna 2014 SWL PCNL Davancci Robot MET Laparoscopy Ureteroscopy

4. Study Cases A case series of 6 large ureter stones 1-2 cm are treated through a modern approach and would have otherwise undergone open surgery. The underneath mentioned cases reflect the endourological approaches adopted even going back to OPEN SURGERY though abrasive and morbid.

5. Case One Diagnosis Female, 36 Years L P U stone: 14 mm Possible Options MET Open surgery PCNL Ureteroscopy Laparoscopy Robot What would you opt for?

6. Diagnosis Male, 54 years One right kidney Anuria R L U stone: 14 mm Case Two Possible Options MET Open surgery PCNL Ureteroscopy Laparoscopy Robot What would you opt for?

7. Case Three Diagnosis Female, 35 years L P U stone: 15 mm Possible Options MET Open surgery PCNL Ureteroscopy Laparoscopy Robot What would you opt for?

8. Case Four Diagnosis Male, 47 years R P U stone: 10 mm MET failed Possible Options MET Open surgery PCNL Ureteroscopy Laparoscopy Robot What would you opt for?

9. Case Five Diagnosis Male, 44 years L L U stone: 22 mm Possible Options MET Open surgery PCNL Ureteroscopy Laparoscopy Robot What would you opt for?

10. Case Six Diagnosis Female, 56 years R K stone : 20 mm Possible Options MET Open surgery PCNL Ureteroscopy Laparoscopy Robot What would you opt for?

11. EAU Recommendations EAU Algorithm 2014 Recommendations for MET LEGR For MET, α-blockers are recommended 1aA Patients should be counselled about the attendant risks of MET, including associated drug side effects, and should be informed that it is administered off-label ϯ ** A* Patients who elect for an attempt at spontaneous passage or MET, should have well-controlled pain, no clinical evidence of sepsis, and adequate renal functional reserve. A Patients should be followed once between 1 and 14 days to monitor stone position and be assessed for hydronephrosis. 4A* Stone location and sizeFirst choiceSecond choice Proximal ureter < 10 mmSWL Proximal ureter > 10 mmURS (retrograde or antegrade or SWL Distal ureter < 10 mmURS or SWL Distal ureter > 10 mmURSSWL Recommended treatment option (if indicated for active stone removal) (GR: A*)

12. EAU Guidelines 2014 Kidney stones Complex stone burden Failure of SWL, PNL, or ureteroscopic procedure Intrarenal anatomical abnormalities: infundibular stenosis; stone in the calyceal diverticulum (particularly in an anterior calyx); obstruction of the ureteropelvic junction; and stricture if endourologic procedures have failed or are not promising Morbid obesity Skeletal deformity, contractures and fixed deformities of hips and legs Comorbidity Concomitant open surgery Non-functioning in lower pole (partial nephrectomy), non-functioning kidney (nephrectomy) Patient choice (after failed minimally invasive procedures, a single procedure avoiding the risk of multiple PNL procedures might be preferred by the case) Stone in an ectopic kidney where percutaneous access and SWL may be difficult or impossible. For the paediatric population, the same considerations apply as for adults. Indications for open surgery

13. Fallouts Sometimes, though financial resources and technical platforms are available, the urologist is obliged to opt for a decision that does NOT logically shadow the EAU Recommendations!!!

14. Case One URS scheduled. Spontaneous stone passage through MET after 3 weeks.

15. Case Two Semi-rigid ureteroscopy. Fragmentation with ballistic lithotripter. Post-OP JJ.

16. Case Three Semi-rigid ureteroscopy. Fragmentation with ballistic lithotripter. Post-OP JJ.

17. Cases Four & Five Case Four Case Five Fragmentation with semi-rigid ureteroscope LASER. Post-OP JJ.

18. Case Six The stone was found embedded in the ureteropelvic junction. Up to 50% of the stone was fragmented with flexible LASER. Cloudy urines observed. JJ placed. Treatment completed using delayed SWL.

19. Comments Though MET and Open Surgery are still practiced due to t he restricted financial resources of patients as well as the availability and the limits of the technical platforms; URS is gaining ground slowly !

20. Patients? Technical platforms & Human resources? Guidelines & Protocol? What are the appropriate treatment choices to be recommended? All in All

21. Open surgery has been the main if not the only treatment for stones in Algeria. Ureteroscopy has opened a path towards minimally invasive surgery in our country:  It has re-instated confidence in the use of conservative treatments as a first option.  Algeria has embarked towards a path to negligibly aggressive modern stone treatment. The successful management of all aspects of stones treatment requires both competence and equipments. The Algerian urologist is obliged to find the best solution to relieve his patients’ sufferings; nevertheless reality is rather problematic! Conclusions