URINARY STONE DISEASES SURGICAL MANAGEMENT

• Most patients harboring “simple” renal calculi can be treated satisfactorily with SWL. However, there are other patients who are unlikely to achieve a successful outcome with SWL

Factors associated with poor stone clearance rates after SWL

• Large renal calculi• Stones within the collecting system• Stones of certain composition (cystine,

calcium oxalate monohydrate, and brushite) • Obesity

Alternative treatment

• Alternative treatment modalities, such as ureteroscopy or PNL, should be considered for patients whom didn’t meet criteria

• Open surgery

Calyceal stone

• Most calyceal stones, in the absence of intervention, are likely to increase in size and cause symptoms of pain or infection.

• Seventy-seven percent of patients experienced progression of calculi, with 26% requiring surgical intervention.

• Those patients who initially presented with calculi larger than 4 mm were more likely to fail observation than were patients with smaller solitary calculi.

Stone Factor• For patients harboring nonstaghorn stones smaller than 10

mm, SWL is usually the primary approach. • For patients with stones between 10 and 20 mm, SWL can

still be considered a first-line treatment unless factors of stone composition, location, or renal anatomy suggest that a more optimal outcome may be achieved with a more invasive treatment modality (PNL or ureteroscopy).

• Patients with stones larger than 20 mm should primarily be treated by PNL unless specific indications for ureteroscopy are present (e.g., bleeding diathesis, obesity).

Indications for active stone removal

• Spontaneous stone passage can be expected in up to 80% in patients with stones < 4 mm in diameter.

• For stones with a diameter > 7 mm, the chance of spontaneous passage is very low .

• The overall passage rate of ureteral stones is:• Proximal ureteral stones: 25%.• Mid-ureteral stones: 45%.• Distal ureteral stones: 70%.

INDICATION OF STONE REMOVAL

Open surgery

• There are no strict guidelines that define which patient should undergo an open surgical procedure for stone removal.

• Some indications, such as a stone burden too large for PNL, clearly rely on the surgeon’s judgment and experience and the availability of equipment.

• Nephrectomy remains an option for patients with nonfunctioning kidneys or stone disease with a normal contralateral kidney.

• Partial nephrectomy is also an option for a stone in a localized area of irrevocably poor function.

• In addition, patients with an associated anatomic abnormality requiring open operative intervention, such as UPJ obstruction and infundibular stenosis, may be candidates for an open surgical approach.

When Open Surgery Must be Conseidered ?

• A stone burden too large for PNL• Non functional stone obstructed kidney with

normal contralateral kidney Consider nephrectomy

• PUJO by stone or large stone within collecting system

• infundibular stenosis

Nephrectomy as the last resort

• Nephrectomy should be the last resort, being acceptable only when the kidney has had an irreversible loss of function to less than 10 percent of normal, even with normal contralateral function.

Kind of open surgery

• Ureterolithotomy• Pielolithotomy• Bivalve nephrolithotomy• Nephrectomy• Vesicolithotomy

Approach ?

Flank approach • Sub costal• Intercostal• LumbotomyAbdominal approach• Laparotomy• Sectio alta

UreterolithtotomyTo the Upper Third. • Use a lumbotomy incision for high stones and a subcostal or

supracostal incision for a stone approaching the middle third or one located in a dilated ureter such that it might fall back into the renal pelvis.

• A Foley muscle-splitting incision is useful if the stone is impacted just below the ureteropelvic junction, usually in line with the lower margin of the kidney.

• A midline incision is used if much of the ureter must be exposed or if it needs to be approached transperitoneally because of previous extensive extraperitoneal procedures

Flank approach – Sub costal incision

Posisioning – Jack Knife position

Incision: Start the incision at the lateral border of the sacrospinalis muscle, 1 cm below the lower edge of the 12th rib.

Follow the lower border of the rib anteriorly, curving the incision caudally as it crosses the anterior abdominal wall to avoid the subcostal nerve.

With a rudimentary 12th rib, place the incision well below the 11th rib.

Incise :1. Latissiumus dorsi and serratus posterior inferior muscles, cutting back

from their anterior free borders2. External and internal oblique muscles starting at their posterior free

border, and incise the serratus posterior inferior muscle. Watch for the 12th intercostal neurovascular bundle that lies between the internal oblique and transversus abdominis muscles.

Incise lumbodorsalis fascia

After lumbodorsalis fascia incised, we must see retroperitoneal fat.

Then we push the fat anteriorly to exposing gerota fascia

When we need large expose, then we may need to cut costo-vertebral ligament with mayo scissors advanced curved side down to avoid cutting theintercostal artery or entering the pleura, which lies beyond the tip of the transverse process. Free the subcostal nerve further, and move it superiorly. Insert a self-retaining retractor, and proceed with entry into Gerota's fascia.

• To perform ureterolithotomy from this approach we must indentify proximal ureter from kidney pelvic

Fixate ureter by bebcock

Incise ureter

Extract stone

Close the ureter to make it watertight either by loosely tying the stay sutures or by putting one or two 4-0 SAS through the adventitia only.

Do not constric the ureter because some edema is to be expected.

Pyelolithotomy• Draw the hilum anteriorly with vein or Gil-Vernet

retractors placed in the lip (not shown). • Incise the pelvis transversely in the form of a U, starting

with a hooked blade and continuing with Potts scissors. • Stay well away from the ureteropelvic junction. If small

stones are present, pass an 8 F infant feeding tube though the ureteropelvic junction to prevent stone migration.

• Stay sutures may not be needed; they can tear the tissue.

BIVALVE NEPHROLITHOTOMY--INTRODUCTION

• Extracorporeal shock wave therapy and endolithotripsy can manage most renal calculi, but for large stones the results from open surgery are as good as, if not better than, those from closed methods and can be done in one operation, at the cost of a longer convalescence.

• The patient should be referred to a center specializing in renal reconstructive surgery when : caliceal stenosis is present and calicoplasty or calirrhaphy is needed to improve intrarenal drainage, when partial nephrectomy is indicated, when the ureteropelvic junction is obstructed, when the stone is very large or does not respond to lithotripsy (cystine), and when the patient's body size, obesity, or other factors contraindicate minimally invasive procedures.

Imaging and Lab’s pre operative assessment

• Intravenous urography with oblique and delayed films allows appreciation of the size and configuration of the stone and shows any obstruction.

• Retrograde urography may be needed to outline the ureter. • Voiding cystography demonstrates the presence or absence of

reflux. • Renal angiography is very useful for staghorn stones to

delineate the vascular supply prior to renal incision. • Total renal function is measured by serum creatinine level.• Perform urine culture and sensitivity testing, and begin

intravenous administration of antibiotics at least 48 hours preoperatively, if indicated

Preparation of bevalve –Renal hypothermia

• The soft ice, formed by freezing, is available as a sterile solution in liter bottles.

• Slush is formed by placing the bottles of physiologic irrigating fluid as a commercially synthesized ultrafiltrate of plasma in a freezer or refrigerator for 4 hours.

• During the last 2 hours each bottle is shaken vigorously every 20 to 30 minutes to ensure that the ice forms as small, soft crystals.

• Form a dam from an 18 X 24 inch rectangular latex rubber sheet with a 9-inch slit in the center, stretched around the kidney and clamped closed around the pedicle, over a laparotomy tape for insulation.

• Alternatively, place a plastic bag over the kidney and make a second opening through which the kidney is delivered.

Flank approach

• Sub costal or intercostal incision (A supracostal 11th- or 12th-rib approach)

CalcicoplastyA, Approximate the cut edges of adjacent calyces with 6-0 CCG on half-circle taper needles. Use a cross-stitch technique to place the knots outside.Tie the suture while depressing the intervening fat with an angle retractor. The finished suture line is shown in Step 9.

Calicoplasty by YV-plasty technique, combining the nfundibula into a single unit:

B, Incise the adjacent walls of both calyces. C and D, Suture the edges of bothinfundibula together to form a single unit.

Kidney Closure

A, Close the capsule with a running lock stitch of 4-0 CCG.

B, Alternatively, place mattress sutures over fat bolsters or Spongestan hemostasis

LOWER URINARY LITHIASIS

• Bladder stones are the most common manifestation of lower urinary tract lithiasis, currently accounting for 5% of all urinary stone disease and approximately 1.5% of urologic hospital admissions in industrialized Western nations

PRIMARY BLADDER CALCULI• these stones develop in the absence of any known

functional, anatomic, or infectious factors and does not necessarily imply that stones have formed de novo in the bladder (Andersen, 1962).

• Primary bladder calculi are most common in children younger than the age of 10, with a peak incidence at 2 to 4 years of age (Valyasevi and Van Reen, 1968; Thalut et al, 1976; Teotia and Teotia, 1990; Ali and Rifat, 2005).

• Stones are usually solitary and, once removed, rarely recur • Primary bladder calculi are more common in children

exposed to low-protein, low-phosphate diets.

SECONDARY BLADDER CALCULI

• typically found in men older than the age of 60 and usually in concert with lower urinary tract obstruction

• Secondary bladder calculi are generally associated withbladder outlet obstruction.

• Patients with spinal cord injury are at increased risk of bladder stone formation.

• Intermittent catheterization decreases the risk of bladder stone formation over an indwelling catheter

Bladder calculi and bladder cancer• Bladder calculi may be associated with urothelial

malignancy, certainly as a byproduct of malignancy in terms of encrustation of bladder tumor or necrotic areas of tissue after transurethral resection of bladder tumor (Smith and O’Flynn, 1975).

• The presence of bladder stones may also promote malignant change through chronic irritation of the bladder mucosa, similar to the link previously noted between mucosal irritation and inflammation from long-term indwelling catheters and squamous cell bladder cancer

CLINICAL PRESENTATION

• The most common presenting symptom of bladder calculi is macroscopic hematuria, which generally is terminal

• Intermittency, frequency, urgency, dysuria, decreased force of the urinary stream, incontinence, and lower abdominal pain aggravated by brisk movement may also be present

SURGICAL APPROACH

MINIMALLY INVASIVE• Transurethral Cystolitholapaxy and Lithotripsy• ESWL• Percutaneous CystolithotomyOPEN CYSTOLITHOTOMY (VESICOLITHOTOMY)