1. Selected Clinical Topics in Urology This presentation was created with funding from Pfizer Inc.

2. Surgical Stone Management Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419

3. Surgical Stone Management  Shock Wave Lithotripsy (SWL)  Ureteroscopy  Percutaneous Stone Treatment Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419

4. Surgical Stone Management Shock Wave Lithotripsy (SWL) Introduction  Since its introduction in 1980, SWL has revolutionized the management of renal and ureteral stone disease and remains the preferred treatment of renal lithiaisis and proximal ureteral stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419

5. Surgical Stone Management  Optimal fragmentation with SWL should result in fragment which should pass easily Shock Wave Lithotripsy (SWL) Introduction Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419

6. Surgical Stone Management  In the physics of lithotripsy, the exact mechanism, which results in fragmentation, has not been completely elucidated  It appears that cavitation mechanics plays the major role in fragmentation Shock Wave Lithotripsy (SWL) Physics of Fragmentation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419

7. Surgical Stone Management Shock Wave Lithotripsy (SWL) Physics of Fragmentation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419

8. Surgical Stone Management Shock Wave Lithotripsy (SWL) Indications for SWL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The most common indication for a SWL is renal calculous disease  Renal stones < 2 cm in diameter, proximal ureteral stones < 1 cm in diameter, and distal stones < 10 mm in diameter can be treated with SWL  Some types of stones are more successfully fragmented with SWL (ie, calcium oxalate dihydrate, uric acid, calcium apatite) compared to more SWL resistant stones (cystine, calcium oxalate monohydrate).  Non urologic indications for SWL include pancreatic and biliary calculi

9. Surgical Stone Management Shock Wave Lithotripsy (SWL) Special Considerations Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  PediatricAge Group  All children require general anesthesia irrespective of whether they are being treated on an older generation, or second or third generation lithotriptor  Solitary Kidney  Investigators have demonstrated that SWL can result in decreased GFR in patients treated for renal lithiasis that have solitary kidneys  Given this finding, patients with solitary kidneys that are treated with SWL should have long term monitoring of their renal function GFR: Glomerular Filtration Rate

10. Surgical Stone Management Shock Wave Lithotripsy (SWL) Special Considerations Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Bilateral Stones  Patients with bilateral stones can be treated either simultaneously or in a staged treatment regimen  Anomalous Kidney  UPJ obstruction secondary to a fixed anatomic stricture is a clear contraindication for SWL  Renal stones >1.5 cm in size may be better treated with PCNL and ureteral stones may be better suited for antegrade ureteroscopy UPJ: Ureteropelvic junction

11. Surgical Stone Management Shock Wave Lithotripsy (SWL) Special Considerations Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Spinal Cord Injury  Patients with spinal cord injury (SCI) are susceptible to develop chronic and complicated stone disease over their lifetime  Upper tract stones in the SCI population are usually soft and fragment well with SWL  SWL can be considered a first line mode of therapy for upper tract stones <1.5 cm in size  Transplant Kidneys  Transplant urinary calculi have been successfully treated with SWL

12. Surgical Stone Management Shock Wave Lithotripsy (SWL) Contraindications to SWL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419 MedicalUrologic Absolute Uncorrected bleeding diathesis Uncorrected hypertension Pregnancy Relative Aortic or renal artery aneurysm Cardiac pacemakers Absolute Untreated UTI Urinary obstruction distal to the stone being treated Inability to visualize stone (skeletal abnormality, body habitus, stone location, radiopacity, stone characteristics, limiting specifications of the lithotripter being used) Relative Anatomic or functional alterations (calyceal diverticulum, horseshoe kidney, ectopic kidney, duplicated kidney) Large stone burden UTI: Urinaray Tract Infection

13. Surgical Stone Management Shock Wave Lithotripsy (SWL) Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Thorough history and physical examination  If medically appropriate, patients should have a preoperative CXR and ECG  Discontinue any drugs (warfarin ((coumadin)), aspirin, clopidogrel  Urine should be sterile prior to treatment  Preoperative blood studies should include complete blood count, prothrombin and partial thromboplastin time, and in some cases a bleeding time CXR: Chest X-ray; ECG: Electrocardiogram

14. Surgical Stone Management Shock Wave Lithotripsy (SWL) Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Intravenous pyelography (IVP) was historically considered obligatory prior to SWL because it provided both a functional and anatomical study of the urinary system  KUB immediately prior to SWL is helpful to confirm the presence of and location of the stone, especially when treating patients on lithotriptors, which rely only on fluoroscopic imaging KUB: Kidney, Ureter and Bladder

15. Surgical Stone Management Shock Wave Lithotripsy (SWL) Technique of SWL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Older model machines such as the HM3 required either general or spinal anesthesia  More contemporary second and third generation machines usually require only intravenous anal gosedation  Patients undergoing ungated shock wave lithotripsy with a EHL device should remain continuously monitored as arrythmias may occur which may require the patient to continue treatment “gated”

16. Surgical Stone Management Shock Wave Lithotripsy (SWL) Postoperative Care Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Routine follow up should be arranged in 2 -4 weeks with a KUB to assess degree of stone fragmentation and stone passage KUB: Kidney, Ureter and Bladder

17. Surgical Stone Management Shock Wave Lithotripsy (SWL) Postoperative Care Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Right renal stone prior to SWL

18. Surgical Stone Management Shock Wave Lithotripsy (SWL) Postoperative Care Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Follow-up KUB at 4 weeks post-SWL reveals excellent fragmentation and clearance of stone burden KUB: Kidney, Ureter and Bladder

19. Surgical Stone Management Shock Wave Lithotripsy (SWL) Postoperative Care Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Subcapsular hematoma of left kidney following left SWL (arrows)  Patient had complete resolution of hematoma on follow-up CT at 6 months

20. Surgical Stone Management Shock Wave Lithotripsy (SWL) Postoperative Care Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Patients with immediate pain out of the ordinary after treatment should be imaged with either ultra sound or CT to rule out perirenal or subcapsular hematoma CT: Computed Tomography

21. Surgical Stone Management Shock Wave Lithotripsy (SWL) Overall Results Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Renal  SWL is the most common first line treatment for the majority of renal stones  5 large early series with the unmodified HM3 demonstrated stone free rates for  renal pelvic 76% (48% - 85%)  upper calyx 69% (46% - 82%)  middle calyx 68% (52% - 76%)  and lower calyx 59% (42% - 73%)  Stone free rates were dependent on size with stones < 10mm reporting excellent stone free rates

22. Surgical Stone Management Shock Wave Lithotripsy (SWL) Overall Results Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Upper Ureteral (in situ, With Stent)  Either SWL or ureteroscopic (URS) treatment are both acceptable treatments for ureteral stones  AUA panel recommended SWL as first line treatment for most patients with stones <10mm in diameter  Distal stones <10 mm can be either treated with URS or SWL as first line therapy

23. Surgical Stone Management Shock Wave Lithotripsy (SWL) Overall Results Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Mid-ureteral Stones  Mid ureteral stones can also be treated with SWL although stone localization can be difficult due to overlying bony structures and body habitus issues  Lower Ureteral Stones  The advantage of SWL over URS is the noninvasiveness of the treatment  URS has superior stone free rates, is more cost effective and the endoscopic equipment is readily available URS: Ureteroscopic

24. Surgical Stone Management Shock Wave Lithotripsy (SWL) Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Complications from SWL can be categorized into immediate and long term  Immediate complications are  issue injury  bleeding  adjacent organ injury  urinary tract obstruction  post treatment obstruction  and urinary tract infection

25. Surgical Stone Management Shock Wave Lithotripsy (SWL) Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Certain clinical conditions such as hypertension, diabetes mellitus, obesity, and coronary artery disease have been reported to be risk factors  Obstruction of the urinary tract by fragments after SWL occur in 5% -10% of cases  Imaging studies should be performed on all patients who are symptomatic or who are in the high risk category

26. Surgical Stone Management Shock Wave Lithotripsy (SWL) Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Long term complications of SWL are rare  Long term complications associated with SWL are renal insufficiency, hypertension, and possible metabolic abnormalities

27. Surgical Stone Management Shock Wave Lithotripsy (SWL) Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Steinstrasse Formation Following SWL LocationIncidence Pelvic ureter Iliac ureter Lumbar ureter 74% - 84.3% 7.8% - 4.3% 7% - 21% Overall rate3.9% - 8.7% Risk factors: Renal stone>2 cm 24% 1-2 cm 16% <1 cm 4% Ureteral stone>1 cm 10% <1 cm 3% Renal pelvis Lower calyx Middle calyx Upper calyx 19% 6% 10% 6%

28. Surgical Stone Management Ureteroscopy Introduction Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Advances in fiberoptics, refinements in laser and lithotripsy technology, and miniaturization of the ancillary equipment used in ureteroscopic treatment of upper urinary tract renal calculus disease  is one of the more common procedures that practicing urologists perform today

29. Surgical Stone Management Ureteroscopy Rigid Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The optical systems in today’s rigid scopes are fiberoptic, enabling scope manufacturers to significantly decrease the size of the scopes without sacrificing optical clarity  Fiberoptics also allowed the working channels to become larger, and avoided the “half moon” effect

30. Surgical Stone Management Ureteroscopy Rigid Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  At present rigid and semi rigid ureteroscopes have tip diameters which range from 6.9 to 10 F with single working channels 4.0–6.0 F and dual working channels from 2.1–5.4 F  Flexible ureteroscopes have tip diameters ranging from 4.9–11.0 F with varying degrees of active primary deflection

31. Surgical Stone Management Ureteroscopy Rigid Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Semi rigid, and especially flexible ureteroscopes should be handled with care  not only by the operating surgeon but also by the operating room technicians and nursing staff charged with sterilizing or disinfecting the scope between uses  Flexible ureteroscopes have a limited life span and should be considered one of the more expensive “disposable” items in the operating room

32. Surgical Stone Management Ureteroscopy Ancillary Equipment in Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Guidewires  The steerable stiff angled guidewire can easily be maneuvered beyond ureteral stones (even when impacted), as well as negotiate tortuous ureters

33. Surgical Stone Management Ureteroscopy Ancillary Equipment in Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Floppy-tipped guidewire is the wire of choice when trying to place a wire beyond an impacted ureteral stone  Note how the tip negotiates around the stone not with the tip but with an atraumatic “knuckle”

34. Surgical Stone Management Ureteroscopy Ancillary Equipment in Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  A working catheter (5 or 6 F) can be used to perform retrograde imaging studies, facilitate guidewire access to the ureteral orifice, and can be used to assist in manipulating guidewires beyond obstructions  When faced with an impacted stone, the catheter can be placed over the wire up to the level of obstruction to stabilize the wire when can then be successfully negotiated beyond the obstruction

35. Surgical Stone Management Ureteroscopy Ancillary Equipment in Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Retrograde pyelogram reveals a midureteral stone  This stone was treated with flexible ureteroscopy and holmium laser lithotripsy

36. Surgical Stone Management Ureteroscopy Ureteral Dilating Devices Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Despite the decrease in routine dilation of the ureteral orifice  occasionally dilation is necessary and preferred over traumatic injury to the ureteral orifice  Garvin and Clayman demonstrated that dilation of the ureteral orifice with a coaxial balloon dilator was atraumatic  and did not lead to long term sequelae such as stricture or reflux

37. Surgical Stone Management Ureteroscopy Ureteral Dilating Devices Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Ureteral dilation can also be achieved with tapered catheters such as the Lieberman catheter (Cook), 8/10 F sheath and obturator (Microvasive, Boston Scientific, Natick,MA)  both of which allows secondary placement of a second safety wire

38. Surgical Stone Management Ureteroscopy Ureteral Dilating Devices Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  An access sheath can facilitate access to the ureter and allow multiple insertions and with drawals of the ureteroscope and minimizing the trauma that could accompany repeated passes of the scope  The access sheath provides continuous drainage of irrigation fluid during ureteroscopy reducing intrapelvic hydraulic pressure while reducing bladder fluid build up  obviating the need for periodic bladder drainage during a long ureteroscopic session

39. Surgical Stone Management Ureteroscopy Ureteral Dilating Devices Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The author uses a 11/13 F sheath if using a sheath  Kourambas et al reported successful initial placement of an access sheath in over 90% of patients

40. Surgical Stone Management Ureteroscopy Ureteral Dilating Devices Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The development of 0-tipped nitinol baskets has been the most important technologic advance in basket technology  They provide  atraumatic deployment  excellent irrigation during use  full deflection of the ureteroscope during stone manipulation  excellent memory characteristics with repeated use  and are kink- resistant which also allows multiple deployment and release of stones

41. Surgical Stone Management Ureteroscopy Ureteral Dilating Devices Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The 1.9 F ZeroTip™ Nitinol Stone Retrieval Basket (Microvasive, Boston Scientific, Natick, Mass.) and 1.7 F NCompass™ Nitinol Stone Extractors (Cook Urological, Spencer, Ind.) are both excellent stone retrieval devices

42. Surgical Stone Management Ureteroscopy Ureteral Dilating Devices Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Nitinol tipless guidewire allows excellent deflection with superior capture and release of stone Microvasive, Boston Scientific, Natick,Mass

43. Surgical Stone Management Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Specialty Catheters  Stone Cone™ Nitinol Retrieval Device (Microva sive, Boston Scientific, Natick, Mass.) is designed  to sweep multiple stone fragments postintracorpo real lithotripsy  and to prevent proximal migration of fragments during intracorporeal lithotripsy

44. Surgical Stone Management Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Lithotripsy Devices  EHL small caliber electrohydraulic probes (1.9 F), more flexible than even small quartz fibers used for laser lithotripsy, may be necessary in treating lower pole renal stones  EHL stone fragmentation occurs as a result of a cavitation bubble

45. Surgical Stone Management Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Lithotripsy Devices  Holmium laser fragments stones through a photothermal mechanism  Holmium laser energy is rapidly absorbed by water so that there is minimal concomitant tissue injury  Fibers in 200 to 100 micron in diameter are available and can tolerate typical energy levels to fragment any and all types of urinary calculi

46. Surgical Stone Management Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Stents  There are multiple stents of varying size, composition, and configuration  There appears to be no real difference in patient stent tolerance despite claims by manufacturers  Stent type is by surgeon preference

47. Surgical Stone Management Ureteroscopy Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  As in SWL, patients should undergo a complete history and physical  Urine should be sterile prior to ureteroscopic stone treatment  Patients should be administered preoperative antibiotics  Bleeding diatheses should be corrected if medically indicated  If normalizing hemostatic parameters are medically contraindicated, ureteroscopy with holmium laser lithotripsy has been safely and successfully performed SWL: Shock Wave Lithotripsy

48. Surgical Stone Management Ureteroscopy Operative Technique Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  C-arm is necessary for ureteroscopy  The urologist should be familiar with the fluoroscopic capabilities and limits if he/she is operating a fixed fluoroscopic unit  Positioning is usually in the lithotomy or modified lithotomy position  General anesthesia with endotracheal intubation is preferred

49. Surgical Stone Management Ureteroscopy Operative Technique Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Knowledgeable ancillary assistance is helpful when performing semi rigid ureteroscopy but essential in flexible ureteroscopy  There are a number of different systems that vary in complexity and cost  A low cost method employs using a pressure bag, which accommodates a 3 LNS bag inflated to provide flow

50. Surgical Stone Management Ureteroscopy Operative Technique Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Urolock™ adaptor from Microvasive  An excellent adaptor which fits on the irrigation port of the ureteroscope; it has a 3- way port for continuous irrigation as well as syringe irrigation when needed  The diaphragm is waterproof but allows repeated placement of lithotripsy and retrieval devices

51. Surgical Stone Management Ureteroscopy Operative Technique Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Counsel patients that mild hematuria and ipsilateral flank discomfort and dysuria is expected following URS  If a stent is left indwelling, also counsel them regarding typical stent related symptoms  KUB or non-contrast CT can be used to assess stone free status  Functional studies (IVP, CT with contrast, nuclear renal scan) should be completed in patients with persistent flank pain, persistent or worsening hydronephrosis CT: Computed tomography; KUB: Kidney, Ureter and Bladder; IVP: Intravenous Urography; URS: Ureteroscopy

52. Surgical Stone Management Ureteroscopy Operative Technique Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419 Indications for Ureteroscopic Treatment of Renal Stones SWL failure Lower pole stone location Morbid obesity Musculoskeletal deformities Bleeding diathesis Calyceal diverticular stones Adverse stone characteristic for SWL Infundibular stenosis Ectopic or horseshoe kidney SWL: Shock Wave Lithotripsy

53. Surgical Stone Management Ureteroscopy Distal Ureteral Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Distal ureteral stones are probably best treated using a semi rigid ureteroscope  A retrograde pyelogram can be performed to confirm the location of the stone(s) and can also delineate the degree of obstruction/impaction of the stone  Holmium laser is the preferred lithotripsy method  Lithotripsy should be initiated at the leading edge of the stone, which is away from the ureteral wall

54. Surgical Stone Management Ureteroscopy Distal Ureteral Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  At times stone fragments will impede the view of the main stone  These fragments can either by removed by basketing the stone and placing them in the bladder or by just removing the scope and allowing the fragments to be irrigated out  Stones that are impacted can usually be “manipulated” from the impacted ureteral segment up into the more dilated and “safe” portion of the ureter  so that the stone can be fragmented without concern of inadvertent ureteral injury

55. Surgical Stone Management Ureteroscopy Distal Ureteral Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Impacted stones usually require at least partial laser treatment before they can be safely “manipulated”  At the end of treatment a retrograde pyelogram can be performed either via the scope or with catheter after scope removal  This can ensure no injury to the ureter, as well as outlining the upper collecting system configuration, which can allow for proper stent placement

56. Surgical Stone Management Ureteroscopy Distal Ureteral Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  KUB of 36-week gravid woman with severe right flank pain  Patient has a distal right ureteral calculus KUB: Kidney, Ureter and Bladder

57. Surgical Stone Management Ureteroscopy Distal Ureteral Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Close-up of KUB reveals this distal ureteral calculus measuring 5 x 8 mm  Stone was successfully removed ureteroscopically  Patient had an uneventful postoperative course and had a normal delivery KUB: Kidney, Ureter and Bladder

58. Surgical Stone Management Ureteroscopy Mid-ureteral Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Flexible ureteroscopy is the preferred technique in treating mid ureteral stones  Semi rigid ureteroscopy of the mid and proximal can be difficult  The author rarely uses a semi rigid scope above the iliac vessels  Relatively easy access to the mid- and proximal ureter with the semi rigid scope can be accomplished in females and in some males, but the risk of injury to the ureteroscope (shaft bending or fracture) and more importantly ureteral injury appears higher

59. Surgical Stone Management Ureteroscopy Mid-ureteral Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Endoscopic view of the mid ureter during passage of the flexible scope up into the collecting system  Note the working nitinol guidewire which is being used as the working wire and the Teflon-coated safety wire

60. Surgical Stone Management Ureteroscopy Mid-ureteral Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Endoscopic view of an impacted mid ureteral stone  The safety wire keeps the ureter straight and optimizes laser lithotripsy

61. Surgical Stone Management Ureteroscopy Proximal Ureteral Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Proximal ureteral stones are best treated using the flexible ureteroscope  Access is similarly achieved as in the technique for mid ureteral stones  Proximal stones and/or partially treated fragments are more prone to proximal migration

62. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Renal stones can be successfully treated with retro grade ureteroscopy using a flexible ureteroscope  In some cases in which a renal stone is being treated with lithotripsy and the endoscopist does not plan to remove fragments, a safety wire placement may be obviated  In this case, once successful fragmentation is achieved, a guide wire is placed through the working channel, the scope is withdrawn and a stent can be subsequently placed, if deemed necessary  In most cases, a safety wire is recommended

63. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Initiation of holmium laser lithotripsy of an upper pole stone  The calyx prevents any migration of the stone during lithotripsy  Note the laser catheter and the laser fiber emanating from the open end

64. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Renal pelvic stones have a tendency to migrate during lithotripsy  The author recommends actively manipulating renal pelvic stones into an upper pole calyx, which allows a “straight shot” as well as a “backstop” (the upper pole calyx)  which prevents any unwanted stone or stone fragment migration  Once in the upper pole, adequate fragmentation can be easily achieved

65. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Flexible ureteroscopy was successful in accessing the lower pole of the left kidney  Endoscopy revealed a 6 x 6 mm stone within the lower pole  The stone was displaced into the upper pole where it was successfully fragmented with the holmium laser

66. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Lower pole stones present a challenge  In some cases, patients can be placed in Trendelberg position and the stones can be manually irrigated into a more accessible mid or upper pole calyx

67. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Secondary deflection of ureteroscope into a dependent calyx during diagnostic ureteroscopy for abnormal urine cytologies

68. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  In some cases access to some lower pole stones cannot be achieved with a laser fiber in place  Sometimes the stone can be basketed (1.9 F baskets provide for more deflection), and then displaced into an upper pole

69. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Lower pole stone engaged with nitinol basket and displaced into upper pole for fragmentation

70. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  In rare cases in which a large lower pole stone cannot be accessed with a laser and is too large to safely be displaced  EH Lusing a 1.9 F probe can be employed to fragment the stone, basket and displace the fragment, and then complete the lithotripsy with the holmium laser

71. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  CT image reveals a large calyceal diverticulum with several calcifications within the large diverticulum CT: Computed Tomography

72. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Flouroscopic image of successful retrograde access into the calyceal diverticulum

73. Surgical Stone Management Ureteroscopy Renal Stones Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Endoscopic view of a cluster of small stone within a calyceal diverticulum treated with retrograde ureteroscopy

74. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Complications can be generally classified either by timing (intraoperative vs. early vs. late), or by significance (minor vs. major)  Most complications usually occur during or immediately post procedure and major complications are fortunately quite rare  Intraoperative complications include:  mucosal abrasion, ureteral false passage, perforation, extravasation, bleeding, thermal injury, equipment malfunction, ureteral intussusception, and ureteral avulsion

75. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Careful use of the ureteroscope, atraumatic dilation of the ureteral orifice, and judicious use of ancillary equipment can reduce the risk of significant abrasion injuries  If significant abrasion is apparent, temporary stenting for 7-10 days is the recommended treatment

76. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Ureteral false passage occurs during intubation of the ureteral orifice as well as during negotiation of a guidewire around an impacted stone  False passage at the ureteral orifice often occurs when the catheter does not follow the intramural course of the ureter (ie, males with BPH, gravid females, etc) BPH: Benign Prostate Hyperplasia

77. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  In a severe false passage at the ureteral orifice, placement of the semi rigid ureteroscope just within the ureteral orifice can usually allow visualization of the true lumen  The true lumen tends to be inferior and lateral to the false passage, which tends to be medial and superior  A guidewire can be placed up the ureteral lumen and one can continue proceeding with the ureteroscopy

78. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Perforations are reported to occur between 1%-15%  with the higher reported incidence rates occurring with larger diameter scopes, complicated stones requiring lengthy procedures, or during treatment of proximal ureteral stones  Minor perforations can be safely managed with an indwelling ureteral stent for 2-4 weeks

79. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Saline should be the only irrigant fluid routinely used during ureteroscopic stone treatment  Holmium energy is readily absorbed by water and has a minimal thermal injury zone of 0.5 to 1mm  Significant thermal injury due to holmium laser use is extremely rare

80. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The most common intra operative malfunctions occur with the flexible scope  and are due to laser fiber damage to the working channel, laser fiber injury to the fiberoptics, or hyper re/de flexion of the scope  Any of these injuries most often render the scope useless  and require either major repair or complete scope replacement

81. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Avulsion, which is reported to occur around 0.3% is due to an attempt to remove a basketed stone from mid or proximal ureter which is too large to safely remove, or incorporating the ureter within the stone basket during stone capture and then attempting to withdraw the basket

82. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Complete avulsion requires immediate surgical repair  An attempt at laparoscopic repair should only be done by those with exceptional laparoscopic skills  otherwise, it requires an open repair  Distal ureteral avulsions can be repaired with a uretero neocystostomy with or without use of a psoas hitch or boari bladder flap

83. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Blunt dissection around the kidney (especially the upper pole)may be necessary in order to create a tension free anastomosis  A primary UPJ repair can be performed for proximal or UPJ injuries  These can also be difficult because the pelvis may not be dilated like in pyeloplasties done for UPJO UPJO: Ureteropelvic Junction Obstruction

84. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Intussussception is a partial thickness mucosal sleeve injury to the ureter  The mechanism of injury is often similar to avulsion injuries  Definitive open repair is probably the recommended treatment

85. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Immediate post operative complications are UTI/sepsis, and obstruction  The risk of infection is 4% - 22.5% in several large series  Sepsis occurs less frequently between 0.3% - 2.0%  A high index of suspicion for sepsis should accompany any patient who has rigors, has mental status changes, is hypotensive, who is febrile above 102.5°F or is hypothermic < 96°F, who has either a profound leukocytosis or leukopenia UTI: Upper Tract Infections

86. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  In patients with mild steinstrasse who fail medical therapy or are severely symptomatic, stent placement or definitive URS with stone removal may be necessary  In patients with significant steinstrasse with large stone burden, percutaneous drainage followed by antegrade URS may be necessary URS: Ureteroscopy

87. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Late complications are ureteral stricture disease  Late strictures occur as a result of URS between 0% - 4%  Ureteral perforations, impacted stones and use of large diameter ureteroscopes are risk factors in formation of ureteral strictures URS: Ureteroscopy

88. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Retrograde pyelogram reveals a severe ureteral stricture at the level of the pelvic vessels  This occurred following attempt at rigid ureteroscopy for a proximal ureteral calculus

89. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Patient underwent a boari flap to repair the stricture

90. Surgical Stone Management Ureteroscopy Complications of Ureteroscopy Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Treatment of ureteral strictures is dependent on location and length of stricture, the degree of function remaining in the affected kidney, overall kidney function and patient preference  Short strictures (<1 cm) may be amenable to endoscopic incision  Chronic, long term stenting, or percutaneous drainage may be recommended for patients with significant comorbid conditions  Longer strictures may involve treatment algorithms previously discussed regarding treatment of avulsion injuries

91. Surgical Stone Management Percutaneous Stone Treatment Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419 Indications for Percutaneous Stone Removal Staghorn calculi Renal pelvis stones >2 cm Lower pole stones >1.5 cm SWL- resistant stones Stones associated with UPJ obstruction Calyceal diverticular stones Pts with contraindications for SWL UPJ: Ureteropelvic Junction; SWL: Shock Wave Lithotripsy

92. Surgical Stone Management Percutaneous Stone Treatment Indications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  CT of the abdomen without contrast is the most common diagnostic survey in patients who present with emergent renal or abdominal complaints  It is the most accurate means of diagnosis for renal stones CT: Computed Tomography

93. Surgical Stone Management Percutaneous Stone Treatment Indications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Non-contrast CT reveals a right renal stone  CT is the most accurate radiologic test to detect renal calculi  Calcium-containing stones, cystine, struvite, and uric acid stones are all radiopaque on CT CT: Computed Tomography

94. Surgical Stone Management Percutaneous Stone Treatment Indications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  CT provides the relationship of the kidneys to other intra abdominal organs  which can facilitate proper percutaneous approaches to the kidney  A CT urogram provides an excellent radiographic study in this regard CT: Computed Tomography

95. Surgical Stone Management Percutaneous Stone Treatment Indications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  CT urogram details a complete upper pole staghorn calculus with several smaller lower pole stones  The pelvis and proximal ureter are opacified with contrast and are non dilated CT: Computed Tomography

96. Surgical Stone Management Percutaneous Stone Treatment Contraindications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Contraindications to percutaneous stone extraction are  bleeding diathesis  abdominal anatomy precluding percutaneous access  unusual body habitus (morbid obesity, very long flank kidney length)

97. Surgical Stone Management Percutaneous Stone Treatment Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Standard preoperative evaluation  In patients with struvite stones  consider placing patients on 7-10 day course of bacterial specific antibiotic prior to the planned percutaneous procedure  Make a thorough examination of the radiologic imaging  in order to plan the proper access(es), approximate the flank kidney length (using CT images), and determine other intra abdominal abnormalities which may call for changes in access CT: Computed Tomography

98. Surgical Stone Management Percutaneous Stone Treatment Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  KUB of this 8-year-old boy revealed significant left renal stone burden KUB: Kidney, Ureter and Bladder

99. Surgical Stone Management Percutaneous Stone Treatment Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  KUB of this 8-year-old boy revealed significant left renal stone burden  Due to the stone burden patient underwent successful PCNL  Access was obtained via an upper pole puncture  The two lower pole stones were removed using a flexible nephroscope KUB: Kidney, Ureter and Bladder; PCNL: Percutaneous Nephrolithotomy

100. Surgical Stone Management Percutaneous Stone Treatment Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Nephrotomogram reveals a partial lower pole staghorn calculus

101. Surgical Stone Management Percutaneous Stone Treatment Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  IVP reveals good function of the right kidney  The lower pole also appears to function well despite the large staghorn occupying the entire lower pole moiety  This stone was removed via a posterior lower pole access IVP: Intravenous Pyelography

102. Surgical Stone Management Percutaneous Stone Treatment Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The technique of percutaneous stone extraction is specific to  the location of the stone, the composition of the stone, other associated renal abnormalities, and body habitus  Percutaneous stone extraction entails the following steps:  percutaneous access, tract dilation, stone manipulation, fragmentation, and removal, and drainage post stone extraction

103. Surgical Stone Management Percutaneous Stone Treatment Preoperative Evaluation Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Large right renal cystine stone in a 21-year-old female  Cystine stones are typically shock-wave resistant  This stone was treated successfully with right PCNL PCNL: Percutaneous Nephrolithotomy

104. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Percutaneous tract placement can be performed in a staged or as a same session manner  If performed in a staged procedure, it is vital that the urologist communicate to the radiologist  which particular access is preferred  which access could be used as an alternate  and, which access will not work PCNL: Percutaneous Nephrolithotomy

105. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419 Equipment Necessary for PCNL Access Retrograde balloon occlusion catheter (allows for RPG during same-session access) Perc access (18-22 G needle) 0.018 in wire, dilator sheath, cumpy catheter, 0.035 in guidewire, 0.035 in Amplatz Super Stiffwire, exchange catheter, balloon dilation catheter, 24-30 F working sheath Endoscopes Flexible cystoscope/nephroscope: used to place the retrograde catheter during same-session PCNL, and access to calyceal system not accessible with rigid scope Rigid nephroscope: used for ultrasonic/ laser lithotripsy, removal of large fragments Flexible ureteroscope: used to inspect the ureter if necessary for stones or stone fragments which are located in the ureter PCNL: Percutaneous Nephrolithotomy

106. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419 Equipment Necessary for PCNL Ancillary Equipment Ultrasonic lithotripter with lithotripter probes EHL with EHL probes 1.9-9 F Holmium laser with 200 – 600 micron fibers Stone forceps Stone baskets (0-tipped nitinol preferred) Drainage 16-24 F Malek ot catheters w/without ureteral extenders 10-16 F nephroureteral catheters 8-16 F pig-tail nephrostomy catheters 6-8 F internal ureteral stents EHL: Electrohydraulic lithotripsy; PCNL: Percutaneous Nephrolithotomy

107. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  In same session PCNL, patients can be initially placed prone (making sure to properly pad the patient)  and flexible cystoscopy with retrograde catheter placement can be performed  An air contrast retrograde pyelogram can be done  to outline the collecting system and aid in proper access (air will outline the posterior calyces) PCNL: Percutaneous Nephrolithotomy

108. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Gaining percutaneous access of a horseshoe kidney with a large pelvic stone PCNL: Percutaneous Nephrolithotomy

109. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Gaining percutaneous access of a horseshoe kidney with a large pelvic stone  Access is via the upper pole as this portion of the kidney is closest to the skin  The most posterior upper pole calyx is outlined by air which was injected via the catheter  Also the risk of vascular injury is less via an upper pole access  Note the presence of the occlusion balloon catheter which was placed just prior to perc access  This catheter prevents antegrade migration of stone fragments from entering the ureter PCNL: Percutaneous Nephrolithotomy

110. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Nephrostogram after successful PCNL in the horseshoe kidney  Note the catheter is through the upper pole PCNL: Percutaneous Nephrolithotomy

111. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The nephroscope is inserted and blood clots are either removed with suction via the lithotripter probe or with forceps  The urothelium of the calyx should be identified If the working sheath is too shallow, the scope can be directed into the collecting system and the sheath advanced or the balloon can be replaced more proximally and the sheath advanced over the inflated balloon  Irrigation for stone removal should be with warmed normal saline  Small stones <10 mm in diameter can either be removed whole using graspers, or baskets PCNL: Percutaneous Nephrolithotomy

112. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Flexible nephroscope was used to access a 1x 2 cm renal pelvic stone  The stone was successfully basketed and removed without the need for lithotripsy PCNL: Percutaneous Nephrolithotomy

113. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Endoscopic view of the stone in the renal pelvis during basket extraction PCNL: Percutaneous Nephrolithotomy

114. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Usually, most stones require fragmentation, which can be accomplished using an ultrasonic suction lithotripter probe  Soft stones (eg, struvite, calciumoxalate dehydrate) can be removed exclusively using the lithotrite  Most stones, however, fragment into various sized fragments which migrate distally PCNL: Percutaneous Nephrolithotomy

115. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Access to distance stone bearing calyces can usually be accomplished using the flexible nephroscope  Pressure irrigation is usually necessary to provide adequate visualization  Inspection of the calyceal system can be facilitated by fluoroscopic injection of contrast via the working channel of the scope  The scope can then be easily directed under both direct and fluoroscopic guidance PCNL: Percutaneous Nephrolithotomy

116. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Stones which require lithotripsy in calyces accessible only with the flexible scope will require either laser or EHL  1.9 F EHL probes provide enough irrigation while having no effect on degree of scope deflection and is preferred by the author over holmium laser  If an occlusion catheter is not used or if there is concern regarding ureteral stones, then antegrade flexible ureteroscopy can be performed and stones treated with combination lithotripsy/basketing EHL: Electrohydraulic lithotripsy; PCNL: Percutaneous Nephrolithotomy

117. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Antegrade ureteroscopy can be used at the time of PCNL to ensure that there are no retained ureteral stone fragments EHL: Electrohydraulic lithotripsy; PCNL: Percutaneous Nephrolithotomy

118. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Antegrade ureteroscopy can be used at the time of PCNL to ensure that there are no retained ureteral stone fragments  An occlusion balloon catheter can be placed with the balloon inflated at the UPJ or in the proximal ureter which may prevent distal migration of stone fragments during PCNL PCNL: Percutaneous Nephrolithotomy; UPJ: Ureteropelvic Junction

119. Surgical Stone Management Percutaneous Stone Treatment Technique of PCNL Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Second session nephroscopy can also be performed 1-3 days following initial PCNL  in patients with known residual stones or stones seen on follow up radiologic studies (non-contrast CT, renal tomograms, or nephrostrogram) CT: Computed Tomography; PCNL: Percutaneous Nephrolithotomy

120. Surgical Stone Management Percutaneous Stone Treatment Postoperative Care Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Postoperative imaging can be performed to document stone free status  Nephrostogram can document the patency of the ureter, and if patent, the nephrostomy  In cases where the initial nephrostogram reveals persistent extravasation or obstruction, the larger nephrostomy tube can be “down sized” to a 10 F pigtail nephrostomy tube and still discharged

121. Surgical Stone Management Percutaneous Stone Treatment Results Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  PCNL has been proven to be a safe and efficacious method of removing stones, with success rates from some series ranging from 90% to 100%  PCNL is the preferred method recommended by the AUA nephrolithiasis guideline panel for surgically treating staghorn or partial staghorn calculi PCNL: Percutaneous Nephrolithotomy

122. Surgical Stone Management Percutaneous Stone Treatment Results Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Retrograde pyelogram following most recent SWL demonstrates a large uric acid renal stone without any significant fragmentation PCNL: Percutaneous Nephrolithotomy; SWL: Shock Wave Lithotripsy

123. Surgical Stone Management Percutaneous Stone Treatment Results Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Retrograde pyelogram following most recent SWL demonstrates a large uric acid renal stone without any significant fragmentation  40-year-old woman referred for management of a renal stone  Patient had undergone 4 unsuccessful prior SWLs  Patient underwent successful left PCNL and was rendered stone-free  Patient continues to remain stone-free on an aggressive hydration and alkalinization program PCNL: Percutaneous Nephrolithotomy; SWL: Shock Wave Lithotripsy

124. Surgical Stone Management Percutaneous Stone Treatment Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419 PCNL: Percutaneous Nephrolithotomy; UTI: Urinary Tract Infection Complications of PCNL Access-relatedImmediate Renal laceration Bleeding Perforation Injury to adjacent organs (pleura, lung, bowel, spleen) UTI/sepsis Retained stone fragments Urinary obstruction Death Endoscopic/Stone Removal- related Late Complications Bleeding Extravasation / fluid absorption Ureteral / pelvic perforation Ureteral stricture Loss of renal function

125. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The ideal puncture passes through the relatively avascular plane of Brödel into the calyx  The guidewire is then passed through the infundibulum into the renal pelvis  This approach avoids the larger renal vessels, which are anatomically related anteriorly and posteriorly to the major calyceal infundibula

126. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Lacerations or perforations, usually of the renal pelvis, can occur during dilation of the tract or while placing the working sheath  and is usually due to over aggressive medial dilation either with the balloon or sequential dilators or inattentive sheath placement

127. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  This can be avoided by continuous fluoroscopic imaging during dilation and especially during sheath placement  Counter traction on the balloon is often necessary when placing the sheath  If laceration occurs, a large bore nephrostomy tube should be placed, and the PCN postponed with external drainage for 24-72 hours to allow healing PCN: Percutaneous Nephrostomy

128. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Right perinephric hematoma following PCN for a large staghorn stone  Patient remained asymptomatic and did not require blood transfusion  The hematoma completely resolved within 3 months PCN: Percutaneous Nephrostomy

129. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Severe bleeding at the time of access can be arterial (rare) or venous  Venous bleeding is due to the working sheath being too shallow and not completely within the calyx or collecting system

130. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Patients undergoing puncture above the 12th rib have an approximate 10% risk of fluid within the pleura  A supra 11th puncture has a 10% risk of hydrothorax or pneumothorax  A working sheath is highly recommended with upper pole punctures to minimize fluid build up within the pleural space

131. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  The incidence of bowel injury is quite rare  Colon injury is approximately 0.2% and is likely to occur in thin patients in which the tract is made too lateral, or in the morbidly obese  Bleeding during stone extraction is usually due to inadvertent migration of the working sheath

132. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Retroperitoneal extravasation of fluid occurs to some degree in all PCNL cases  It is important to use normal saline to prevent hyposmolar hemolysis and hyponatremia (TURP syndrome) PCNL: Percutaneous Nephrolithotomy

133. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Ureteral avulsion during percutaneous nephrolithotomy is rare (0.01%) and requires open repair  Low grade fever (<100.5°F) in the first 12 hours following percutaneous stone is common and may be due to atelectasis or transient bacteremia  Fevers >101.5°F occur less commonly and patients should undergo blood and urine cultures, chest x ray, and continued on a broad spectrum antibiotic

134. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Deaths associated with percutaneous nephrolithotomy are rare and often related to other comorbid conditions  such as fatal arrhthymias, respiratory failure  Overwhelming sepsis and fatal pulmonary embolus has also been reported

135. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Hemorrhage due to an arterio venous fistula or pseudoaneurysm typically occurs anywhere from 2 days to 2 weeks following PCNL PCNL: Percutaneous Nephrolithotomy

136. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Patient underwent emergent renal angiogram which revealed a pseudoaneurysm  56-year-old male underwent left PCNL  Patient had an episode of gross hematuria 2 weeks following procedure PCNL: Percutaneous Nephrolithotomy

137. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Patient had successful coil embolization with complete resolution of the pseudoaneurysm

138. Surgical Stone Management Percutaneous Stone Treatment Complications Faerber G J. Surgical Stone Management. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 14: 379-419  Patients who complain of one episode or intermittent gross hematuria  should be suspected of having a fistula or pseudoaneurysm  and undergo emergent renal arteriography