1. Stone disease 3
Open surgery of kidney 54

2. Surgical Management of Upper Urinary Tract Calculi 48
Kidney Calculi
Pelolithotomy
Nephrolithotomy
Although stone-free rates of these modern
surgical techniques were excellent, morbidity was significant,
and the search for new techniques and technologies
continued.

3. Ureteral Calculi
Ureterolithotomy
Endourology
Before the development of endoscopy attempts to blindly extract
calculi were not uncommon.

4. The development of minimally invasive surgical techniques for
the treatment of patients suffering from urinary lithiasis has been
greatly dependent on technologic advances in the fields of fiberoptics,
radiographic imaging, and lithotripsy (shockwave,
ultrasonic, electrohydraulic, and laser).
These advancements have accelerated the evolution of modern techniques
of calculus removal, including ureteroscopy, percutaneous
nephrolithotomy (PNL), and extracorporeal
shockwave lithotripsy (SWL).

5. term endourology as closed controlled manipulation
within the genitourinary tract
Ureteroscopy
Currently available ureteroscopes range from 54 to 70 cm in
length and have a tapered shaft diameter that increases proximally.
As the tip of the ureteroscope is inserted into the ureter and
passed retrograde, the ureter is slowly dilated.
Most modern
ureteroscopes have a single working channel, and some have a
second irrigation channel that serves to distend the ureter and
maintain visualization.

6. Parallel to improvements in rigid and flexible ureteroscopes
were advances in intracorporeal lithotripters, including ultrasonic,
electrohydraulic, pneumatic, and laser probes, allowing
efficient stone fragmentation through the miniaturized modern
ureteroscopic equipment.

7. Percutaneous Stone Removal
Subsequent advances
in endoscopes, imaging equipment, and intracorporeal lithotripters
allowed urologists and radiologists to refine
These percutaneous techniques through the late 1970s and early 1980s
into well-established methods for removal of upper urinary tract
calculi.

8. Extracorporeal Shockwave Lithotripsy
Examples of high-energy shockwaves include the blast effect associated with explosions, as well as the potentially windowshattering
sonic boom created when aircraft pass beyond the speed of sound.
Engineers at Dornier Medical Systems in what was
then West Germany, during research on the effects of shockwaves on military hardware, demonstrated that these shockwaves are
reflectable and therefore focusable.
The possibility of applying
shockwave energy to human tissue was discovered when, by
chance, a test engineer touched a target body at the very moment
of impact of a high-velocity projectile. The engineer felt a sensation
similar to an electric shock, although the contact point at the
skin showed no damage at all

9. more than 1 million patients are treated annually with SWL.
RENAL CALCULI
The primary goal of surgical stone management is to achieve maximal stone clearance with minimal morbidity to the patient.
The introduction of SWL as well as continuing
advancements in the field of endourology have allowed most patients with renal stones to be treated in a minimally invasive fashion.
However, as the armamentarium of treatment modalities
available to the urologist has increased, new controversies regarding
the indications for these therapies have developed. Currently,
urologists face the challenge of selecting the optimal treatment
modality on the basis of the patient’s and the stone’s characteristics.
Four minimally invasive treatment modalities are available
for the treatment of patients with kidney stones and are discussed
in this chapter: SWL, PNL, ureteroscopy, and laparoscopic stone
surgery.

10. 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
include large renal calculi, stones within dependent or
obstructed portions of the collecting system, stones of
certain composition (cystine, calcium oxalate monohydrate,
and brushite), and obesity or a body habitus that
inhibits imaging and targeting of the stone.
For patients
with these clinical characteristics, alternative treatment modalities,
such as ureteroscopy or PNL, should be considered. The urologist,
then, when treating a patient with a renal calculus, must ask:
Is the patient an appropriate candidate for SWL, or
should other treatment modalities be used?

11. Bacteriologic evaluation of the urine is mandatory for all
patients. The composition of any previous stone material passed
or removed from the patient is extremely important. If previous
stones have contained significant amounts of calcium oxalate
monohydrate (whewellite) or brushite, fragmentation with SWL
may be expected to be more difficult.

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

13. Staghorn calculi are those stones that fill the major part of the
renal collecting system. Typically, they occupy the renal pelvis and
branch into most of the calyces, mimicking the horns of a deer .
Most staghorn stones are composed of struvite
. Until the early 1970s some physicians believed
that patients harboring staghorn calculi should not be treated
However, a better understanding of the natural
history of staghorn stones has evolved. It is now generally accepted
that, if left untreated, a staghorn calculus is associated with progressive
deterioration of renal function. Additionally, morbidities
associated with an untreated staghorn stone include pain, recurrent
urinary tract infection, and sepsis events.

14. untreated struvite staghorn calculi eventually
destroy the kidney and pose a significant risk to the
patient’s life.

15. Stone burden (size and number) is perhaps the single
most important factor in determining the appropriate
treatment modality for a patient with renal calculi.
The negative effect of an increasing stone burden (size
and number) on the results of SWL has been described

16. 50% to 60% of all solitary renal calculi are
less than 10 mm in diameter . Treatment results of SWL
for this substantial group of patients are
generally satisfactory
Patients with calculi between 10 and 20 mm are often
treated with SWL as first-line management.

17. 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).

18. Treatment Decisions by Stone Composition
patients with such
stones (i.e., brushite, cystine, calcium oxalate monohydrate)
should be treated by SWL only when the stone
burden is small (i.e., <1.5 cm).

19. Renal Anatomic Factors
There are certain anatomic factors, either congenital or acquired,
that can hinder stone clearance after SWL. Congenital anomalies
manifest not uncommonly in the upper urinary tract, and almost
all that affect the drainage of the kidney are associated with an
increased incidence of calculous disease.
Such abnormalities
include ureteropelvic junction (UPJ) obstruction, horseshoe
kidney, and other ectopic or fusion anomalies as well as calyceal
diverticula. Hydronephrosis, too, is associated with a failure to
clear stone fragments after SWL.