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

2. Recent management
Of Urolithiasis

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

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

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

6. Hospitalization? Emergencies Refractory Nausea Debilitation
Extremes of age
Refractory Pain

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

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

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

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

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

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

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

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

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

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

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

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

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

20. Staghorn stone
Open surgery
Sandwich
PcNL and ESWL

21. Ureter Anatomy Narrowing of ureter UPJ Crossing with iliac vessel
intramural

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

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

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

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

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

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

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

29. Thanks