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INTRODUCTIONINTRODUCTION

Staghorn stones are unquestionably an indication for interventional therapy, since conservative treatment show an increased rate of nephrectomy (up to half) and an increase in associated morbidity (i.e. dialysis); in many cases (up to 28%) the disease resulted in death

Open surgery has been the corner stone of treatment of urolithiasis for more than 30 years till 80s

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INTRODUCTIONINTRODUCTIONwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it

After 1980 PCNL monotherapy first and then combined treatments have been

suggested (PCNL+ESWL+PCNL (sandwich therapy)),( PCNL+ESWL (open

sandwich therapy))

ENDOUROLOGY VS OPEN SURGERYENDOUROLOGY VS OPEN SURGERYwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it

J.J. Rassweiler1, C. Renner1, F. Eisenberger2: The management of complex renal stones. BJU International Volume 86, Issue 8, pages 919–928, November 2000

EVOLUTION OF PCNLEVOLUTION OF PCNLwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it

SUPINE PCNLEASY RETROGRADE ACCESS

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ENDOSCOPIC COMBINED INTRARENAL SURGERYECIRS

Scoffone C., Scarpa RM

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ECIRS

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COMPLETE STAGHORN STONECOMPLETE STAGHORN STONEwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it

SUPINE PCNL WITH 3 ACCESSES

RIRS 2° LOOK

COMPLETE STAGHORN STONE IN HORSESHOE KIDNEYCOMPLETE STAGHORN STONE IN HORSESHOE KIDNEY

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ECIRS WITH DOUBLE ACCESS

PCNL 2nd LOOK

RIRS 3rd LOOK

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NO MORE OPEN SURGERY?NO MORE OPEN SURGERY?

GUIDELINESGUIDELINES

Advances in SWL and endourological surgery (URS and PNL) have significantly decreased the indications for open stone surgery, which is now often a 2°- or 3° -line treatment option needed in 1.0-5.4% of cases only .

The incidence of open stone surgery is ~1.5% of all stone removal interventions in developed countries, and in developing countries, it has dropped from 26% to 3.5 % in recent years (3,5).

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• 2012 EAU guidelines for urolithiasis

GUIDELINESGUIDELINES

5.7.1.1 Indications for open surgery There is a consensus that most complex stones, including partial and complete staghorn stones, should be approached primarily with PNL or combined PNL and SWL. If a reasonable number of percutaneous approaches are not likely to be successful, or if multiple, endourological approaches have been performed unsuccessfully, open surgery may be a valid treatment option.

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• 2012 EAU guidelines for urolithiasis

GUIDELINESGUIDELINES

5.7.1.1 Indications for open surgery There is a consensus that most complex stones, including partial and complete staghorn stones, should be approached primarily with PNL or combined PNL and SWL. If a reasonable number of percutaneous approaches are not likely to be successful, or if multiple, endourological approaches have been performed unsuccessfully, open surgery may be a valid treatment option.

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• 2012 EAU guidelines for urolithiasis

GUIDELINESGUIDELINESwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it

• 2012 EAU guidelines for urolithiasis

CONCLUSIONCONCLUSION

However, open surgery is still needed for the most difficult stones, which supports the importance of maintaining proficiency, skills and expertise in open renal and ureteral surgical techniques such as extended pyelolithotomy, pyelonephrolithotomy, anatrophic nephrolithotomy, multiple radial nephrotomy, partial nephrectomy and renal surgery under hypothermia

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• 2012 EAU guidelines for urolithiasis

PLEASE CHIEF,

TEACH ME HOW

TO DO IT!

PLEASE CHIEF,

TEACH ME HOW

TO DO IT!

……….Modern endourologist should master FIRST all

the available ENDOUROLOGICAL solutions (rigid and

flexible nephroscopy, RIRS) to reach the stone-free status BEFORE CONSIDER OPEN SURGERY.

ALMOST…

RENAL CALCULI FEATURESRENAL CALCULI FEATURES

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Laparoscopic urinary stone surgery: an updated evidence-based review.Laparoscopic pyelolithotomy is feasible but rarely indicated in the present era

. Laparoscopic nephrolithotomy may be indicated to remove a stone from an

anterior diverticulum or when PNL or flexible ureteroscopy have failed

Skolarikos A et al: Urol Res. 2010 Oct;38(5):337-44.

provided that all endourological solutions are clearly contraindicated as first treatment option!!

staghorn calculus (stag-horn) n. a

branched stone forming a cast of the

collecting system of the kidney and

therefore filling and obstructing the calyces

and pelvis. It is usually associated with

infection and can cause pyonephrosis and,

if neglected, a perinephric abscess.

OPEN SURGERY?OPEN SURGERY?

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Does open stone surgery still play a role in the treatment of urolithiasis? Data of a primary urolithiasis center.stone-free rate after a single procedure: 69% (18/26 patients).

CONCLUSIONS:Although today most stone cases can be handled by minimally

invasive treatment, open stone surgery maintains a mandatory role in very selected

cases

Honeck P, Alken P, Michel MS.: J Endourol. 2009 Jul;23(7):1209-12

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EVOLUTION OF UROLITHIASISEVOLUTION OF UROLITHIASIS

STAGHORN STONES 1990-2000: 56%STAGHORN STONES 2000-2009: 13%

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