Palestinian Board of SurgeryPalestinian Board of Surgery

Residency Training Residency Training ProgrammeProgramme

Prepared by :-Dr. Hazem El haddad

Recent managementRecent management

Of UrolithiasisOf Urolithiasis

Treatment of the stoneTreatment of the stone The primary goal of surgical stone management is to The primary goal of surgical stone management is to

achieve maximal stone clearance with minimal achieve maximal stone clearance with minimal

morbidity to the Patientmorbidity to the Patient..

Depends on :Depends on : Stone locationStone location Stone burdenStone burden Kidney functionKidney function Availability of man powerAvailability of man power Availability of instrumentAvailability of instrument

MMANAGEMENTANAGEMENT

(3 Principles)(3 Principles)

Recognize EmergenciesRecognize Emergencies Adequate AnalgesiaAdequate Analgesia Impact of size and locationImpact of size and location

EEmergenciesmergencies

Sepsis with obstruction Sepsis with obstruction (struvite stones?)(struvite stones?)

AnuriaAnuria ARFARF Urologic consultationUrologic consultation

HHospitalizationospitalization??

EmergenciesEmergencies Refractory NauseaRefractory Nausea DebilitationDebilitation Extremes of ageExtremes of age Refractory PainRefractory Pain

Renal Colic/Ureter ColicRenal Colic/Ureter Colic Patent pain colicPatent pain colic

• NSAIDNSAID• MorphineMorphine• Morphine like drugs :Morphine like drugs :

TramadolTramadol

Medical expulsion therapy for stone Medical expulsion therapy for stone << 5mm 5mm• Alpha blockerAlpha blocker

MManage The anage The StoneStone

After adequate analgesia and ruling out After adequate analgesia and ruling out emergenciesemergencies

Principles here are stone size and Principles here are stone size and locationlocation

Probability of Stone PassageProbability of Stone Passage

Stone location and Stone location and sizesize

Probability of Probability of

passage (%)passage (%)Proximal ureterProximal ureter

> 5 mm> 5 mm00

5 mm5 mm5757

< 5mm< 5mm5353

Middle section of ureterMiddle section of ureter

> 5 mm> 5 mm00

5 mm5 mm2020

< 5mm< 5mm3838

Distal ureterDistal ureter

> 5 mm> 5 mm2525

5 mm5 mm4545

< 5mm< 5mm7474

Treatment Modalities for Renal Treatment Modalities for Renal and Ureteral Calculiand Ureteral Calculi

LimitationsLimitations ComplicationsComplications

Requires spontaneous passageRequires spontaneous passage Ureteral obstruction byUreteral obstruction by

of fragmentsof fragments stone fragments stone fragments

Less effective in patients withLess effective in patients with Perinephric hematomaPerinephric hematoma

morbid obesity or hard stonesmorbid obesity or hard stones

TreatmentTreatment Indications Indications Advantages Advantages Extracorporeal Extracorporeal Radiolucent calculi Radiolucent calculi Minimally invasive Minimally invasive

shock waveshock wave Renal stones < 2 cm Renal stones < 2 cm Outpatient Outpatient

lithotripsylithotripsy Ureteral stones < 1 cm Ureteral stones < 1 cm procedure procedure

Treatment Modalities for Renal Treatment Modalities for Renal and Ureteral Calculiand Ureteral Calculi

LimitationsLimitations ComplicationsComplications

InvasiveInvasive Ureteral stricture orUreteral stricture or

Commonly requiresCommonly requires injury injury

postoperative ureteral stentpostoperative ureteral stent

TreatmentTreatment IndicationsIndications AdvantagesAdvantages UreteroscopyUreteroscopy Ureteral stonesUreteral stones DefinitiveDefinitive

Outpatient Outpatient procedureprocedure

Treatment Modalities for Renal Treatment Modalities for Renal and Ureteral Calculiand Ureteral Calculi

LimitationsLimitations ComplicationsComplications

May be difficult to clearMay be difficult to clear Ureteral stricture or Ureteral stricture or injuryinjury

fragmentsfragments

Commonly requiresCommonly requires

postoperative ureteral stentpostoperative ureteral stent

TreatmentTreatment IndicationsIndications AdvantagesAdvantages UreterorenoscopyUreterorenoscopy Renal stones < 2 cmRenal stones < 2 cm DefinitiveDefinitive

Outpatient Outpatient procedureprocedure

Treatment Modalities for Renal Treatment Modalities for Renal and Ureteral Calculiand Ureteral Calculi

LimitationsLimitations ComplicationsComplications

InvasiveInvasive BleedingBleeding

Injury to collecting systemInjury to collecting system

Injury to adjacent structuresInjury to adjacent structures

TreatmentTreatment IndicationsIndications AdvantagesAdvantages PercutaneousPercutaneous Renal stones >2 cmRenal stones >2 cm Definitive Definitive

nephrolithotomynephrolithotomy Proximal ureteralProximal ureteral stones > 1 cm stones > 1 cm

Kidney stoneKidney stoneWith huge hydronephrosis or With huge hydronephrosis or pyonephrosis :pyonephrosis :

Percutaneous Nephrostomy is Percutaneous Nephrostomy is mandatorymandatory

aim to improve kidney functionaim to improve kidney function

Kidney stone without enlargement of Kidney stone without enlargement of collecting systemcollecting system

<< 5mm 5mm• Watchful waitingWatchful waiting• ESWLESWL

5mm – 20 mm5mm – 20 mm• ESWLESWL• PcNLPcNL• if no urologist if no urologist open surgery open surgery

> 20 mm> 20 mm• ESWL + Double JESWL + Double J• PcNLPcNL• Open surgeryOpen surgery

Staghorn stoneStaghorn stone• Open surgeryOpen surgery• PcNLPcNL• ESWL (fractional)ESWL (fractional)

Kidney stone without enlargement Kidney stone without enlargement of collecting systemof collecting system

Efficacy of ESWLEfficacy of ESWL

< 10 mm< 10 mm10 – 20 mm10 – 20 mm ca oxalate ca oxalate

monohydratemonohydrate cystinecystine < 15 mm< 15 mm > 20 mm> 20 mm

84 (40 – 92)84 (40 – 92)77 (50 – 85)77 (50 – 85)38 – 8138 – 8160 – 6360 – 6371714040

Stone size Stone free rate (%)

Efficacy of PcNLEfficacy of PcNL

< 20 mm< 20 mm In lower calyxIn lower calyx

10 – 20 mm10 – 20 mm

8484 much better much better

than ESWLthan ESWL

Stone size Stone free rate (%)

Retreatment of ESWLRetreatment of ESWL Maximal 3-5 timesMaximal 3-5 times depends on : type of the machinedepends on : type of the machine For electrohydrolic intent 4-5 daysFor electrohydrolic intent 4-5 days For Piezoelectric ± 2 daysFor Piezoelectric ± 2 days

Staghorn stoneStaghorn stone

Open surgeryOpen surgery SandwichSandwich

PcNL and ESWLPcNL and ESWL

Ureter Ureter AnatomyAnatomy Narrowing of uretNarrowing of ureteerr

• UPJUPJ• Crossing with iliac vesselCrossing with iliac vessel• intramuralintramural

Treatment of Ureteric stone Treatment of Ureteric stone depends ondepends on: :

SizeSize LocationLocation ComplicationComplication

•ObstructionObstruction• InfectionInfection•Kidney functionKidney function

Treatment of Ureteric Treatment of Ureteric stonestone

Observation : for stone less than Observation : for stone less than 5mm except for :5mm except for : InfectionInfection InInttractable painractable pain Single kidneySingle kidney Transplant kidneyTransplant kidney Reduced kidney functionReduced kidney function

M E TM E T Diuresis 2 liter/24 hoursDiuresis 2 liter/24 hours NSAIDNSAID Alpha blockerAlpha blocker

Treatment of Ureteric StoneTreatment of Ureteric StoneLocationLocationTreatmentTreatment

ProximalProximal< 1 cm< 1 cm

ESWLESWL URS lithotripsyURS lithotripsy UreterolithotomyUreterolithotomy

> 1 cm> 1 cm UreterolithotomyUreterolithotomy ESWLESWL PcNLPcNLURS + LithotripsyURS + Lithotripsy

Treatment of Ureteric StoneTreatment of Ureteric StoneDistalDistal < 1 cm< 1 cm URS + LithotripsyURS + Lithotripsy

ESWLESWL UreterolithotomyUreterolithotomy

> 1 cm> 1 cm URS – LithotripsyURS – Lithotripsy UreterolithotomyUreterolithotomyyy ESWLESWL

Bladder stoneBladder stone

Urethral stoneUrethral stone Holmium Laser (Endoscopy)Holmium Laser (Endoscopy) Push back Push back bladder stone bladder stone

SourcesSources IAUIIAUI Guidelines PenatalaksanaanGuidelines Penatalaksanaan penyakit batu saluran kemih, penyakit batu saluran kemih,

20072007 Pocket Guidelines EAU 2010Pocket Guidelines EAU 2010

ThanksThanks