Surgical management of Upper urinary tract calculi

1. Surgical management of Upper urinary tract calculi m.h.izadpanahi, md, febu Fellowship of urologic oncology IUMS, Isfahan, iran

2. background • Kidney stones are common and costly • Affect 10% of population • Prevalence rates are increasing • Cost> US $2 billion per year

3. Rationale for txNonstaghornRenal Calculi • First,stone-related symptoms or stone growth, with a calculated risk of approximately 50% at 5 years. • Second, spontaneous stone passage occurs about 15% of the time and is more likely in stones 5 mm in size or smaller.

5. Staghorn stones • Untreated staghornstones are associated with 1- recurrent UTIs 2- urosepsisevents 3- renal functional deterioration, and a higher likelihood of death • Complete renal function loss in 50% of affected kidneys can occur after 2 years without treatment

6. modalities • ESWL • URS or RIRS • PCNL • laparoscopic or robotic assisted stone surgery

7. ESWL(mechanism of action) • All shock waves, despite their source, are capable of fragmenting stones when focused • Fragmentation is achieved by several mechanisms • forces result in erosion at the entry and exit sites of the shock wave

8. ESWL

9. Postoperative care • active ambulatory status to facilitate stone passage • Gross hematuria should resolve during the first postoperative week • Fluid intake should be encouraged • Follow-up in approximately 2 weeks for discussion and evaluation of a KUB and renal ultrasonography

10. ESWL(complications) • perirenal hematomas:Severe pain unresponsive to routine intravenous or oral medications(Dx=CT) • Steinstrasse (stone street) • Stone residue(depends on the size and location of stone)

11. URS or TUL

13. TUL

16. lithoclast

17. PNL

18. PNL

19. PNL

20. PNL

21. PNL

22. PNL

28. ESWL and PCNL outcomes

29. Staghorn Stones. • PCNL is the method of choice for treatingpartial and complete staghorn kidney stones • Observationand nonoperative management should be discouraged, becauseeventually cause complete loss of function in theaffected kidney, can be the cause of recurrent UTIs and sepsisepisodes, and are associated with an increased overall mortality

31. URETERAL CALCULI the chief determinant of stone passage: 1- is the diameter of the stone in its transverse orientation . 2- the location of the stone within the ureter at presentation with a review of the literature demonstrating a 71% chance of passage of a distal ureteral stone versus 22% for proximal stones

33. For stones that do not move in a reasonable time frame, or in the setting of recurring severe pain, or if the patient prefers, surgical therapy is indicated. Primary options include SWL and URS, although PCNL and antegradenephroscopy may be indicated for select cases

34. Distal Ureter. As discussed earlier, distal stones are most likely to pass with observation or MET . The most typical site for impaction in this region of the ureter is at the UVJ; stones reaching this location often cause significant irritativesymptoms owing to stimulation of the bladder, a clinical sign that helps localize them. When stones fail to pass, once again surgical therapy is indicated.

35. A UTI associated with an obstructing upper tract stone (ureteral or renal) represents a true urologic emergency and requires emergent urinary tract drainage. This is accomplished by either ureteral stenting or percutaneous nephrostomy. Attempts to definitively treat the obstructing stone should be postponed until the patient is stabilized and the infection is completely treated.78

36. Renal Function The general consensus is that symptomatic upper tract stones located in renal units with approximately 15% or less split function should be considered for nephrectomy, and stone-specific, nephron-sparing treatments should not be pursued.

37. Morbid Obesity A BMI above 40 kg/m2 is considered morbid obesity by the World Health Organization. Ureterorenoscopy and PCNL outcomes appear to be relatively independent of obesity status, whereas those after SWL are drastically worse.

38. Old Age and Frailty A number of groups have looked at PCNL outcomes in elderly populations and have found essentially unchanged surgical success, albeit with a higher rate of complications.Shockwave lithotripsy in the elderly is feasible as well, but it may be associated with an increased risk of perinephrichematoma.

39. Uncorrected Coagulopathy Uncorrected coagulopathy is a contraindicationto SWL and PCNL; however, URS can be successfully undertaken in such circumstances with little to no increase in surgical morbidity.

40. Prior Renal Surgery Prior renal surgery is not a contraindication to any form of renal stone surgery and presents no new specific concerns. Thus, all treatment modalities may be employed as necessary, given appropriate indications (SWL, URS, PCNL).

41. Renal Transplants • because of the lack of innervation in renal transplants, obstructing stones do not manifest with typical renal colic. • vague graft site discomfort, fevers, oliguria, hematuria, or rising creatinine may be the only presenting signs

42. SWLhas been described for stones in transplant kidneys and is an option for stones smaller than 1.5 cm; however, high re-treatment rates and auxiliary procedure rates should be expected

43. PCNLremains the preferred treatment choice for large-burden stones (>1.5 cm) or if less invasive methods have failed. Stone-free rates ranging from 77% to 100%, similar to rates in the general population, have been reported

44. Evaluation of OutcomeAssessment and Fate of Residual Fragments • In the modern era with the rise of endourology and the frequent use of SWL, URS, and PCNL, postoperative residual fragments are relatively common. • The definition and optimal management of residual fragments continue to generate controversy.