Renal stones endoscopic Renal stones endoscopic managementmanagement

Dr sarwar noori Dr sarwar noori mahmoodmahmood

F.I.C.MS(urology), F.I.C.MS(urology), F.E.B.UF.E.B.U

Indications for treatmentIndications for treatment

Presence of symptoms and /or Presence of symptoms and /or obstruction obstruction

in a functioning kidneyin a functioning kidney

Treatment of Renal Treatment of Renal StonesStones

Four OptionsFour Options 1) conservative ,1) conservative ,

2) non-invasive:2) non-invasive: ESWL ESWL

3) minimal invasive : 3) minimal invasive : PCNL, URS PCNL, URS

4) open surgery4) open surgery

New technologyNew technology : : morbidity, morbidity, hospital stay,hospital stay,

invasivenessinvasiveness

Natural history of renal stones

SPONTANEOUS CLEARANCE OF STONES IN 3 MONTHS

< 4 m.m. 96%

4 to 6 m.m. 80%

6 to 8 m.m. 60%

8 to 10 m.m. 20%

KIDNEYS

URETERS

BLADDER

PROSTATE

URETHRA

URINARY SYSTEMSpontaneous clearance of stones takes place

ONLY WHEN—

1.There is good flow of urine/function on the affected side

&

2.There is no distal obstruction

MANAGEMENT OF RENAL MANAGEMENT OF RENAL CALCULI by ESWLCALCULI by ESWL

<< 2cm in diameter and/or surface 2cm in diameter and/or surface area < 500 mmarea < 500 mm22

Treatment : ESWL mono-therapyTreatment : ESWL mono-therapy

>> 2cm in diameter and/or 2cm in diameter and/or surface area > 500 mmsurface area > 500 mm22

Treatment : PCNL +/- ESWLTreatment : PCNL +/- ESWL

Combination therapyCombination therapy

Treatment of Renal Treatment of Renal StonesStones

ESWLESWL

Generation of shock Generation of shock wavewave

T H E M A G I C W O R D--- LITHOTRIPSY

EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY

WHAT ARE SHOCK WAVES?

There should be a limited amount of gravel , which is expected to be passed out spontaneously within reasonable time limit , without causing much discomfort/colics .

IDEAL SITUATION FOR SUCCESSFUL

E.S.W.L.

Renal calculus of less than 2 cm having hetrogenous calcification/ architecture

In X- ray , in a well functioning renal unit with no distal obstruction

PROBLEMS WITH E.S.W.L.

Stones did not break:

obesity

*Chemical composition of stone

Stones did not pass –out:

*Poor or no function of this kidney

*Comparatively large amount of gravel got stuck and choked the system

Percutaneous nephrolithomy PCNL

The key-hole surgery

Indication of PCNL: Indication of PCNL: >2.5-3.0 cm>2.5-3.0 cm failure of ESWL (matrix,cystine,ca failure of ESWL (matrix,cystine,ca

oxalate monohydrate)oxalate monohydrate) cystine stone >1.5 cmcystine stone >1.5 cm lower calyx stone ≥ 2.0cm(narrow, lower calyx stone ≥ 2.0cm(narrow,

long, acute angel infuldibulopelvic long, acute angel infuldibulopelvic angel)angel)

caliceal diverticulumcaliceal diverticulum UU stone >1cm not respond to ESWL or UU stone >1cm not respond to ESWL or

difficult with URS.difficult with URS.

FUCTIONAL ANATOMY OF KIDNEYFOR

PERCUTANEOUS TECHNIQUE 

1.              VASCULAR  

2.              CALYCEAL 

3.              ANATOMIC RELATION

 

PERCUTANEOUS RENAL SURGERY 

PRE – OP WORK UP 

Urine culture

Renal function test

Haematological profile

Caogulation profile

KUB and IVU

US.                            

 

Steps for PCNLSteps for PCNL

Retrograde ureteric catheterization Retrograde ureteric catheterization Fluoroscopy-guided percutaneous Fluoroscopy-guided percutaneous

puncture(B-ultrasound for simple case)puncture(B-ultrasound for simple case) Tract dilationTract dilation LithotripsyLithotripsy Double-J stent and nephrostomy tube Double-J stent and nephrostomy tube

placementplacement

ANAESTHESIANAESTHESIAA

Epidural anesthesia (Most cases)Epidural anesthesia (Most cases) GGeneral anesthesiaeneral anesthesia (Obesity and lung (Obesity and lung

dysfunction)dysfunction) Local anesthesiaLocal anesthesia （（ for second-lookfor second-look ））

Body positionBody position prone position (most prone position (most

cases)cases) side-lying side-lying

positionposition （（ obesityobesity 、、 cardiorescardiorespiratory dysfunctionpiratory dysfunction ））

supine supine positionposition （（ transplantetransplanted kidneyd kidney））

Retrograde ureteric Retrograde ureteric catheterizationcatheterization

6Fr ureteric catheter open end 6Fr ureteric catheter open end Wash out small stonesWash out small stones Prevent small stones moving from Prevent small stones moving from

pelvis into ureterpelvis into ureter

AMPLATZ SHEATH

- Metallic

- Teflon

X-rayX-ray UltrasonograpUltrasonographyhy

Which one is betterWhich one is better ？？ 2 methods combination 2 methods combination better.why?better.why?

Air pneumatic lithotripterAir pneumatic lithotripter Ho:YAG laser Ho:YAG laser 3th generation EMS3th generation EMS

Which one is better?Which one is better?

Double-J stent and nephrostomy tube Double-J stent and nephrostomy tube placement,Tubeless PCNL NOT placement,Tubeless PCNL NOT

commoncommon

PERCUTANEOUS RENAL SURGERY

COMPLICATIONS  

1.                        RENAL PELVIC PERFORATION  2.                        HAEMORRHAGE  3.                        INJURY ADJACENT ORGANS  4.                        UROSEPSIS  5.                        FLUID ABSORPTION   6.                        AV MALFORMATION  

Ureteric stoneUreteric stone

INDICATIONS FOR INTERVENTION:INDICATIONS FOR INTERVENTION:The classical indications for intervention are well The classical indications for intervention are well

known & include the following:known & include the following:* Presence of infection* Presence of infection* Presence of obstruction* Presence of obstruction* Persistent colic with no advancement of the stone* Persistent colic with no advancement of the stone* A stone more than 0.5 cm in diameter* A stone more than 0.5 cm in diameterThe classical indications have recently been modified The classical indications have recently been modified

because of the advent of new technology & the high because of the advent of new technology & the high expectations of today's patients.expectations of today's patients.

THERAPEUTIC OPTIONS:THERAPEUTIC OPTIONS:These include:These include:* Surgery* Surgery* Percutaneous surgery* Percutaneous surgery* Ureteroscopy with Electrohydraulic lithotripsy(EHL), * Ureteroscopy with Electrohydraulic lithotripsy(EHL),

Ultrasound lithotripsy, Ultrasound lithotripsy, Laserlithotripsy, Electro-mechanical Impactor Laserlithotripsy, Electro-mechanical Impactor

lithotripsy, & Lithoclast lithotripsy.lithotripsy, & Lithoclast lithotripsy.* ESWL* ESWL* Spontaneous passage* Spontaneous passage

MANAGEMENT OF MANAGEMENT OF URETERIC STONESURETERIC STONES

-Stones < 0.5 cm in diameter doesn’t -Stones < 0.5 cm in diameter doesn’t pass pass

spontaneously 4 to 6 weeks and /or spontaneously 4 to 6 weeks and /or causing symptoms : ESWL causing symptoms : ESWL monotherapymonotherapy

-Stones > 0.5 cm in diameter & < 1 -Stones > 0.5 cm in diameter & < 1 cm in cm in

diameter : ESWL monotherapydiameter : ESWL monotherapy

MANAGEMENT OF MANAGEMENT OF URETERIC STONESURETERIC STONES

Stones > 1 cm in diameter : trial of Stones > 1 cm in diameter : trial of ESWL monotherapyESWL monotherapy

Patient counselled:Patient counselled:

1.1. Repeat session may be Repeat session may be necessarynecessary

2.2. URS/PCNL/ureterolithotomy URS/PCNL/ureterolithotomy

RESULTS OF RESULTS OF URETROSCOPIC URETROSCOPIC

LITHOTRIPSY (URS)LITHOTRIPSY (URS)Achieved stone free status = 85% to 90%Achieved stone free status = 85% to 90%

Failures:Failures:

1.1. Access problemsAccess problems

2.2. Stone migrationStone migration

Flexible URS for upper third ureteric Flexible URS for upper third ureteric calculicalculi

especially in the maleespecially in the male

URS complications:URS complications: pain ,sepsis ,damage to ureteral pain ,sepsis ,damage to ureteral

mucosa and wall, failuremucosa and wall, failure

RENAL STONESRENAL STONES

NephrolithotomyNephrolithotomy

PREVENTION OF PREVENTION OF STONESSTONES

1.1. Treatment of causesTreatment of causes

2.2. Dietary manipulationsDietary manipulations

3.3. Medications - indication Medications - indication durationduration

DIETARY ADVICEDIETARY ADVICE

1.1. HydrationHydration

2.2. Avoid oxalate-rich foodAvoid oxalate-rich food

3.3. Avoid calcium-rich food ?Avoid calcium-rich food ?

4.4. Avoid refined carbohydratesAvoid refined carbohydrates

5.5. Increase crude fibresIncrease crude fibres

MEDICATIONSMEDICATIONS

1.1. ThiazidesThiazides

2.2. AllopurinolAllopurinol

3.3. AntibioticsAntibiotics

4.4. Sodium bicarbonateSodium bicarbonate

5.5. Potassium citratePotassium citrate

6.6. Magnesium saltsMagnesium salts

7.7. PyridoxinePyridoxine