Algerian Association of Urology

Stone Diseases in Algeria:

URS Replaces Slowly Open
H. KOUICEM, Algeria
Surgery

 Introd
uction
In Algeria, urolithiasis is a wide-spread health problem. Until
recently, stone diseases were almost exclusively treated via open
surgery, due to financial restrictions leading to a lack of minimally
invasive technological infrastructure.
Only recently, ureterorenoscopy and LASER stone fragmentation
are introduced.

Open Surgery Ureteroscopy

 Therapeutic
Options
MET available Until OPEN SURGERY
2014

Davancci Robot Roboflex

Avicenna 2014
Laparoscopy

PCNL
Ureteroscopy SWL
 Study Cases

A case series of 6 large ureter stones 1-2 cm are

treated through a modern approach and would have
otherwise undergone open surgery.

The underneath mentioned cases reflect the endourological

approaches adopted even going back to OPEN SURGERY though
abrasive and morbid.
 Case One
Possible
Diagnosi Options
s MET
Open surgery
Female, 36 Years
PCNL
Ureteroscopy
L P U stone: 14
Laparoscopy
mm
Robot

What would you opt for?

 Case Two
Possible
Diagnosi Options
s MET
Open surgery
Male, 54 years PCNL
Ureteroscopy
One right kidney Laparoscopy
Robot
Anuria

R L U stone: 14
mm

What would you opt for?

 Case
Three Possible
Options
Diagnosi MET
Open surgery
s PCNL
Ureteroscopy
Female, 35 years Laparoscopy
Robot
L P U stone: 15 mm

What would you opt for?

 Case
Four Possible
Options
Diagnos
MET
is Open surgery
PCNL
Male, 47 years Ureteroscopy
Laparoscopy
R P U stone: 10
mm
Robot

MET failed

What would you opt for?

 Case
Five Possible
Options
MET
Open surgery
Diagnosi PCNL
s Ureteroscopy
Laparoscopy
Male, 44 years Robot

L L U stone: 22
mm

What would you opt for?

 Case
Six Possible
Options
Diagnos MET
Open surgery
is PCNL
Ureteroscopy
Female, 56 years Laparoscopy
Robot
R K stone : 20 mm

What would you opt for?

 EAU
Recommendat
ions
Recommendations for MET LE GR
For MET, -blockers are recommended 1a A
Patients should be counselled about the attendant risks of A*
MET, including associated drug side effects, and should be
informed that it is administered off-label **
Patients who elect for an attempt at spontaneous passage or A
MET, should have well-controlled pain, no clinical
evidence of sepsis, and adequate renal functional reserve.
Patients should be followed once between 1 and 14 days to 4 A*
monitor stone position and be assessed for hydronephrosis.

Recommended treatment option (if indicated for active stone removal) (GR: A*)

Stone location and size First choice Second choice

Proximal ureter < 10 mm SWL

Proximal ureter > 10 mm URS (retrograde or antegrade or SWL

Distal ureter < 10 mm URS or SWL

Distal ureter > 10 mm URS SWL

EAU Algorithm 2014
 Indications for open surgery
Kidney stones
Complex stone burden

Failure of SWL, PNL, or ureteroscopic procedure

Intrarenal anatomical abnormalities: infundibular stenosis; stone in the calyceal diverticulum

(particularly in an anterior calyx); obstruction of the ureteropelvic junction; and stricture if
endourologic procedures have failed or are not promising

Morbid obesity

Skeletal deformity, contractures and fixed deformities of hips and legs

Comorbidity

Concomitant open surgery

Non-functioning in lower pole (partial nephrectomy), non-functioning kidney (nephrectomy)

Patient choice (after failed minimally invasive procedures, a single procedure avoiding the risk of
multiple PNL procedures might be preferred by the case)

Stone in an ectopic kidney where percutaneous access and SWL may be difficult or impossible.

For the paediatric population, the same considerations apply as for adults.

EAU Guidelines 2014

 Fallouts

Sometimes, though financial resources and technical platforms are

available, the urologist is obliged to opt for a decision that does NOT
logically shadow the EAU Recommendations!!!
 Case
One
URS scheduled. Spontaneous stone passage through MET after
3 weeks.
 Case
Two
Semi-rigid ureteroscopy. Fragmentation with ballistic lithotripter.
Post-OP JJ.
 Case
Three
Semi-rigid ureteroscopy. Fragmentation with ballistic lithotripter.
Post-OP JJ.
 Cases
Four &
Case Five
Five
Fragmentation with semi-rigid ureteroscope LASER.
Post-OP JJ.

Case Four
 Case
Six
The stone was found embedded in the ureteropelvic
junction. Up to 50% of the stone was fragmented with
flexible LASER. Cloudy urines observed. JJ placed.
Treatment completed using delayed SWL.
 Comments
Though MET and Open
Surgery are still practiced
due to the restricted financial
resources of patients as well as
the availability and the limits of
the technical platforms;
URS is gaining ground slowly!
 All in
All
What are the appropriate treatment choices to be recommended?
 Conclusions
Open surgery has been the main if not the only
treatment for stones in Algeria. Ureteroscopy has
opened a path towards minimally invasive surgery in
our country:
It has re-instated confidence in the use of conservative
treatments as a first option.
Algeria has embarked towards a path to negligibly
aggressive modern stone treatment.

The successful management of all aspects of stones treatment requires

both competence and equipments.

The Algerian urologist is obliged to find the best solution to relieve his
patients sufferings; nevertheless reality is rather problematic!