STRATEGIES FOR NONMEDICAL

MANAGEMENT OF UPPER
URINARY TRACT CALCULI
UGWUANYI A.C
29/3/2021
 Outline
• INTRODUCTION
• Historical perspective
• Statement of surgical importance
• Relevant anatomy
• MANAGEMENT STRATEGIES
• Pretreatment evaluation
• Natural history of upper tract calculi
• Renal calculi
Factors affecting management of renal calculi
Renal pole calculi
• Ureteral calculi
Factors affecting management of ureteral calculi
Outline cont’d
• EVALUATION OF OUTCOME
• PERCULIARITIES
• CONCLUSION
• REFERENCES
 Introduction
• Although stone disease is one of the most common afflictions of
modern society, it has been described since antiquity. With
westernization of global culture, however , the site of stone formation
has migrated from lower to upper urinary tract.
• Lifetime prevalence of kidney stone disease is 1-15% varying with age,
gender, race and geographical location.
• Revolutionary advances in the minimally invasive and noninvasive
management of stone diseases over the past 2 decades have greatly
facilitated the ease with which stones are removed.
 Introduction
• Rise in endourology has gained popularity due to advances in
technology in the field of fiberoptics, radiographic imaging and
lithotripsy.
• For most urologists the armamentarium to surgically treat urinary
stone disease consists of 4 minimally invasive modalities: shockwave
lithotripsy (SWL), ureterorenoscopy (URS), percutaneous
nephrolithotomy (PCNL) and laparoscopic or robotic-assisted
surgeries
 Historical perspective
• 1473: first attempt to remove stone in a French archer by Bagnolet
• 1550: Cardan of Milan drained lumbar abscess and 18 stones
• 1880: Henry Morris - first nephrolithotomy in a healthy kidney
• 1964: Ambroise Pare – gave first account of ureteral stone
• 1968: Smith and Boyce – Anatrophic nephrolithotomy
• 1879: Thomas Emmet performed first ureterolithotomy
• 1912: Hugh Hamptom- URS with paediatric cystoscope
• 1941: Ruppel and Brown – carried out first PCNL
• 1980: First treatment of human with SWL based on Dornier HM3 lithotrpter
 STATEMENT OF SURGICAL
IMPORTANCE
• Renal stone surgery aims to maximize stone removal and minimize
patient morbidities.
• Deciding on the optimal treatment for a given patient is not always
clear and depends on many variables : stone-related factors, anatomic
and clinical factors, technical factors and available technology.
RELEVANT ANATOMY
Natural history
• Overall renal stone disease progression i.e stone growth, initially
asymptomatic that becomes symptomatic occurs in 50-80% of cases
with calculated risk of 50% at 5years
• Spontaneous stone passage (≤5mm) – 15%
• Larger stone, renal pelvic stone – symptomatic
• Risk of intervention on asymptomatic stone is 10-20% at 3-4 years
• Staghorn: AUA recommends surgical treatment
Natural history (2)
• Obstruction of ureter lead to raised pressure on the renal pelvis,
calyces and renal capsule causing colic and if not relieved leads to
nephron damage
• Intermittent colic is due to movement down the ureter resulting in
relief of obstruction
• Stone transverse diameter and location (distal/proximal) determines
possibility of stone passage
• Distal – 71%, proximal – 22%; 5mm – 68%, 6-10mm – 47%
Indication for treatment
• Pain
• Infection
• Obstruction
• Active stone growth
• Significant haematuria
 Pretreatment evaluation
• Medical history: predisposing conditions: recurrent UTI, anatomic
abnormal abnormality, hyperparathyroidism, RTA type I, IBD chronic
disorder
• Previous stone composition- dense stone (cystine, brushite,
CaOx.H2O)
• Previous failed surgery:-require more invasive surgery and correction
of anatomic anomaly
• Obese patient, comorbidities (coagulopathy, HTN, CVA)
• Those with high cardiovascular risk would remain on anticoagulant
 Pretreatment evaluation (2)
• Imaging: size, number, anatomy, location, obstruction, stone characteristics
• Laboratory tests:
Urine m/c/s : presence of infection, and treat approximately with culture
directed antibiotics (≥1wk) before definitve treatment of stone
Urinalysis: crystal may suggest stone type, PH
EUCr: compromised renal function – nephrectomy
Serum chemistry – PTH, RTA
Clotting profile – coagulopathy
FBC – PCNL, laparoscopy, open surgery
 Pretreatment resuscitation
• Patient should be optimised adequately before venturing into definitive
stone surgery to reduce morbidity
• UTI: Culture-directed antibiotics should be instituted at least 1week
prior to stone surgery
• Pain: Adequate Analgesia bearing in mind nephrotoxic agents
• Obstruction: ureteral stenting or percutaneous nephrostomy to
decompress the collecting system.
• Coagulopathy: Deranged coagulation is corrected based on patient's
risk stratification, or opinions of surgery best suited for this condition
should be chosen.
Management strategy
Renal calculi
Stone related factors
1. Treatment decision by stone burden
I. ˂1cm (50-60%)
 SWL, URS,PCNL
 In aberrant anatomy – open or laparoscopic surgery
 SWL: 1st line of treatment (least invasive, easy skill, reasonable clearance rate)
 Flexible URS: alternative to SWL. Dense stone, lower pole stone, obesity,
pregnancy
 PCNL: if SWL and URL fail or contraindicated
II. Stone size 1-2cm (SWL, URS, PCNL)
Factors to consider: Location (Lower pole & non lower pole), composition, density and
anatomy of patient
SWL: non lower pole, non-SWL-resistant, non-obese
URS: obese, failed SWL
PCNL (mini & micro): equivalent URS

III. Stone size ˃2cm

PCNL: 1st line
URS: where PCNL is contraindicated (Frailty, coagulopathy, refusal of transfusion).
Require staged procedure
 Staghorn calculi
PCNL Preferred 1st line (AUA, EUA guideline)
Nephrectomy: Poorly/non-functioning kidney
Sandwich therapy: PCNL – SWL – PCNL
URS: where PCNL is contraindicated
Laparoscopic/Robotic assisted: Ectopic kidney for safe access
Open nephrolithotomy: when complicating factors makes PCNL
impossible or when reasonable stone free rate is poor
2. Treatment decision by stone localization
I. Lower pole stones:
Because of acute infundibulopelvic angle, long infundibular length and
narrow infundibular width URS & SWL stone clearance are poor
PCNL: preferred
II. Non lower pole stone:
SWL: Dictated by size and composition
URS: size, density and patient anatomy are more important factors
PCNL: upper pole location is an independent predictor of incomplete stone
clearance
3. Treatment decision by stone composition
• Stone composition affect SWL but not other modalities
• SWL-resistant stone: cysteine, CaPO4, CaOx.H2O, struvite, CaOx.2H2O,
uric acid
• SWL: is contraindicated if stone HU ˃1000
• Matrix stone: PCNL (preferred), URS
Renal anatomic factors
• Ureteropelvic junction obstruction (UPJO)
• Calyceal diverticula
• Horseshoe kidney
• Renal ectopia
UPJO
• Before treatment of renal stone, determines whether
• A) UPJO is the cause of stone formation – Small stones in calyces, renal
pelvis hydronephrosis
• B) Renal pelvis/UPJ stone causes edema that obstructs UPJ – stone
lodges close to UPJ
UPJO + stone:
• PCNL + antegrade endopyelotomy
• Retrograde endopyelotomy + URS
• Laparoscopic/robotic pyelolithotomy or nephrolithotomy + pyeloplasty
Calyceal diverticula
• Location: upper (50%), middle (30%), lower pole (20%)
• URS (1st line):
• ˂2cm stone, upper & middle calyces with short neck.
• Holmium laser enhances stone clearance by incising and abating neck
of diverticula
• PCNL (1st line): most calyceal diverticula stone
• Laparoscopic/robotic: reserved for anteriorly located symptomatic
diverticula not amenable to less invasive methods.
Horseshoe kidney (HSK)
• SWL, URS: ˂15mm, non-lower pole stone
NB: SWL – exclude UPJO, poor pelvicalyceal drainage
Use prone/modified supine position if HSK is more medial
PCNL: ≥15mm, failed SWL or URS
Renal Ectopia
• Location: Pelvis (mostly), abdomen, thorax, crossed retroperitoneum
• Treatment approach depends on: stone burden, kidney location,
impediment to kidney drainage
• SWL: <1.5cm, no UPJO, no poor drainage
• URS: >2cm, no UPJO, no poor drainage, require multiple sessions
• PCNL/Laparoscopy: >2cm, no UPJO,
• Laparoscopy: >2cm, UPJO (allows for repair)
Lower pole calculi
Lower pole calculi
• Has worse stone clearance rate compared with other location when stratified by size and
composition
• SWL: <1cm, HU <1000, SSD <10cm, favourable anatomy
• URS: <1cm, HU >1000, SSD >10cm, unfavourable anatomy;
• 1-2cm, PCNL contraindicated
• PCNL >1cm
• Anatomic factors that decreases lower pole stone clearance (SWL)
• Infundibulum width <4mm
• Acute infundibulum angle 90o
• Infundibulum length >3cm
• Multiple lower pole infundibula
Ureteral calculi
Factors affecting management of ureteral
stones
Options of treatment: SWL, URS, PCNL< Laparoscopy/Robotic assisted surgery
A. Stone factors
1. Treatment decision by localization
I. Proximal and mid-ureter:
SWL,URS: ≤1cm
Prox: SWL URS,
Mid: URS > SWL
Very large ureteral stone not amenable to SWL/URS – PCNL
II. Distal ureter (<1cm, >1 cm):
URS – 94% (preferred)
SWL – 74%
2. Decision by stone burden
Stone burden significantly affect SWL success for ureteral stones at all
location whereas stone burden minimally affect URS success
URS is more effective than SWL thus URS is preferred to SWL
3. Decision by composition:
URS: indicated in SWL resistant stones – cysteine, Brushite etc
B. Ureteral Anatomic factors
1. Megaureter
• Obstructing: Ureteroscopy + endoureterotomy + stone retrieval
• Obstructing and refluxing megaureter – reimplantation
• URS is limited because of access after reimplantation
• Obstructed: ureterolithotomy + ureteroneocystostomy
• Non-obstructing megaureter: SWL, URS

2. Duplicated collecting system

• Complete or partial duplication (intramural)
• Complete: RPG for both ureteral orifices, identify ureteral stone and treat with URS
• Partial: RPG, Dilation of ureteral orifice then ureteroscopy
3. Ureteral stricture/stenosis
• Physical property of structure: short/long segment
• Short segment: Endoureterotomy + stone removal
• Long segment:
• Endoureterotomy + stenting (allowing for healing) 1st stage.
URS (2nd stage) – For stone removal
• Open, laparoscopic/robotic assisted – stricture and stone
Clinical factors for upper urinary tract stone
1. UTI
• Must be treated before any stone treatment
• Short course of culture directed antibiotics
• For infectious stone, completely remove stone fragments to prevent
recurrent UTI and stone growth
• Thus PCNL and URS are preferred to SWL
2. Renal function
• Stone with <15% ipsilateral split renal function – Nephrectomy
• On background poor renal function : SWL, PCNL are advocated as they do not affect
renal functions
• URS is believed to damage renal parenchyma but few studies do not support this
3. Solitary Kidney
• Low threshold for treatment of asymptomatic stone as obstruction requires urgent
attention
• Ensure adequate drainage after stone treatment
• In setting of UTI, electrolyte imbalance and clinical instability initial urinary
decompression via stent or PC nephrostomy drainage is undertaken
4. Morbid obesity
• Because of associated comorbidities, optimization and risk stratification
is necessary
• SSD is a higher predictor of stone free rate than BMI
• URS and PCNL outcome are relatively independent of obesity unlike SWL
5. Old age/Fraility
• URS and PCNL have similar outcome though PCNL has greater bleeding
complication
• SWL is associated with increased perinephric hematoma
6. Spinal deformity/Limb contracture
• PCNL (Preferred): outcome similar to general population
• URS: Use of flexible scope and access sheath are advocated
• SWL: positioning and stone targeting are challenging and so hampers
success
7. Uncorrected coagulopathy
• URS: has little or no increased morbidity. Use with Holmium – YAG
laser lithotripsy
• SWL, PCNL: contraindicated
8. Prior renal surgery
• Resulting fibrosis, scar and deformity of the intrarenal collecting system complicate
stone surgery
• Rare in developed countries due to decrease in open surgery
• In presence of obstruction (UPJO, infundibular stenosis) from scar/fibrosis SWL in
contraindicated, thus URS & PCNL are employed
9. Urinary diversion
• Imaging to define anatomy of urinary diversion and stone location
• SWL, PCNL, antegrade and retrograde URS or a combination are options of
treatment. Flexible ureteroscopes are used
• In presence of obstruction SWL is contraindicated
10. Renal transplant
• Principle: remove stone because lack of innervation results in absent
renal colic
• SWL (≤15mm): prone position is required as graft is near bony pelvis
• URS (≤15mm): Antegrade/retrograde
• PCNL (preferred): indicated when stone ≥15mm, failed SWL, URS
• Metal-tipped fascia dilator is needed in some cases because of thick
fibrous capsule that develop around graft
11. Duration of ureteral stone presence
• Active treatment of any form is indicated when stone obstruction last
for ˃4weeks as it may lead to irreversible renal damage
• Intermittent imaging is recommended for stones attempting to pass
spontaneously.
Evaluation of outcome
Assessment and fate of residual fragments (RFn)
• Residual fragments are relatively common in the era of endourology
• Definition and optimal management of such are controversial

• Concept of Clinical insignificant Residual fragments (CIRF)

• CIRF are fragments 2-4mm that is nonobstructive, noninfectious associated with
sterile urine in an otherwise asymptomatic patient
• Outcome is reported based on stone free rate (SFR) and success rate
• This however, is difficult to interpret due to lack of standard definition of CIRF and
varying modalities in assessing SFR as well as longer duration it takes fragments to
pass following SWL
• Thus Effectiveness quotient, EQ was introduced
EQ = %stone free___________________________ × 100
100% + retreatment + % auxillary procedure
• CIRF is a misnomer as many small RFn eventually becomes clinically
significant and asymptomatic
• Probability that CIRF will become clinically significant following SWL
increases with:
• Increasing fragments burden, fragment number, lower pole fragment
and longer follow-up
• Modality of imaging affects stone detection post-procedure
• XR – 60% sensitivity ≥2mm
• USS – 24.57% worse for ureteral stone
• XR + USS: similar or better than IVU
• Flexible nephroscope – Gold standard
• CT (100% sensitivity) – first choice but must be balanced with danger
of radiation exposure.
 PERCULARITY
• Open surgery remains the commonest modality of treatment of stone
in our environment despite accounting for ˂1% in developed nation
 CONCLUSION
• To ensure optimal treatment of a given patient with upper tract
urinary stone, it is imperative to understand stone- related factors,
renal anatomic and clinical factors and match it with available
technology and urologist experience.
 REFERENCE
• David A. Leavitt, MD, Jean J.M.C.H de la Rosette, MD, PhD, and David
M. Hoenig, MD. Strategies for nonmedical management of upper
urinary tract calculi. In: Wein J.A, Kavoussi L.R et al. (eds.) Campbell-
Walsh Urology. Philadelphia: Elsevier, Inc; 2016. p 1235-1259.