Advances in the surgical management of nephrolithiasis.

The surgical management of urinary calculus disease has undergone a dramatic evolution over the past 2 decades. Twenty years ago, open surgical procedures for urinary calculi were some of the most frequently performed urologic procedures. Since then, however, stone management has been at the forefront of "minimally invasive" intervention. Specifically, the initiation and refinement of percutaneous and ureteroscopic access to the upper tracts, along with the rapid and nearly simultaneous development of both extracorporeal and intracorporeal lithotripsy techniques, has limited the role of open surgery to less than 1% of patients undergoing intervention for their stone disease. This manuscript will review the current indications for the surgical management of urinary calculi, the basic physics of the most frequently utilized vehicles for both extracorporeal and intracorporeal lithotripsy, and the respective roles of extracorporeal and intracorporeal lithotripsy with percutaneous or ureteroscopic access and open surgery. In addition, the results and complications associated with each of these forms of intervention will be reviewed. Finally, a discussion of specific clinical challenges to the urologist will be presented.

Ureteroscopic management of lower-pole renal calculi: technique of calculus displacement.

PURPOSE: We review our technique of ureteroscopic management of lower pole renal calculi with Nitinol basket displacement and holmium laser stone fragmentation. METHODS: Lower pole calculi are identified with a 7.5F flexible ureteroscope. In patients in whom the laser fiber reduces ureteroscopic deflection, precluding reentry into the lower pole, a Nitinol basket or grasper is used to displace the calculi into an upper pole calix for easier fragmentation. RESULTS: The Nitinol device can be passed into the lower pole through the fully deflected ureteroscope without any loss of deflection. Irrigation is significantly reduced by the basket, but this factor does not impede stone retrieval. CONCLUSIONS: Ureteroscopic management of lower pole stones is a reasonable alternative to SWL or percutaneous nephrolithotomy in low-volume stone disease. If the stone cannot be fragmented in situ, Nitinol basket capture through a fully deflected ureteroscope into a less dependent position facilitates stone fragmentation.

Simplified ureteral stent placement with the assistance of a ureteral access sheath.

PURPOSE: When using a ureteral access sheath following a ureteroscopic procedure, placement of an internal ureteral stent can be simplified by inserting the stent through the sheath without the need to reinsert the cystoscope. MATERIALS AND METHODS: An indwelling ureteral stent with the pull string attached is inserted over the guide wire into the access sheath followed by the pusher. The guide wire is partially withdrawn allowing the stent to form a coil in the renal pelvis, using the pull string to adjust the stent position. The fluoroscopy unit is then focused onto the bladder and the guide wire is slowly withdrawn until its tip is at the level of pubic symphysis. The pusher and guide wire are then removed and the pull string is cut at the urethral meatus. RESULTS: Among 71 cases studied 60 required ureteral stent placement. In 43 of the 60 cases (72%) the ureteral access sheath greatly facilitated ureteroscopy, and a stent was placed through the access sheath in 34 (79%). Stent placement through the access sheath was successful in all cases, with an average time saving of 2.3 minutes per case, compared to placing the stent by reinserting a cystoscope. CONCLUSIONS: If an access sheath has already been placed during a ureteroscopic procedure and stent insertion is deemed necessary, the stent can be easily placed through the access sheath under fluoroscopic guidance without the need to reinsert the cystoscope. Our experience suggests that all urologists who routinely perform ureteroscopic procedures can easily master this timesaving technique.