Urinary Tract Calculi VI: Surgical Management

Small bladder stones are removed using cystolitholapaxy via cystoscopy. For larger stones, transurethral or percutaneous suprapubic cystolitholapaxy is performed, where ultrasonic, laser, or electrohydraulic energy breaks up the stones, which are then flushed out through bladder irrigation. This minimally invasive approach avoids open surgery.

Percutaneous nephrolithotomy involves making a small incision in the patient's back and inserting a nephroscope through a sheath into the kidney. Under fluoroscopic or ultrasound guidance, ultrasonic, laser, or electrohydraulic energy fragments the stones, and debris is irrigated out of the kidney. This technique handles larger stones effectively.

Laser lithotripsy uses a holmium laser directed through a ureteroscope to fragment ureteral or bladder stones, with fragments removed or flushed out. Extracorporeal shock wave lithotripsy uses focused shock waves to break kidney or upper ureter stones smaller than 2 cm, allowing fragments to pass naturally through urine.

Open surgical procedures such as nephrolithotomy, pyelolithotomy, ureterolithotomy, or cystotomy may be necessary in severe cases depending on stone size and location. Surgery is indicated when stones cause severe pain, infection, obstruction, or when minimally invasive options are unsuitable for patient management.

A flexible or rigid ureteroscope is inserted to access stones in the ureter or renal pelvis. Ureteroscopy is combined with ultrasonic, laser, or electrohydraulic lithotripsy to fragment stones before removal, offering a minimally invasive treatment option for patients with upper urinary tract calculi.

Medical intervention is necessary when stones exceed 5 millimeters and cannot pass spontaneously, when accompanied by symptomatic infection like fever or pyelonephritis, when they impair kidney function, or cause persistent severe pain, nausea, or urinary retention. Patients with one kidney also require intervention.

Extracorporeal shock wave lithotripsy is preferred for kidney or upper ureter stones smaller than 2 centimeters. Shock waves generated by a lithotripter are focused on the stone using fluoroscopy or ultrasound guidance, breaking it into fragments that pass naturally through urine without surgical incision.