Base bibliographique

This review of the literature about cost in urinary lithiasis indicates that there is nothing regarding France. Some German and especially American publications on this subject are available. The main idea arising from these studies is that medical prevention could reduce the global cost in urinary lithiasis.

International classification of staghorn calculi is always lacking. French classification is described. Physiopatholgy of staghorn calculi is based on urinary infection. Staghorn stones in emerging countries will be composed frequently of calcium oxalate. Recurrent urinary infection and urinary stasis favour staghorn stone formation and are clinically significant. Medical treatment is rather uneffective. Only antibiotics and elimination of all residual fragments could be recommended.

It is recommended to treat staghorn calculi by percutaneous nephrolithotomy (PCNL) either alone or in combination with Extra Corporeal Shockwave Lithotrips (ESWL). Antegrade or retrograde fibroscopy, multiple accesses could also improve PCNL stone-free rates. ESWL alone is limited to partial staghorn calculi in adults or to staghorn calculi in children. Open surgery has more or less completely passed.

Congenital or acquired ureteral anomalies are not frequent but can be associated with a urinary stone. Different anatomical anomalies will be reviewed and their treatment, as well as stone treatment, will be described. In case of ureteral anomalies, stone composition is not the same than for other urinary stones which indicates a role played by urinary infection and metabolic disorders.

The review of the literature about ureteropelvic junction (UPJ) obstruction and concomitant renal stone has highlighted two major aspects. First, urinary stagnation due to UPJ obstruction is frequently associated with metabolic disorders such as hypercalciuria. Second, results of laparoscopic pyeloplasty are at least as good as those of open surgery but with the advantages of a minimal access approach. Exploration of the renal cavity with the laparoscope or a fibroscope allows to treat in the same time a concomitant renal calculi.

Urinary tract modifications by surgical treatment of invasive bladder cancer or renovesical reflux will require some technical tricks to treat urolithiasis. Papers illustrating theses specific tricks will be presented.

Open surgery for stones of the upper urinary tract has very few indications, failures or complications of other techniques, greater than 2cm stones, hard stones, anatomical abnormalities and complex stones. Open surgery for stone may be difficult and need specific tools. For the kidney, the anatrophic nephrotomy is an effective procedure which spares the renal function. For the ureter, the mini-ureterotomy is no more invasive than laparoscopy. The stone-free rate of open surgery is over 90%. The main complications are stenosis, fistula and infections.

The management of upper urinary tract stones needs an imaging for the diagnosis, the evaluation and the follow-up of the stones. The imaging has to be of good quality. For the simple acute flank pain, regular plain film with ultrasonography can be sufficient. For complex acute flank pain, a CT-scan with or without contract medium injection is mandatory. To plan the optimal treatment of the stone, injection of contrast medium is necessary if the diagnosis imaging is of poor quality. Imaging is systematically needed after the urological treatment of a stone. Regular plain film with ultrasonography is sufficient for the follow-up.

Urinary infection is a risk factor for lithiasis. Urinary tract infection is a factor of gravity of urinary stone. The stone can exist before the infection which colonizes the stone, infected stone. The infection can be the cause of the stone, infectious stone (struvite stone). Infectious stones can be secondary to a non urinary infectious agent, oxalobacter formigenes (OF) and nanobacteria. The first-line treatment of struvite stone is percutaneous surgery. Perioperative antibiotics, renal urines and stone cultures are obligatory.

Urinary lithiasis is an uncommon cause of chronic renal failure. Risky stones of chronic renal failure are cystinuria, tubular acidosis and chronic bowel diseases. Moreover, bilateral stones, late metabolic diagnosis and infection are factors that can induce an alteration of the renal function. Staghorn stone is a grave disease for the renal function and the life of the patient. There is no room for conservative treatment for staghorn stones. For solitary kidney, the stone treatment may improve the renal function. Incidence of stone in the dialysis population is 5–13%. In the dialysis population, it is recommended a yearly renal sonography and citrate, and magnesium treatment. All the urological procedures of stone removal are available in case of renal failure but the techniques must spare the renal function and avoid surgical complication. Urines must be with no infection and a urinary drainage is mandatory.

Percutaneous access is a difficult step in percutaneous nephrolithotomy. Different methods have been described to facilitate percutaneous access. To increase stone-free rate, supracostal or multiple access is required. Indications, results and complications of these specific accesses are reviewed.

Percutaneous nephrolithotomy has sometimes particular indications related to the patient, his anatomy or the stone itself. These situations will be described.

Recent technological changes of percutaneous nephrolithotomy are reviewed. Results and complications of the most recent publications are presented.

International recommendations about urolithiasis are summarized and illustrated by those elaborated by the urolithiasis committee of the French Urological Association.

Since percutaneous nephrolithotomy (PCNL) was initially described, different technical modifications have been described. Among them, miniperc which only used small nephroscope and access sheath from 11 to 20Fr. This technique could not yet been recommended. Supine position is also a technical modification from original PCNL. Supine position is able to reduce colic injury and could be proposed in specific indications.

Diagnosis of urolithiasis during pregnancy is a common condition not more frequent than in non pregnant women. Ultrasonography will be the main tool of diagnosis. If sonography fails, ionizing radiation will be used only if MRI is not available. One must take care of the mother and the foetus because preterm delivery is increased in case of lithiasis during pregnancy. Conservative treatment is favoured taking care of specific contraindications of medical therapy related to pregnancy. In case of complications, drainage of the urinary system by retrograde or antegrade approach will be considered. Endoscopic treatment is realized only in case of failure of drainage or in the post-partum with etiologic investigations.

Laparoscopic approach is used to treat urinary lithiasis. Pyelolithotomy and ureterolithtomy being excluded from this review, indications for laparoscopy consist in treatment of calyceal diverticula, nephrectomy and/or ureterectomy for non-functioning kidneys, or laparoscopy-assisted percutaneous nephrolithotomy in ectopic kidney, horseshoe kidney or calyceal diverticula. Laparoscopy gives the benefits of a mini-invasive treatment with reduced blood loss, pain, hospital stay and recovery. In these indications, laparoscopy is still a skillfull demanding procedure.

Renal stones can be treated by laparoscopic approach. Laparoscopy is used instead of open surgery which indications remains limited regarding high efficacy of ESWL or endoscopic procedures in urinary lithiasis. This review highlights that all open surgical procedures have been performed by laparoscopy, the most often being pyelolithotomy either by retroperitoneal or transperitoneal approach. These laparoscopic procedures are skillful demanding procedures. Robotic will probably increase a little bit laparoscopic approach to treat renal stones by its facilitating effect to perform suture.

Laparoscopy has been used to treat ureteral stones. This review highlighted that many of the publications are coming from centers of emerging countries. This seems to be due to big size of the stones and high cost of endoscopic procedures in these countries. Indications of laparoscopic ureterolithotomy are similar to those of open surgery and mainly consist in extracorporeal shock wave lithotripsy (ESWL) or endoscopic failure or wrong indications (big or impacted stones). Advantages of laparoscopic ureterolithotomy consist in a decrease analgesic requirement, a shorter hospitalize stay and a shorter recovery time. But, operative time remains higher than with open surgery. Complications such as urinary fistulae are decreased when ureteral suture is correctly performed or when a double-J ureteral stent is placed.

Radioactivity is represented by ⍺, β and γ-rays emission which can by interaction with substance produce ionisation. Humankind is exposed to natural radioactivity as well as human activities related radioactivity. Radioactiviy risk is dose related and biological dose is expressed in millisievert (mSv). Annual biological dose related to natural radioactivity is around 2 to 3mSv. Regarding urinary lithiasis, radiation can occur during diagnosis and treatment phases for the patient and the latter for the surgeon. Objective of radioprotection is to protect people from radioactivity and is organised by different decrees. Annual biological dose received by internal or external exposition should not exceed 20mSv a year. Some essential concepts must be known and good practice rules have to be followed.