THE ROLE OF OPEN STONE SURGERY IN 2002
( Download pdf )

BRIAN R. MATLAGA, DEAN G. ASSIMOS

Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA

ABSTRACT

     Introduction: At one time, the standard treatment for patients with renal and ureteral calculi was open surgical lithotomy. Advances made in the past two decades have dramatically changed the way in which patients with urinary calculi are treated. In light of this present trend towards minimally invasive therapies, it is important to define which patients might be best served by undergoing an open surgical procedure for stone treatment.
     Materials and Methods: The authors review the current indications for open surgical removal of urinary calculi. Particular attention is paid to developments described in recent literature.
     Results: The development of percutaneous nephrostolithotomy, ureteroscopic stone removal, and extracorporeal shock wave lithotripsy has greatly diminished the role of open surgery in the treatment of urinary calculi. While most patients may be treated via these less invasive modalities, there are some patients to whom an open surgical procedure is the optimal therapy.
     Conclusions: There remains a role, albeit small, for open surgical stone removal. The patients who benefit from these procedures generally have extremely complex calculous disease with associated anatomic and physiologic derangements.

Key words: kidney; kidney calculi; urolithiasis; treatment; surgery
Braz J Urol, 28: 87-92, 2002

INTRODUCTION

     Surgical treatment of patients with nephrolithiasis has seen unparalleled progress in the past two decades. The majority of patients with renal and ureteral calculi who have previously required open surgical lithotomy are now managed via less invasive therapy. The advent of percutaneous nephrostolithotomy (PNL), ureteroscopic stone removal (URS) and extracorporeal shock wave lithotripsy (SWL) created this therapeutic revolution (1). However, even with the introduction of these techniques, there still remains a role for open surgical stone removal. It is a small group of patients who have complex calculous disease and unique anatomic and physiologic anomalies that are candidates for this approach.

CURRENT TRENDS IN OPEN STONE SURGERY

     Ostensibly, in the current age of minimally invasive surgery, open stone surgery is less commonplace than it once was. Following the introduction of SWL at a major stone treatment center, Assimos et al. (2) reported an open stone surgery rate of 4.1%. Nearly one-half of the patients requiring open surgery were deemed endoscopic treatment failures. Almost all of the patients who failed endoscopic management had complex calculous disease with anatomic and physiologic anomalies. Bichler et al. (3) from the University of Tubingen describe an open surgery rate of 2.7%. This included patients with large staghorn calculi, those with renal calculi and concomitant anatomic obstruction of the renal collecting system, and those failing SWL and endoscopic therapy. Sy et al. (4) review the treatment of stone disease at Singapore General Hospital and describe an open stone surgery rate of 2%. Stone burden, failure of less invasive modalities, non-functioning kidney, concurrent open surgery, medical co-morbidities, patient preference, anatomic collecting system obstruction, and extreme morbid obesity were indications for open surgery in this series. Within the past two decades, a number of other investigators have reviewed what they perceived to be the role of open stone surgery. Their findings are consistent with the aforementioned study (5-11). Herein, we review the indications for open surgical stone removal.

SYMPTOMATIC CALCULI IN CALYCEAL DIVERTICULA

     Calyceal diverticula are classified as type I, those communicating with a minor calyx or an infundibulum and typically located in a polar area, or type II, those emanating from the renal pelvis or a major calyx (12). Stones located in calyceal diverticula can usually be effectively removed with percutaneous or retrograde ureterorenoscopic techniques, and in select cases with SWL (13-15).
     There are times, however, when it is either not possible or not safe to access the diverticular cavity with endourologic techniques. An example is an anterior calyceal cavity, as percutaneous access could result in excessive bleeding. As well, some centrally located type-II diverticula may be intimately associated with hilar vessels and have no overlying renal parenchyma. While some of the patients with anterior calyceal diverticula can be treated effectively with an ureteroscopic approach, others cannot. These individuals, as well as those with Type II anatomy, should be considered candidates for open surgery (16).
There are two basic open surgical approaches one can pursue when treating these patients. The first approach involves unroofing the calyceal cavity. Following this, the calculus is removed, the diverticular epithelium is obliterated, and the calyceal ostium is closed. The second surgical approach is a partial nephrectomy, which is particularly appropriate for large polar diverticula associated with cortical scarring. Oftentimes in this situation, there is minimal functioning tissue surrounding the diverticular cavity.

CALCULI IN KIDNEYS WITH CONCOMITANT URETEROPELVIC JUNCTION OBSTRUCTION

     The majority of patients with renal calculi and associated ureteropelvic junction obstruction can be treated effectively with PNL and antegrade endopyelotomy. However, there are certain patients who will not have good results with this approach. This includes patients with extremely large renal colleting systems, those with a long segment of strictured ureter, those with diminished renal function, and perhaps those with associated crossing vessels. Open surgery should be considered for these cases, as well as small children, for whom there is not adequate instrumentation available, and perhaps patients with solitary kidneys.

PATIENTS WITH ABNORMAL BODY HABITUS

     Morbidly obese patients, especially when short, present unique management problems. Their posterior panniculus adiposus may put targeted calculi beyond the second focal point and surrounding blast path of the lithotripter. Furthermore, their weight may be beyond the capacity of the lithotripter table or gantry. The subcutaneous tissues of these individuals may engulf percutaneous access sheaths and instruments. Adequate fluoroscopic imaging and patient positioning may not be possible. Thus, PNL and URS may not be safe or viable treatment options for some of these patients, particularly those weighing in excess of 300 kg (17).
     By default, then, open stone surgery may be the safest and most reasonable treatment for select morbidly obese patients (18). However, it must be recognized that this patient population is at a high risk of operative and post-operative complications. Surgical therapy should be reserved, then, for patients who have failed medical management and who are at risk of sepsis and permanent renal damage (19).

PATIENTS REFRACTORY TO SWL, PNL, OR URS

     A small number of patients are refractory to SWL, PNL, or URS and may require open stone surgery as a salvage procedure (20,21). The introduction of better techniques of intracorporeal stone fragmentation such as the holmium laser and the pneumatic lithotriptor, as well as the development of better basket and grasping devices, better patient treatment selection, and increasing technical experience have made such salvage procedures very rare events.

PATIENTS WITH INFLAMMATORY RENAL CONDITIONS AND CALCULOUS DISEASE

     Patients with xanthogranulomatous pyelonephritis associated with renal calculi are optimally treated with nephrectomy (22). On occasion, patients with renal calculi and perinephric abscesses or emphysematous pyelonephritis may be managed via a percutaneous approach. However, open surgical intervention may ultimately be required in this patient group (23). Patients with renal calculi located in non-functioning polar areas of the kidney may be candidates for open surgical partial nephrectomy.

PATIENTS WITH OTHER FORMS OF COLLECTING SYSTEM OBSTRUCTION

     Patients with ureteral stones associated with ureteroceles, ectopic ureters, or obstructing congenital megaureter may benefit from open stone removal performed in conjunction with the correction of the underlying anomaly. Patients with renal stones and associated infundibular stenosis may require open surgical reconstruction of the collecting system using anatrophic techniques. Certain patients with less severe degrees of infundibular stenosis can be treated with percutaneous and ureteroscopic techniques (24,25). However, those patients with severe infundibular stenosis are optimally treated with well-established open surgical techniques, calicorraphy and calicoplasty (26). If this process is in a poorly functioning lower or upper pole, partial nephrectomy may again be a viable treatment option.

PATIENTS WITH STONES IN ECTOPIC KIDNEYS

     The majority of patients harboring calculi in ectopic (horseshoe, renal transplant, and cross-fused) kidneys can be treated effectively with minimally invasive techniques. They may occasionally require open surgical stone removal for other reasons outlined in this manuscript. Patients with pelvic kidneys and large volume renal stones may require open surgical approach because percutaneous access may be dangerous due to the presence of surrounding structures, such as the bowel (27). However, a laparoscopic assisted PNL may be another viable approach (28).

IN CONJUNCTION WITH OTHER SURGERY

     Open surgical removal may be undertaken in conjunction with other open surgical urologic procedures. An illustrative case would be a pyelolithotomy or proximal ureterolithotomy performed in conjunction with ipsilateral partial nephrectomy for removal of a solid parenchymal tumor. It is important that this does not adulterate or compromise the other procedure.

SELECT PATIENTS WITH STAGHORN CALCULI

     The majority of patients with staghorn calculi can be effectively treated with PNL-based therapy. However, there are certain cases where open surgery should be considered. Nephrectomy should be considered if the affected kidney does not function or has negligible function. The functional integrity of the contralateral kidney should be determined before the latter approach is undertaken.
     It is very difficult to attain a stone-free status with PNL in patients with giant staghorn calculi (> 2500 mm2) as demonstrated by the findings of Lam et al. (29). Unfavorable collecting system anatomy in this setting further dilutes PNL results as reported by these investigations. We have not found this to be true with anatrophic nephrolithotomy, which should be considered for such patients (30). This latter approach has been found to be more cost-effective at our institution as well as in other regions of the world (31).

LAPAROSCOPY

     Laparoscopic stone removal may be employed in select cases to circumvent open stone surgery. One must use the same criteria utilized for open surgery when selecting this approach. One must avoid selecting laparoscopic stone removal based on enchantment with this technique.
     The feasibility of laparoscopic stone removal is well documented. Successful ureterolithotomy has been performed using both transperitoneal and retroperitoneal approaches by a number of investigators (32-34). Laparoscopic pyelolithotomy in both normal and ectopic kidneys has been performed (35). Laparoscopic nephrolithotomy has been described (36). While anatrophic nephrolithotomy has not yet been performed in humans, it has been accomplished in a porcine model. Laparoscopic removal of stones in complex calyceal diverticula using a marsupialization technique and partial nephrectomy has been reported (37,38). Laparoscopic pyelolithotomy may be performed in conjunction with pyeloplasty. When the renal pelvis is transected, a flexible cystoscope is passed through the laparoscopic port and the calculi are grasped and removed from the collecting system. The pyeloplasty then proceeds as usual. Results are reported to be similar to those achieved with open surgery (39).
     Urinary calculi residing in ectopic kidneys may also be removed with laparoscopic techniques. In fact, one of the first reported laparoscopic pyelolithotomies was performed on a patient having a stone in a pelvic kidney (40). Laparoscopic removal of calyceal diverticular stones has been reported by a number of investigators (41,42). The utilization of laparoscopy to facilitate PNL in such patients was mentioned earlier in this manuscript.
     Laparoscopic nephrectomy may be considered in patients with staghorn calculi and poorly functioning kidneys (43). However, this approach should be avoided if xanthogranulomatous pyelonephritis is suspected, as operating time has been reported to be significantly longer and morbidity significantly greater as compared to an open surgical approach (44).

CONCLUSIONS

     In summary, there is still a role, albeit minimal, for open surgical stone removal. These patients typically have extremely complex calculous disease with associated anatomic and physiologic derangements. It is important to identify these patients early on so that less effective therapy is not chosen.

REFERENCES

  1. Chaussy C, Brendel W, Schmiedt E: Extracorporeally induced destruction of kidney stones by shock waves. Lancet, 2: 1265-1268, 1980.
  2. Assimos DG, Boyce WH, Harrison LH, McCullough DL, Kroovand RL, Sweat KR: The role of open stone surgery since extracorporeal shock wave lithotripsy. J Urol, 142: 263-267, 1989.
  3. Bichler KH, Lahme S, Strohmaier WL: Indications for open stone removal of urinary calculi. Urol Int, 59: 102-108, 1997.
  4. Sy FY, Wong MY, Foo KT: Current indications for open stone surgery in Singapore. Ann Acad Med Singapore, 28: 241-244, 1999.
  5. Gallegos G: Surgery for urinary tract stone disease. Practitioner, 239: 654-656, 1995.
  6. Hauri D: The role of open surgery. Urol Res, 18: 57-60, 1990.
  7. Hauri D: Surgical therapy. Urol Int, 41: 385-386, 1986.
  8. Kincaid-Smith P: Is surgery for renal calculi necessary in 1985? Med J Aust, 143: 136-137, 1985.
  9. Rady MYA, Rady AM: Conventional open surgery for renal stones in the era of modern techniques. Br J Clin Pract, 41: 704-706, 1987.
  10. Paik ML, Resnick MI: Is there a role for open stone surgery? Urol Clin North Amer, 27: 323-331, 2000.
  11. Boyle ET Jr, Segura JW, Patterson DE: The role of open surgery in stone disease. J Urol, 141: 243A, 1989.
  12. Wulfsohn MA: Pyelocaliceal diverticula. J Urol, 123: 1-8, 1980.
  13. Hulbert JC, Reddy PK, Hunter DW, Castaneda-Zuniga W, Amplatz K, Lange PH: Percutaneous techniques for the management of calyceal diverticula containing calculi. J Urol, 135: 225-227, 1986.
  14. Fuchs GJ, David RD: Flexible ureterorenoscopy, dilatation of a narrow calyceal neck, and ESWL: A new, minimally invasive approach to stones in calyceal diverticula. J Endourol, 2: 244, 1989.
  15. Psihramis KE, Dretler SP: Extracorporeal shock wave lithotripsy of calyceal divertucula calculi. J Urol, 138: 707-711, 1987.
  16. Cohen TD, Preminger GM: Management of calyceal calculi. Urol Clin North Amer, 24: 81-96, 1997.
  17. Hoffman R, Stoller ML: Endoscopic and open stone surgery in morbidly obese patients. J Urol, 148:1108-1111, 1992.
  18. Paik MI, Wainstein MA, Spirnak JP, Hampel N, Resnick MI: Current indications for open stone surgery in the treatment of renal and ureteral calculi. J Urol, 159: 374-378, 1998.
  19. Strauss RJ, Wise L: Operative risks of obesity. Surg Gynecol Obstet, 146: 286-291, 1978.
  20. Liong ML, Claymn RV, Gittes RF, Lingeman JE, Huffman JL, Lyns ES: Treatment options for proximal ureteral urolithiasis: review and recommendations. J Urol, 141: 504-509, 1989.
  21. Paik MI, Wainstein MA, Spirnak JP, Hampel N, Resnick MI: Current indications for open stone surgery in the treatment of renal and ureteral calculi. J Urol, 159: 374-378, 1998.
  22. Chuang CK, Lai MK, Chang PL, Huong MH, Chu SH, Wu CJ, Wu HR: Xanthogranulomatous pyelonephritis: experience in 36 cases. J Urol, 147: 333-336, 1992.
  23. Hudson MA, Weyman PJ, van der Vliet AH, Catalona WJ: Emphysematous pyelonephritits: successful management by percutaneous drainage. J Urol, 136: 884-886, 1986.
  24. Eshghi M, Tuong W, Fernandez R: Percutaneous (endo) infundibulotomy. J Endourol, 1: 107, 1987.
  25. Clayman RV, Hunter D, Surya V, Castaneda-Zuniga WR, Amplatz K, Lange PH: Percutaneous intrarenal electrosurgery. J Urol, 131: 864-867, 1984.
  26. Assimos DG: Anatrophic Nephrolithotomy. In: Glenn JF (ed.). Urologic Surgery (ed 4). Philadelphia, Lippincott, p. 96, 1991.
  27. Lampel A, Hohenfellner M, Schultz-Lampel, D, Laziaa M, Bohnen K, Thurof JW: Urolithiasis in horseshoe kidneys: therapeutic management. Urology, 47: 182-186, 1996.
  28. Caldwell TC, Burns JR: Current operative management of urinary calculi after renal transplantation. J Urol, 140: 1360-1363, 1988.
  29. Lam HS, Lingeman JE, Barron M, Newman DM, Mosbaugh PG, Steele RE, Knapp PM, Scott JW, Nyhuis A, Woods SR: Staghorn calculi: Analysis of treatment results between initial percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy monotherapy with reference to surface area. J Urol, 147: 1219-1225, 1992.
  30. Harrison LH, Assimos DG: Anatrophic Nephrolithotomy. In: Harrison LH, Kandel LB (eds.). Techniques in Urologic Stone Surgery. Mount Kisco, Futura, pp. 293-323, 1986.
  31. Goel MC, Ahlawat R, Bhandari M: Management of staghorn calculus: analysis of combination therapy and open surgery. Urol Int, 63: 228-233, 1999.
  32. Raboy A, Ferzli GS, Ioffreda R, Albert PS: Laparoscopic ureterolithotomy. Urology, 39: 223-225, 1992.
  33. Gaur DD: Laparoscopic operative retroperitoneoscopy: use of a new device. J Urol, 148: 1137-1139, 1992.
  34. Wickham JEA: The Surgical Treatment of Renal Lithasis. In: Wickham JEA (ed.). Urinary Calculus Disease. New York, Churchill Livingstone, pp. 145-148, 1979.
  35. Harmon WJ, Kleer E, Segura JW: Laparoscopic pyelolithotomy for calculus removal in a pelvic kidney. J Urol, 155: 2019-2020, 1996.
  36. Van Cangh PJ, Abi Aad AS, Lorge F, Wese FX, Opsomer R: Laparoscopic nephrolithotomy: the value of intracorporeal sonography and color Doppler. Urology, 45: 516-519, 1995.
  37. Ruckle HC, Segura JW: Laparoscopic treatment of stone-filled calyceal diverticulum: a definitive, minimally invasive therapeutic option. J Urol, 151: 122-124, 1994.
  38. Winfield HN, Donovan JF, Godet AS, Clayman RV: Laparoscopic partial nephrectomy: initial case report for benign disease. J Endourol, 7: 521-526, 1993.
  39. Chen RN, Moore RG, Kavoussi LR: Laparoscopic pyeloplasty. Urol Clin North Am, 25: 323-330, 1998.
  40. Eshgi AM, Roth JS, Smith AD: Percutaneous transperitoneal approach to a pelvic kidney for endourological removal of staghorn calculus. J Urol, 134: 525-527, 1985.
  41. Chang TD, Dretler SP: Laparoscopic pyelolithotomy in an ectopic kidney. J Urol, 156: 1753, 1996.
  42. Ramakumar S, Segura JW: Laparoscopic surgery for renal urolithiasis: pyelolithotomy, calyceal diverticulectomy, and treatment of stones in a pelvic kidney. J Endourol, 14: 829-832, 2000.
  43. Keeley FX, Tolley DA: A review of our first 100 cases of laparoscopic nephrectomy: defining risk factors for complications. Br J Urol, 82: 615-618, 1998.
  44. Bercowsky E, Shalhav AL, Portis A, Elbahnasy AM, McDougall EM, Clayman RV: Is the laparoscopic approach justified in patients with xanthogranulomatous pyelonephritis. Urology, 54: 437-442, 1999.

______________________
Received: August 28, 2001
Accepted: September 30, 2001

_______________________
Correspondence address:
Dr. Dean G. Assimos
Department of Urology
Wake Forest University School of Medicine
Medical Center Boulevard
Winston-Salem, North Carolina 27157, USA
Fax: + + (1) (336) 716-5711