Retrieval methods for urinary stones

This paper attempts to assess the current status of the various modalities of available treatment for urinary stone disease in the Kerala scenario. A total of 300 patients who attended the stone clinic with urinary stone disease and had stones retrieved by different means were selected for the study. Their clinical symptoms, demographic profile, size, number and position of stones, metabolic profiles, retrieval modalities and end result of treatment in terms of stone clearance were assessed. Instances of failure, incomplete clearance and complication events were noted. Based on the experiences, a flowchart was created for appropriate decision-making in urinary stone management. The modalities of retrieval included nephrectomy, nephrolithotomy, pyelo-nephrolithotomy, extended pyelolithotomy, pyelolithotomy, ureterolithotomy, cystolithotomy, urethrolithotomy, ESWL, PCNL, URS, cystolithotripsy, urethrolithotripsy and spontaneous passage. The clearance rate of stone was maximum in open surgery. The extent of stone clearance by ESWL depended on various factors. PCNL was mostly limited by the difficulties in achieving puncture at the stone site. Availability of a variety of flexible nephroscopes also altered the success rate of the procedure. There were good success rates in pushing stones from the ureter to the pelvis followed by PCNL. In patients who had successful PCNL, postoperative morbidity was significantly reduced in terms of the number of days of hospitalization, time taken for return to work, absence of urinary leak, site infection, urinoma formation and urinary tract infection. URS was performed in many patients and stones retrieved. However, the indication for the procedure remains doubtful as the size of most of the stones thus retrieved was less than 6 mm. These would have passed out spontaneously or with chemotherapeutic support. URS, lithotripsy and basketting were confronted by upward migration of stones to the kidney, requiring further procedures for retrieval. Introduction of double J stents helped in relieving urinary obstruction, particularly in patients presenting with anuria, but retained stents, forgotten stents and failed stone retrieval were common following the procedure. The procedure of URS was simplified by the presence of dilated ureter in spontaneous stone passers or those with distal obstruction and proximal dilatation. It is concluded from the study that open surgery still remains the sheet anchor of treatment of urinary stones in many patients in Kerala. Newer lesser invasive procedures should be ethically selected. Decisions should be patient based, taking into consideration the economic feasibility for the procedure proposed.