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INTRODUCTIONINTRODUCTION
Staghorn stones are unquestionably an indication for interventional therapy, since conservative treatment show an increased rate of nephrectomy (up to half) and an increase in associated morbidity (i.e. dialysis); in many cases (up to 28%) the disease resulted in death
Open surgery has been the corner stone of treatment of urolithiasis for more than 30 years till 80s
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INTRODUCTIONINTRODUCTIONwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it
After 1980 PCNL monotherapy first and then combined treatments have been
suggested (PCNL+ESWL+PCNL (sandwich therapy)),( PCNL+ESWL (open
sandwich therapy))
ENDOUROLOGY VS OPEN SURGERYENDOUROLOGY VS OPEN SURGERYwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it
J.J. Rassweiler1, C. Renner1, F. Eisenberger2: The management of complex renal stones. BJU International Volume 86, Issue 8, pages 919–928, November 2000
EVOLUTION OF PCNLEVOLUTION OF PCNLwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it
SUPINE PCNLEASY RETROGRADE ACCESS
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ENDOSCOPIC COMBINED INTRARENAL SURGERYECIRS
Scoffone C., Scarpa RM
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ECIRS
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COMPLETE STAGHORN STONECOMPLETE STAGHORN STONEwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it
SUPINE PCNL WITH 3 ACCESSES
RIRS 2° LOOK
COMPLETE STAGHORN STONE IN HORSESHOE KIDNEYCOMPLETE STAGHORN STONE IN HORSESHOE KIDNEY
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ECIRS WITH DOUBLE ACCESS
PCNL 2nd LOOK
RIRS 3rd LOOK
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NO MORE OPEN SURGERY?NO MORE OPEN SURGERY?
GUIDELINESGUIDELINES
Advances in SWL and endourological surgery (URS and PNL) have significantly decreased the indications for open stone surgery, which is now often a 2°- or 3° -line treatment option needed in 1.0-5.4% of cases only .
The incidence of open stone surgery is ~1.5% of all stone removal interventions in developed countries, and in developing countries, it has dropped from 26% to 3.5 % in recent years (3,5).
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• 2012 EAU guidelines for urolithiasis
GUIDELINESGUIDELINES
5.7.1.1 Indications for open surgery There is a consensus that most complex stones, including partial and complete staghorn stones, should be approached primarily with PNL or combined PNL and SWL. If a reasonable number of percutaneous approaches are not likely to be successful, or if multiple, endourological approaches have been performed unsuccessfully, open surgery may be a valid treatment option.
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• 2012 EAU guidelines for urolithiasis
GUIDELINESGUIDELINES
5.7.1.1 Indications for open surgery There is a consensus that most complex stones, including partial and complete staghorn stones, should be approached primarily with PNL or combined PNL and SWL. If a reasonable number of percutaneous approaches are not likely to be successful, or if multiple, endourological approaches have been performed unsuccessfully, open surgery may be a valid treatment option.
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• 2012 EAU guidelines for urolithiasis
GUIDELINESGUIDELINESwww.guidogiusti.itwww.guidogiusti.it www.etce.itwww.etce.it
• 2012 EAU guidelines for urolithiasis
CONCLUSIONCONCLUSION
However, open surgery is still needed for the most difficult stones, which supports the importance of maintaining proficiency, skills and expertise in open renal and ureteral surgical techniques such as extended pyelolithotomy, pyelonephrolithotomy, anatrophic nephrolithotomy, multiple radial nephrotomy, partial nephrectomy and renal surgery under hypothermia
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• 2012 EAU guidelines for urolithiasis
PLEASE CHIEF,
TEACH ME HOW
TO DO IT!
PLEASE CHIEF,
TEACH ME HOW
TO DO IT!
……….Modern endourologist should master FIRST all
the available ENDOUROLOGICAL solutions (rigid and
flexible nephroscopy, RIRS) to reach the stone-free status BEFORE CONSIDER OPEN SURGERY.
ALMOST…
RENAL CALCULI FEATURESRENAL CALCULI FEATURES
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Laparoscopic urinary stone surgery: an updated evidence-based review.Laparoscopic pyelolithotomy is feasible but rarely indicated in the present era
. Laparoscopic nephrolithotomy may be indicated to remove a stone from an
anterior diverticulum or when PNL or flexible ureteroscopy have failed
Skolarikos A et al: Urol Res. 2010 Oct;38(5):337-44.
provided that all endourological solutions are clearly contraindicated as first treatment option!!
staghorn calculus (stag-horn) n. a
branched stone forming a cast of the
collecting system of the kidney and
therefore filling and obstructing the calyces
and pelvis. It is usually associated with
infection and can cause pyonephrosis and,
if neglected, a perinephric abscess.
OPEN SURGERY?OPEN SURGERY?
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Does open stone surgery still play a role in the treatment of urolithiasis? Data of a primary urolithiasis center.stone-free rate after a single procedure: 69% (18/26 patients).
CONCLUSIONS:Although today most stone cases can be handled by minimally
invasive treatment, open stone surgery maintains a mandatory role in very selected
cases
Honeck P, Alken P, Michel MS.: J Endourol. 2009 Jul;23(7):1209-12
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EVOLUTION OF UROLITHIASISEVOLUTION OF UROLITHIASIS
STAGHORN STONES 1990-2000: 56%STAGHORN STONES 2000-2009: 13%
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