Surgical Management

By Michael Grasso, M.D.
Chief of Urology, St. Vincents Hospital
Professor of Urology at New York Medical College

In 1996 there are many modalities available to treat upper urinary tract calculi. It is the mission of the American Urologic Association Nephrolithiases Guidelines Panel to develop guidelines for treating upper urinary tract calculi. The first task of this group was to address current treatment of large, staghorn stone burdens. By reviewing the literature en-toto, this non-biased body of the American Urologic Association set guidelines that are now currently in place.

In regards to large stone burdens, that is calculi greater than 2.5 cm in greatest diameter, the governing body felt rather strongly that open surgical intervention–that is, making a large incision to remove a stone–should be strictly prohibited with very few exceptions. Additionally, the feeling was that ESWL (Extracorporeal Shock Wave Lithotripsy) does have a role for the moderately-sized renal calculi. The Guidelines Panel felt strongly, however, that stone burdens greater than 2.5 cm, or those in complex collecting systems, should be treated endoscopically. Percutaneous nephrostolithotomy (placing a tube into the kidney through the skin to fragment and evacuate the stone material) was felt to be the primary treatment for staghorn stones.

The Guidelines Panel also felt rather strongly that a course of watchful waiting for large stone burdens was not acceptable. Additionally, renal function should be assessed prior to treatment. Kidneys with very little recoverable function (less than five to ten percent of total renal function) may be best treated with a primary nephrectomy, depending on other clinical variables including the renal function on the opposite side.

In summation, the American Urologic Association’s Nephrolithiasis Guidelines Panel has set the tone for the 1990’s as far as treating large renal calculi. These stones should be treated endoscopically in most cases, with ESWL being a treatment for smaller stone burdens or as an adjunctive therapy in combination with endoscopic debulking and evacuation of stone fragments. Copies of the AUA Guidelines Panel recommendations are available by writing to the following address: American Urological Association, Inc. Health Policy Department, 1120 North Charles Street, Baltimore MD 21201.