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IS THERE A ROLE FOR OPEN STONE SURGERY?
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UROLITHIASIS
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IS THERE A ROLE FOR OPEN STONE SURGERY? Michael L. Paik, MD, and Martin I. Resnick, MD
The surgical management of urinary-stone disease has undergone dramatic changes and seen the implementation of technological innovations that are unsurpassed in the field of urologic surgery over the past 20 years. Before these advancements of the past two decades, open surgery was the only surgical option for urolithiasis. The introduction and development of percutaneous renal surgery, the significant achievement of extracorporeal shock-wave lithotripsy (ESWL) (Dornier Medical Systems, Marietta, Georgia), the refinement of ureteroscopy, and technical advancements in the available modalities for intracorporeal lithotripsy have led to a revolution in the manner in which urinary-stone disease is managed surgically. The indications for open stone surgery have been narrowed significantly, and for the most part open surgery has become a second- or third-line treatment option. The surgical removal of renal stones was documented in the ancient Greek and Roman civilizations but is more detailed in the literature dating back to the 1500s and 1600s. During this time period and for years thereafter, stone operations were performed only in the setting of infected, obstructed kidneys. Ingalls is credited with the first planned nephrolithotomy in the United States in 1872, and Morris is credited with performing the first nephrolithotomy in the setting of an uninfected kidney in England in 1880.33Further
advancements were made this century, with respect to surgical approaches to the kidney and collecting system, as surgeons arrived at a better understanding of the anatomy of the intrarenal vasculature. The development of ESWL has been, since its introduction by Chaussy et a1 in 1980; probably the most significant factor responsible for the precipitous decline in the use of open surgery for stone treatment. No other single achievement has revolutionized the discipline of stone treatment. In 1989, Chaussy and Fuchs8 estimated that 70% of urinary stone patients could be treated with ESWL monotherapy, with an additional 25% able to be treated by ESWL in combination with endourologic modalities. Most of the remaining credit for the vast reduction in open stone operations during this time period can be attributed to the development of percutaneous nephrolithotomy, first introduced in 1976 by Fernstrom and Johannson." Segura30 reported that percutaneous lithotripsy was the preferred treatment modality in 15% to 20% of stone patients. The development of smaller-caliber semirigid ureteroscopes and flexible ureteroscopes, along with the parallel advances in intracorporeal lithotripsy devices, has accounted for the infrequent performance of ureterolithotomy in contemporary stone management. With all of these technologic advancements and the resultant change in philosophy in the
From the Department of Urology, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio
UROLOGIC CLINICS OF NORTH AMERICA VOLUME 27 NUMBER 2 * MAY 2000
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surgical management of urinary stone disease, one is left to wonder what exactly is the role of open stone surgery in contemporary stone management. As the newer, lesser invasive modalities have taken over stone treatment, urologists, especially recently trained practitioners and those who will enter the field in the future, are and inevitably will be less thoroughly trained in the techniques of open stone procedures. As the use of open stone surgery has diminished with time, it has become increasingly more difficult, in this era of minimally invasive surgery, to properly define the role of open surgery and the acceptable indications to resort to open procedures in the management of renal and ureteral calculi. In this article, the authors attempt to better define the acceptable indications for open stone surgery, to review the commonly accepted advantages of open stone procedures, and to establish the expected results and outcomes following open surgery for stone disease.
CURRENT TRENDS
Most of the steep decline in performance of open surgery for urinary stones occurred in the 1980s. The introduction of percutaneous nephrolithotomy and the improvements in ureteroscopic equipment and techniques brought on the initial reduction in the percentage of open stone operations performed. The advent of ESWL then led to the near elimination of the need to perform open surgery to eradicate renal and ureteral calculi. The widespread access to and availability of ESWL for the practicing urologist by the midto late 1980s meant that most upper urinary tract stones no longer required an incision for removal. In 1989, Assimos et all reported a 4.1% rate of open stone surgery after the establishment of ESWL at a major stone treatment center. Nearly one half of the patients in this series were deemed to have failed primary endoscopic treatment. GillenwateP stated that during a comparable time period, the open stone surgery rate was only 0.3% at his institution. From 1985 through 1990 various other reports in the literature dealt with the issue of the role of open stone surgery with the arrival of the lesser invasive modalities. All of these reports concurred that the newer treatment methods in essence had taken over, but that there was still a
minor role for open surgery for select indications.1, 12,14,15.20, 25 As surgical stone treatment evolved into the 1990s and the minimally invasive modalities became firmly established and more technically refined, one would have expected an even further decline in the rate of open surgery. Open stone surgery continued, however, to occupy a small niche in the armamentarium of stone treatment. Kane et all8 reported a 3.1% rate of open procedures at a center dedicated to tertiary endourologic surgery for stone disease. Anatomic abnormalities accounted for most of the indications (31%), with failure of endourologic procedures being less frequent (17%). It is reasonable to infer that improving skill and expertise, as well as improving technology with respect to endourologic procedures, could explain the declining rate of endoscopic failures over time. The overall rate of open stone procedures, however, seems to have reached the nadir. At the authors’ institution, from 1991 to 1995, the rate of open stone surgery was 5.4%.=Although our slightly higher rate may reflect a higher percentage of complex stone patients and a higher percentage of patients who were referred specifically after primary endoscopic or ESWL failures, one can argue that there is still a finite population of patients who are managed best by open surgery, either primarily or secondarily after failed initial attempts with less-invasive treatments. First the availability of the newer treatment modalities, then patient demand and the desire to avoid painful incisions and long recovery periods, and finally concerns for cost containment and the pressure to provide costeffective care and shorter hospitalizations after surgery have created a treatment philosophy that defines success as the ability to eradicate the stone with the least invasive modality, and that holds that open surgery should be avoided unless all else fails or is highly likely to fail. Open surgery thus may be viewed by the urologist and the patient as indicating or implying failure. This type of outlook on stone treatment could lead to an overwhelming bias against open surgery and could result potentially in the appropriate treatment option being foregone, withheld, or delayed, to the detriment of the patient with urinary calculus disease. It is imperative that urologists continue to recognize the unusual circumstances and acceptable indications for performing open surgery to remove urinary
IS THERE A ROLE FOR OPEN STONE SURGERY?
stones, thus preventing open stone surgery from becoming a lost surgical art. INDICATIONS
Early in the development of the less-invasive approaches, open procedures still were being performed frequently to treat patients who had failed one or a combination of the newer modalities. Also, during the nascent stage of less-invasive stone therapy, there were many places in which the instruments were not yet available and urologists were not yet adequately skilled in these techniques. As the instruments, technology, and technical skills became more widespread, primary treatment with ESWL, percutaneous nephrolithotomy, or ureteroscopy became accepted and preferred for most urinary stones. As we approach the end of the millenium, open stone surgery has only a limited role in stone management, but its indications remain important nonetheless. In this section the authors discuss the commonest, current, and acceptable indications for open stone surgery based on our recent experience (Table 1). Complex Stone Disease
Complex stone disease and significantly large stone burden remain indications for open surgery in select clinical scenarios. It is certainly true that even complete staghorn
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calculi now can be approached safely and effectively with percutaneous nephrolithotomy either alone or in combination with ESWL. Open surgery, however, likely will continue to have a role in the management of this type of stone disease, especially in those kidneys with dilated collecting systems. In our experience, complex stone burden represents the most frequent indication for an open stone procedure, occurring in 55% of cases.23 Complex stones are those that occupy the entire renal pelvis, with multiple extensions into the calyces and complete staghorn calculi. Various reports in the literature over the past two decades have established that percutaneous nephrolithotomy, either alone or in combination with ESWL, is an effective treatment modality for large renal stones (larger than 3 cm) and staghorn calculi (Table 2). The stone-free rates for this treatment are reported to be from 50% to 87% in different series.”, 19, **, 22* 28, 32, w 36 Stone-free rates generally have been reported to be higher with open procedures (Table 3). In comparing the percutaneous approach with anatrophic nephrolithotomy, Snyder and Smith32 found that the retained stone fragment rate was 13%for percutaneous extraction and 0% for open surgery. Boyce and Elkins3reported a 15% recurrence rate at an average follow-up period of 3 years after anatrophic nephrolithotomy. At our institution, open stone surgery resulted in a 93% postoperative stone-free rate.= Despite the slightly higher stone-free rates
Table 1. INDICATIONS FOR OPEN STONE SURGERY AT CASE WESTERN RESERVE UNIVERSITY, BY PROCEDURE
Complex stone burden Treatment failures Percutaneous surgery ESWL Percutaneous + ESWL Transurethral endoscopy Anatomic abnormality Ureteropelvic-junction obstruc*on Infundibular stenosis Calyceal diverticulum Ureteral stricture Morbid obesity Comorbid medical diseases Concomitant open surgery Nonfunctioning lower pole
Pyelollthotomy (15 Cases)
Anatrophic Nephrolithotomy (14 Cases)
9 3 2 0
13
1 0 4
3 1 0 0 2
3 0 0
Ureterollthotomy (6 Cases)
0 0 0 0 0
1
1
0 1 0 0 2 0 0
0
1
ESWL = extracorporeal shock-wave lithotripsy. (From Paik ML, Wainstein MA, Spimak JC et al: Current indications for open stone surgery in the treatment of renal and ureteral calculi. J Urol 159:374-379, 1998)
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Table 2. STUDIES OF PERCUTANEOUS NEPHROLITHOTOMY FOR STAGHORN CALCULI Authors
No. of Kldneys
No. of Procedures
Stone-free %
Lam et alzl Snyder and Smith" Winfield et a P Kahnoski et all7 Schulz et alu' Karlsen and GjolbergIY
91 75 23 52 90 54
2.7 1.2 2.7 2.6 2.7 2.4
87 87 86
achievable with open surgery, one must weigh the enormous benefits that percutaneous approaches to complex stones bring to the equation. Percutaneous nephrolithotomy allows the patient to avoid large incisions for open renal surgery, decreases postoperative pain and narcotic requirements, results in a shorter convalescence period than open surgery, and, for stones that can be successfully treated in one setting, results in shorter hospitalizations. Brannen et a14 and Brown et a1,5 in the mid-1980s reported that percutaneous procedures led to significantly decreased recovery time and cost compared with open surgery. Preminger et alZ4found, however, that for stones greater than 2.5 cm in size, percutaneous surgery was somewhat more costly than open surgery, although it resulted in significantly shorter recuperative time and less cost. For the larger, more complex stones and for complete staghorn calculi, for which multiple percutaneous or ESWL procedures are likely to be required for stone eradication, the benefits of shorter hospitalization and convalescent times begin to diminish rapidly in comparison with a traditional open surgical stone procedure. In addition, the cost of multiple lesser invasive procedures is likely to outweigh the cost of a single open procedure, despite the continued cost advantage related to shorter recovery time associated with percutaneous procedures. Other reports in the literature continued to argue in favor of open surgery over percutaneous nephrolithotomy or combination therapy for staghorn calculi in certain situations. Esen et allo found that for patients with com-
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plete or partial staghorn stones, open surgery resulted in a stone-free rate of 80%, versus 50% for combination therapy and 25% for ESWL monotherapy. Assimos et a12 reported that in patients with staghom calculi and any degree of pelvicalyceal dilatation, anatrophic nephrolithotomy resulted in stone-free rates from 89% to 100°/o, whereas percutaneous nephrolithotomy with or without ESWL led to stone-free rates of only 12% to 25%. The question remains of which patients with complex stones are served best by percutaneous approaches or combination therapy, and which should be considered for open surgery as the primary treatment. Most, if not all, urologists treating upper-tract stone disease would agree that a majority of complex, larger (greater than 2-3 cm) stones including partial and complete staghorn calculi, should be approached primarily with percutaneous nephrolithotomy, and if necessary secondary percutaneous procedures or ESW. In certain select cases, ESWL monotherapy may be appropriate. Open surgery becomes a more acceptable treatment option, however, if a reasonable combination of percutaneous ESWL procedures is unlikely to result in treatment success. This is in accordance with the findings of the American Urological Association Nephrolithiasis Clinical Guidelines Panel in 1994.3l Most reasonable surgeons and patients would prefer a single open surgical procedure over a long, difficult, and protracted treatment course requiring numerous percutaneous procedures along with ESWL. What number represents a reasonable number of attempts at percutaneous stone removal is up
Table 3. STUDIES OF OPEN SURGERY FOR STAGHORN CALCULI Authors
No. of Kidneys
No. of Procedures
Stone-free %
Rocco et alZh Rodrigues Netto et aI2' Paik et alu Assimos et alz Esen et allo
47 28 14 10 10
1 1 1
87 82 93 90 80
1 1
IS THERE A ROLE FOR OPEN STONE SURGERY?
to the individual patient and the treating urologist. This most likely is to be the case in patients with complete or giant staghorn calculi and dilated collecting systems. These are the patients in whom open surgery is still likely to represent a valid primary treatment option, despite the availability and efficacy of less-invasive modalities. Endourologic or ESWL Treatment FaiIures
Patients who cannot be treated successfully with percutaneous approaches, ESWL, or ureteroscopic lithotripsy have a significant chance of ultimately requiring open surgery. Again, one needs to determine how many procedures a patient will require before treatment is declared a failure with one or a combination of less-invasive modalities. Much of this depends on the expertise of the treating urologist and the determination of the patient. Those urologists who are adept or trained specifically in endourology may have a higher threshold for giving up on treatment with the lesser invasive modalities, even if it requires multiple treatments and multiple combinations of modalities. Urologists who are not as skilled in endourological procedures may be quicker to resort to open procedures. Nonetheless, the inability to successfully eradicate a stone with the less-invasive modalities is certainly an indication for open stone surgery. Treatment failures, especially endoscopic failures with respect to ureteral stones, have diminished since the early days of endourological approaches to stones. In 1989, Assimos et al’ reported a 43% endoscopic failure rate for ureteral stones as an indication for open surgery. In 1995, Kane et all8 reported that endourologic failures for ureteral stones represented 10%of the indications for open stone surgery at their institution. In 1998, the authors reported that only 12% of open stone cases at our institution represented failures with endoscopic ureteral stone treatment.23 With the development of newer instruments for intracorporeal lithotripsy, including the pneumatic lithotripter and the ho1mium:yttrium-aluminum-garnet laser, there are fewer stones that are not amenable to ureteroscopic lithotripsy and that are beyond the reach of the endourologist. Of five patients who failed ureteroscopic approaches to ureteral stones at the authors’
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institution, all had stones at least 2 cm in size with an average of 2.3 cm.23For this reason, it may be reasonable to approach ureteral calculi of this or larger size with primary ureterolithotomy. Ureteral stones that are relatively large and are likely to be impacted also may be considered for primary ureterolithotomy, because these stones may be difficult to treat endoscopically without incurring an increased risk for ureteral injury or perforation. Endourologic treatment failures for renal calculi accounted for 17% of the indications for open surgery at the authors’ institution.u This includes failures of percutaneous nephrolithotomy alone or in combination with ESWL. Failure of endourologic management of renal calculi usually implies failure on multiple attempts, because most urologists would persist in trying to remove a complex renal stone with more than one attempt through a percutaneous tract before moving on to open surgery. Again, this goes to the-question of what is a reasonable number of attempts with percutaneous treatment or ESWL, which must be determined in each individual case by the urologist and the patient. Anatomic Abnormalities
Urinary-tract anatomic abnormalities can predispose the stone-forming patient to recurrent stone disease after initial successful treatment and eradication. Intrarenal and collecting-system abnormalities also can complicate the surgical approach. In addition to breaking up or removing the stone, the anatomic defect must be treated in order for the procedure to be deemed a success. Additional endourologic surgical expertise and instruments are required to correct these defects through the existing endourologic access sites. Because of the additional complexity that arises with concomitant anatomic abnormalities, the likelihood of open stone surgery rises with the presence of an anatomic defect. Specific anatomic abnormalities that can complicate the stone process include congenital and acquired ureteropelvic-junction (UPJ) obstruction, calyceal diverticulum, infundibular stenosis, and ureteral stricture. At the authors’ institution, 24% of the patients requiring open stone surgery had an anatomic abnormality that necessitated combined open stone removal with correction of the anatomic defect.23
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Renal calculi and concomitant UPJ obstruction certainly can be approached percutaneously, either in the same setting or in a staged procedure. Most renal stones are amenable to percutaneous lithotripsy, and percutaneous endopyelotomy can be performed through the same percutaneous tract, either at the same time (for primary UPJ obstruction) or delayed (if there is concern that the UPJ obstruction could be secondary to edema from the calculus). For simple or small renal pelvic stones, the combined percutaneous approach would seem to be the treatment of choice. As the stone burden increases or if there are confounding anatomic factors, more contemplation may be given to a combined open approach to the coexisting problems. Complex stones, the presence of a crossing vessel, or the presence of a large dilated renal pelvis are relative indications for open surgery. In the authors’ series, of the patients undergoing combined open stone removal and UPJ repair, one had failed previous percutaneous stone removal, another had a horseshoe kidney, and a third patient was younger than 1 year of age. From the authors’ experience, they advocate giving strong consideration to a combined open approach for patients with a large or complex stone burden or confounding anatomic factors related to the UPJ obstruction. For patients with mild to moderate stone burden and a straightforward UPJ obstruction, the percutaneous approach should be considered the first-line treatment. Stones in calyceal diverticula, or associated with stenotic or obstructed infundibula, can be approached percutaneously to eradicate the stone and to obliterate the diverticulum or perform infundibuloplasty. Most of these stones can be treated successfully in this combined manner. There are situations, however, in which open surgery can be considered. In the authors‘ series, there was one patient who had failed previous percutaneous treatment secondary to a narrow diverticular neck, another patient with a diverticulum associated with an anterior calyx, and a third patient with a large stone filling a dilated diverticulum who were successfully treated with open surgery. Surgeon experience with the endourologic techniques also may factor into the decision making. Ureteral stricture or obstruction distal to a ureteral calculus precludes simple ESWL or ureteroscopic lithotripsy. One must treat successfully the obstructing process as well as
the stone to promote drainage of fragments and prevent recurrent stone formation secondary to obstruction or urinary stasis. Ureteral strictures can be treated with endoscopic dilation concomitantly with stone removal or fragmentation. In one of the authors’ patients, a 2-cm ureteral stone, as well as stricture of the distal ureter, were treated successfully with combined ureterolithotomy and ipsilatera1 ureteroneocystostomy. The approach in these patients needs to be individualized, and certain circumstances, such as large stone burden or stricture length or certain locations may dictate the preference for an open surgical approach.
Patient Anatomy Certain factors relating to patient anatomy can interfere with or preclude endourologic access or ESWL therapy. Obesity is probably the most commonly encountered anatomic factor. Morbidly obese patients with stones present a difficult challenge no matter what treatment modality is implemented. Percutaneous access, tract length, and patient positioning are problems frequently encountered in obese patients. Percutaneous nephrolithotomy, however, has been shown to be a successful treatment method in obese patients by Carson et a17 and Hoffman and Stoller.16 ESWL can be technically difficult or impossible if the stone cannot be positioned within the focal point of the lithotripter or if the patient is too heavy for the table. Any open surgery in an obese patient can be more difficult secondary to body habitus and limitations in surgical exposure, and also because of the higher risk of complications. In certain patients, endourologic procedures and ESWL may be technically impossible or carry a significantly increased chance of failure or complications for any of the previously stated reasons, so that open surgery is preferred, even with only a moderate stone burden, which usually would be treated with a lesser invasive modality. In the authors’ experience, open stone surgery was performed in 10% of patients because of morbid obesity, and all were treated successfully with minimal morbidity.u Other anatomic or body habitus considerations include severe limb contractures or the inability to position in the prone position secondary to pulmonary disease.ls Ectopic kid-
IS THERE A ROLE FOR OPEN STONE SURGERY?
neys or malrotation also can limit or interfere with access. Open surgery may be indicated in these cases; however, percutaneous access still can be achieved successfully with adjunctive methods such as laparoscopic assistance. Transplanted kidneys present anatomic considerations in stone management. The location of the transplant kidney or the surrounding anatomy may dictate the need for an open procedure; however, successful treatment also can be achieved with percutaneous access or ESWL.6 Comorbid Disease
The presence of significant comorbid medical diseases and advanced age can factor into the decision making on how to treat the stone-forming patient. The ideal therapy for such patients takes into consideration the desire to achieve a stone-free state with the avoidance of significant morbidity and complications, and the desire to avoid multiple or prolonged procedures. Despite the fact that the procedures may be considered less invasive, each procedure still requires some sort of anesthesia and its resultant risk. Sometimes these types of patients are served best by a single, uncomplicated open procedure to achieve all of these goals. Open surgery certainly carries higher anesthetic risks and requires generously sized incisions. There is great benefit, however, in avoiding the potential for multiple procedures and prolonged hospitalizations. In certain elderly patients or those with multiple medical problems, the benefits of achieving a stone-free state with one open procedure outweigh the risk involved with a major surgery and outweigh the potential risk for requiring multiple lesser invasive procedures leading to a more difficult, protracted treatment course. Despite that the stone itself may be very amenable to endourologic access or ESWL therapy, the goal of the physician is to treat the patient as a whole.
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ally nonfunctioning kidneys. These patients are candidates for simple nephrectomy as treatment of their stone disease. Occasionally, a renal stone is associated with a poorly functioning or nonfunctioning moiety of the kidney. It may be necessary in these cases to perform removal of the stone via partial nephrectomy, allowing simultaneous removal of the nonfunctioning and obstructed segment of the kidney. Partial nephrectomy also may be indicated if a stone is associated with an anatomic abnormality that cannot be treated by endourologic techniques.35The stone and the segment of the kidney associated with the abnormal intrarenal unit can be excised intact.
Patient Preference
The final consideration in choosing the appropriate treatment modality for the stoneforming patient always should be the preference of the well-informed, competent patient. This is certainly not the least important factor. After the other variables have been factored into the decision making, ultimately the patient must choose what type of treatment he or she is willing to undergo. It is the responsibility of the surgeon to ensure that the patient has been given all of the necessary information regarding the benefits, risks, and expectations of success or failure for each of the alternative therapeutic modalities available in the most unbiased manner possible. It is only then that the patient can make the most appropriate individual decision on treatment. The authors believe that, given the choice, a small percentage of patients prefers to undergo open surgery rather than take the risk of requiring more than one less-invasive procedure, despite the fact that the urologist may feel that the less-invasive treatment is the appropriate choice. In these select cases, as long as the patient is an appropriate surgical candidate, the authors believe his or her preference ultimately should be honored.
Nephrectomy
Patients who are recurrent stone formers with frequent renal parenchymal infections and chronic high-grade obstruction are prone to developing poorly functioning and eventu-
SUMMARY
Modern day urinary-stone treatment involves procedures and techniques that were
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not even available 20 years ago. The relatively rapid and sometimes explosive development of ESWL, percutaneous techniques, and ureteroscopy and intracorporeal lithotripsy has ushered in the era of minimally invasive stone management. In many regards, open surgery has such a limited role that its performance often is regarded as a sign of failure. To think of open stone surgery in this manner is likely to do a disservice to a small but important segment of the urinary-stone patient population. The critical responsibility of the urologist treating stone disease is to be able to recognize those clinical situations in which open stone surgery may represent at least a viable and reasonable alternative to less-invasive modalities. The duty of the surgeon is then to be able to present this option to the patient in an unbiased fashion and to effectively perform and implement this form of treatment if chosen. It is only with this approach that open surgery will continue to be correctly applied on those rare occasions and will not become a lost surgical art in the era of minimally invasive surgery.
References 1. Assimos DG, Boyce WH, Harrison LH, et al: The role of open stone surgery since extracorporeal shock wave lithotripsy. J Urol 142263-267, 1989 2. Assimos DG, Wrenn JJ, Harrison LH, et al: A comparison of anatropic nephrolithotomy and percutaneous nephrolithotomy with and without extracorporeal shock wave lithotripsy for management of patients with staghom calculi. J Urol 145:710-714, 1991 3. Boyce WH, EIkins IB: Reconstructive renal surgery following anatrophic nephrolithotomy: Followup of 100 consecutive cases. J Urol 111:307-312, 1974 4. Brannen GE, Bush WH, Correa RJ, et al: Kidney stone removal: Percutaneous versus surgical lithotomy. J Urol 1336-12, 1985 5. Brown MW, Carson C 111, Dunnick NR, et al: Comparison of the costs and morbidity of percutaneous and open flank procedures. J Urol 135:1150-1152, 1986 6. Caldwell TC, Burns J R Current operative management of urinary calculi after renal transplantation. J Urol 140:1360-1363, 1988 7. Carson C 111, Danneberger JE, Weinberth JL: Percutaneous lithotripsy in morbid obesity. J Urol 139243, 1988 8. Chaussy CG, Fuchs GJ: Current state and future developments of noninvasive treatment of human urinary stones with extracorporeal shock wave lithotripsy. J Urol 141:782-789, 1989 9. Chaussy C, Brendel W, Schmiedt E: Extracorporally induced destruction of kidney stones by shock waves. Lancet i3:1265-1268, 1980
10. Esen AA, Kirkali Z , Guler C: Open stone surgery: Is it still a preferable procedure in the management of staghorn calculi? lnt Urol Nephrol 26247-253, 1994 11. Femstrom I, Johannson B: Percutaneous pyelolithotomy: A new extraction technique. Scand J Urol Nephrol 10257-259, 1976 12. Gallegos C: Surgery for urinary tract stone disease. Practitioner 239:654456, 1995 13. Gillenwater J Y Editorial comment. J Urol 142267, 1989 14. Hauri D: The role of open surgery. Urol Res 18(suppl 1):57-60, 1990 15. Hauri D: Surgical therapy. Urol Int 41:385-386, 1986 16. Hoffman R, Stoller ML: Endoscopic and open surgery in morbidly obese patients. J Urol 148:1108-1111, 1992 17. Kahnoski RJ, Lingeman JE, Coury TA, et al: Combined percutaneous and extracorporeal shock wave lithotripsy for staghorn calculi: An alternative to anatrophic nephrolithotomy. J Urol 135579481, 1986 18. Kane CJ, Bolton DM, Stoller ML: Current indications for open stone surgery in an endourology center. Urology 45218-220, 1995 19. Karlsen S, Gjolberg T Branched renal calculi treated by percutaneous nephrolithotomy and extracorporeal shock waves. Scand J Urol Nephrol 23201-205, 1989 20. Kincaid-Smith P: Is surgery for renal calculi necessary in 1985? Med J Aust 143:136-137, 1985 21. Lam HS, Lingeman JE, Mosbaugh PG, et al: Evolution of the technique of combination therapy for staghom calculi: A decreasing role for extracorporeal shock wave lithotripsy. J Urol 148:1058-1062, 1992 22. Lingeman JE, Coury TA, Newman DM, et al: Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. J Urol 138:485-490, 1987 23. Paik ML, Wainstein MA, Spimak JP, et al: Current indications for open stone surgery in the treatment of renal and ureteral calculi. J Urol 1593374379, 1998 24. Preminger GM, Clayman RV, Hardeman SW, et al: Percutaneous nephrostolithotomy vs open surgery for renal calculi. JAMA 254:1054-1058, 1985 25. Rady MYA, Rady AM: Conventional open surgery for renal stones in the era of modem techniques. Br J Clin Pract 41:704706, 1987 26. Rocco F, Casu M, Carmignani L, et al: Long-term results of intrarenal surgery for branched calculi: is such surgery still valid? Br J Urol 81:79&800, 1998 27. Rodrigues Netto N, Jr, Lemos GC, Palma PCR, et al: Staghom calculi: Percutaneous versus anatrophic nephrolithotomy. Eur Urol 15:9-12, 1988 28. Schulze H, Hertle L, Kutta A, et al: Critical evaluation of treatment of staghorn calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J Urol 141:8224325, 1989 29. Segura JW: Current surgical approaches to nephrolithiasis. Endocrinol Metab Clin North Am 19:919935, 1990 30. Segura JW: The role of percutaneous surgery in renal and ureteral stone removal. J Urol 141:780-781, 1989 31. Segura JW, Preminger GM, Assimos DG, et al: Nephrolithiasis clinical guidelines panel summary report o n the management of staghorn calculi. J Urol 151:1648-1651, 1994 32. Snyder JA, Smith AD: Staghom calculi: Percutaneous extraction versus anatrophic nephrolithotomy. J Urol 136~351-354,1986 33. Spimak JP, Resnick MI: Stone treatment. In Gillen-
IS THERE A ROLE FOR OPEN STONE SURGERY? water JY, Grayhack JT, Howards SS, et a1 (eds): Adult and Pediatric Urology. St. Louis, Mosby, 1996, pp 695-747 34. Streern SB, Lammert G: Long-term efficacy of combination therapy for struvite staghorn calculi. J Urol 147:563-566, 1992 35. Timoney AG, Payne SR, Walmsley BH, et al: Partial
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nephrectomy: An option in calculus disease? Br J Urol 62511-514, 1988 36. Winfield HN, Clayman RV, Chaussy CG, et al: Monotherapy of staghorn renal calculi: A comparative study between percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J Urol 139:895-899, 1988 Address r e p i t i t requests to Martin I. Resnick, MD Department of Urology University Hospitals of Cleveland Case Western Reserve University School of Medicine 11100 Euclid Avenue Cleveland, OH 44106
UROLITHIASIS
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IS THERE A ROLE FOR OPEN STONE SURGERY? Michael L. Paik, MD, and Martin I. Resnick, MD
The surgical management of urinary-stone disease has undergone dramatic changes and seen the implementation of technological innovations that are unsurpassed in the field of urologic surgery over the past 20 years. Before these advancements of the past two decades, open surgery was the only surgical option for urolithiasis. The introduction and development of percutaneous renal surgery, the significant achievement of extracorporeal shock-wave lithotripsy (ESWL) (Dornier Medical Systems, Marietta, Georgia), the refinement of ureteroscopy, and technical advancements in the available modalities for intracorporeal lithotripsy have led to a revolution in the manner in which urinary-stone disease is managed surgically. The indications for open stone surgery have been narrowed significantly, and for the most part open surgery has become a second- or third-line treatment option. The surgical removal of renal stones was documented in the ancient Greek and Roman civilizations but is more detailed in the literature dating back to the 1500s and 1600s. During this time period and for years thereafter, stone operations were performed only in the setting of infected, obstructed kidneys. Ingalls is credited with the first planned nephrolithotomy in the United States in 1872, and Morris is credited with performing the first nephrolithotomy in the setting of an uninfected kidney in England in 1880.33Further
advancements were made this century, with respect to surgical approaches to the kidney and collecting system, as surgeons arrived at a better understanding of the anatomy of the intrarenal vasculature. The development of ESWL has been, since its introduction by Chaussy et a1 in 1980; probably the most significant factor responsible for the precipitous decline in the use of open surgery for stone treatment. No other single achievement has revolutionized the discipline of stone treatment. In 1989, Chaussy and Fuchs8 estimated that 70% of urinary stone patients could be treated with ESWL monotherapy, with an additional 25% able to be treated by ESWL in combination with endourologic modalities. Most of the remaining credit for the vast reduction in open stone operations during this time period can be attributed to the development of percutaneous nephrolithotomy, first introduced in 1976 by Fernstrom and Johannson." Segura30 reported that percutaneous lithotripsy was the preferred treatment modality in 15% to 20% of stone patients. The development of smaller-caliber semirigid ureteroscopes and flexible ureteroscopes, along with the parallel advances in intracorporeal lithotripsy devices, has accounted for the infrequent performance of ureterolithotomy in contemporary stone management. With all of these technologic advancements and the resultant change in philosophy in the
From the Department of Urology, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio
UROLOGIC CLINICS OF NORTH AMERICA VOLUME 27 NUMBER 2 * MAY 2000
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surgical management of urinary stone disease, one is left to wonder what exactly is the role of open stone surgery in contemporary stone management. As the newer, lesser invasive modalities have taken over stone treatment, urologists, especially recently trained practitioners and those who will enter the field in the future, are and inevitably will be less thoroughly trained in the techniques of open stone procedures. As the use of open stone surgery has diminished with time, it has become increasingly more difficult, in this era of minimally invasive surgery, to properly define the role of open surgery and the acceptable indications to resort to open procedures in the management of renal and ureteral calculi. In this article, the authors attempt to better define the acceptable indications for open stone surgery, to review the commonly accepted advantages of open stone procedures, and to establish the expected results and outcomes following open surgery for stone disease.
CURRENT TRENDS
Most of the steep decline in performance of open surgery for urinary stones occurred in the 1980s. The introduction of percutaneous nephrolithotomy and the improvements in ureteroscopic equipment and techniques brought on the initial reduction in the percentage of open stone operations performed. The advent of ESWL then led to the near elimination of the need to perform open surgery to eradicate renal and ureteral calculi. The widespread access to and availability of ESWL for the practicing urologist by the midto late 1980s meant that most upper urinary tract stones no longer required an incision for removal. In 1989, Assimos et all reported a 4.1% rate of open stone surgery after the establishment of ESWL at a major stone treatment center. Nearly one half of the patients in this series were deemed to have failed primary endoscopic treatment. GillenwateP stated that during a comparable time period, the open stone surgery rate was only 0.3% at his institution. From 1985 through 1990 various other reports in the literature dealt with the issue of the role of open stone surgery with the arrival of the lesser invasive modalities. All of these reports concurred that the newer treatment methods in essence had taken over, but that there was still a
minor role for open surgery for select indications.1, 12,14,15.20, 25 As surgical stone treatment evolved into the 1990s and the minimally invasive modalities became firmly established and more technically refined, one would have expected an even further decline in the rate of open surgery. Open stone surgery continued, however, to occupy a small niche in the armamentarium of stone treatment. Kane et all8 reported a 3.1% rate of open procedures at a center dedicated to tertiary endourologic surgery for stone disease. Anatomic abnormalities accounted for most of the indications (31%), with failure of endourologic procedures being less frequent (17%). It is reasonable to infer that improving skill and expertise, as well as improving technology with respect to endourologic procedures, could explain the declining rate of endoscopic failures over time. The overall rate of open stone procedures, however, seems to have reached the nadir. At the authors’ institution, from 1991 to 1995, the rate of open stone surgery was 5.4%.=Although our slightly higher rate may reflect a higher percentage of complex stone patients and a higher percentage of patients who were referred specifically after primary endoscopic or ESWL failures, one can argue that there is still a finite population of patients who are managed best by open surgery, either primarily or secondarily after failed initial attempts with less-invasive treatments. First the availability of the newer treatment modalities, then patient demand and the desire to avoid painful incisions and long recovery periods, and finally concerns for cost containment and the pressure to provide costeffective care and shorter hospitalizations after surgery have created a treatment philosophy that defines success as the ability to eradicate the stone with the least invasive modality, and that holds that open surgery should be avoided unless all else fails or is highly likely to fail. Open surgery thus may be viewed by the urologist and the patient as indicating or implying failure. This type of outlook on stone treatment could lead to an overwhelming bias against open surgery and could result potentially in the appropriate treatment option being foregone, withheld, or delayed, to the detriment of the patient with urinary calculus disease. It is imperative that urologists continue to recognize the unusual circumstances and acceptable indications for performing open surgery to remove urinary
IS THERE A ROLE FOR OPEN STONE SURGERY?
stones, thus preventing open stone surgery from becoming a lost surgical art. INDICATIONS
Early in the development of the less-invasive approaches, open procedures still were being performed frequently to treat patients who had failed one or a combination of the newer modalities. Also, during the nascent stage of less-invasive stone therapy, there were many places in which the instruments were not yet available and urologists were not yet adequately skilled in these techniques. As the instruments, technology, and technical skills became more widespread, primary treatment with ESWL, percutaneous nephrolithotomy, or ureteroscopy became accepted and preferred for most urinary stones. As we approach the end of the millenium, open stone surgery has only a limited role in stone management, but its indications remain important nonetheless. In this section the authors discuss the commonest, current, and acceptable indications for open stone surgery based on our recent experience (Table 1). Complex Stone Disease
Complex stone disease and significantly large stone burden remain indications for open surgery in select clinical scenarios. It is certainly true that even complete staghorn
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calculi now can be approached safely and effectively with percutaneous nephrolithotomy either alone or in combination with ESWL. Open surgery, however, likely will continue to have a role in the management of this type of stone disease, especially in those kidneys with dilated collecting systems. In our experience, complex stone burden represents the most frequent indication for an open stone procedure, occurring in 55% of cases.23 Complex stones are those that occupy the entire renal pelvis, with multiple extensions into the calyces and complete staghorn calculi. Various reports in the literature over the past two decades have established that percutaneous nephrolithotomy, either alone or in combination with ESWL, is an effective treatment modality for large renal stones (larger than 3 cm) and staghorn calculi (Table 2). The stone-free rates for this treatment are reported to be from 50% to 87% in different series.”, 19, **, 22* 28, 32, w 36 Stone-free rates generally have been reported to be higher with open procedures (Table 3). In comparing the percutaneous approach with anatrophic nephrolithotomy, Snyder and Smith32 found that the retained stone fragment rate was 13%for percutaneous extraction and 0% for open surgery. Boyce and Elkins3reported a 15% recurrence rate at an average follow-up period of 3 years after anatrophic nephrolithotomy. At our institution, open stone surgery resulted in a 93% postoperative stone-free rate.= Despite the slightly higher stone-free rates
Table 1. INDICATIONS FOR OPEN STONE SURGERY AT CASE WESTERN RESERVE UNIVERSITY, BY PROCEDURE
Complex stone burden Treatment failures Percutaneous surgery ESWL Percutaneous + ESWL Transurethral endoscopy Anatomic abnormality Ureteropelvic-junction obstruc*on Infundibular stenosis Calyceal diverticulum Ureteral stricture Morbid obesity Comorbid medical diseases Concomitant open surgery Nonfunctioning lower pole
Pyelollthotomy (15 Cases)
Anatrophic Nephrolithotomy (14 Cases)
9 3 2 0
13
1 0 4
3 1 0 0 2
3 0 0
Ureterollthotomy (6 Cases)
0 0 0 0 0
1
1
0 1 0 0 2 0 0
0
1
ESWL = extracorporeal shock-wave lithotripsy. (From Paik ML, Wainstein MA, Spimak JC et al: Current indications for open stone surgery in the treatment of renal and ureteral calculi. J Urol 159:374-379, 1998)
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Table 2. STUDIES OF PERCUTANEOUS NEPHROLITHOTOMY FOR STAGHORN CALCULI Authors
No. of Kldneys
No. of Procedures
Stone-free %
Lam et alzl Snyder and Smith" Winfield et a P Kahnoski et all7 Schulz et alu' Karlsen and GjolbergIY
91 75 23 52 90 54
2.7 1.2 2.7 2.6 2.7 2.4
87 87 86
achievable with open surgery, one must weigh the enormous benefits that percutaneous approaches to complex stones bring to the equation. Percutaneous nephrolithotomy allows the patient to avoid large incisions for open renal surgery, decreases postoperative pain and narcotic requirements, results in a shorter convalescence period than open surgery, and, for stones that can be successfully treated in one setting, results in shorter hospitalizations. Brannen et a14 and Brown et a1,5 in the mid-1980s reported that percutaneous procedures led to significantly decreased recovery time and cost compared with open surgery. Preminger et alZ4found, however, that for stones greater than 2.5 cm in size, percutaneous surgery was somewhat more costly than open surgery, although it resulted in significantly shorter recuperative time and less cost. For the larger, more complex stones and for complete staghorn calculi, for which multiple percutaneous or ESWL procedures are likely to be required for stone eradication, the benefits of shorter hospitalization and convalescent times begin to diminish rapidly in comparison with a traditional open surgical stone procedure. In addition, the cost of multiple lesser invasive procedures is likely to outweigh the cost of a single open procedure, despite the continued cost advantage related to shorter recovery time associated with percutaneous procedures. Other reports in the literature continued to argue in favor of open surgery over percutaneous nephrolithotomy or combination therapy for staghorn calculi in certain situations. Esen et allo found that for patients with com-
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77 55
plete or partial staghorn stones, open surgery resulted in a stone-free rate of 80%, versus 50% for combination therapy and 25% for ESWL monotherapy. Assimos et a12 reported that in patients with staghom calculi and any degree of pelvicalyceal dilatation, anatrophic nephrolithotomy resulted in stone-free rates from 89% to 100°/o, whereas percutaneous nephrolithotomy with or without ESWL led to stone-free rates of only 12% to 25%. The question remains of which patients with complex stones are served best by percutaneous approaches or combination therapy, and which should be considered for open surgery as the primary treatment. Most, if not all, urologists treating upper-tract stone disease would agree that a majority of complex, larger (greater than 2-3 cm) stones including partial and complete staghorn calculi, should be approached primarily with percutaneous nephrolithotomy, and if necessary secondary percutaneous procedures or ESW. In certain select cases, ESWL monotherapy may be appropriate. Open surgery becomes a more acceptable treatment option, however, if a reasonable combination of percutaneous ESWL procedures is unlikely to result in treatment success. This is in accordance with the findings of the American Urological Association Nephrolithiasis Clinical Guidelines Panel in 1994.3l Most reasonable surgeons and patients would prefer a single open surgical procedure over a long, difficult, and protracted treatment course requiring numerous percutaneous procedures along with ESWL. What number represents a reasonable number of attempts at percutaneous stone removal is up
Table 3. STUDIES OF OPEN SURGERY FOR STAGHORN CALCULI Authors
No. of Kidneys
No. of Procedures
Stone-free %
Rocco et alZh Rodrigues Netto et aI2' Paik et alu Assimos et alz Esen et allo
47 28 14 10 10
1 1 1
87 82 93 90 80
1 1
IS THERE A ROLE FOR OPEN STONE SURGERY?
to the individual patient and the treating urologist. This most likely is to be the case in patients with complete or giant staghorn calculi and dilated collecting systems. These are the patients in whom open surgery is still likely to represent a valid primary treatment option, despite the availability and efficacy of less-invasive modalities. Endourologic or ESWL Treatment FaiIures
Patients who cannot be treated successfully with percutaneous approaches, ESWL, or ureteroscopic lithotripsy have a significant chance of ultimately requiring open surgery. Again, one needs to determine how many procedures a patient will require before treatment is declared a failure with one or a combination of less-invasive modalities. Much of this depends on the expertise of the treating urologist and the determination of the patient. Those urologists who are adept or trained specifically in endourology may have a higher threshold for giving up on treatment with the lesser invasive modalities, even if it requires multiple treatments and multiple combinations of modalities. Urologists who are not as skilled in endourological procedures may be quicker to resort to open procedures. Nonetheless, the inability to successfully eradicate a stone with the less-invasive modalities is certainly an indication for open stone surgery. Treatment failures, especially endoscopic failures with respect to ureteral stones, have diminished since the early days of endourological approaches to stones. In 1989, Assimos et al’ reported a 43% endoscopic failure rate for ureteral stones as an indication for open surgery. In 1995, Kane et all8 reported that endourologic failures for ureteral stones represented 10%of the indications for open stone surgery at their institution. In 1998, the authors reported that only 12% of open stone cases at our institution represented failures with endoscopic ureteral stone treatment.23 With the development of newer instruments for intracorporeal lithotripsy, including the pneumatic lithotripter and the ho1mium:yttrium-aluminum-garnet laser, there are fewer stones that are not amenable to ureteroscopic lithotripsy and that are beyond the reach of the endourologist. Of five patients who failed ureteroscopic approaches to ureteral stones at the authors’
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institution, all had stones at least 2 cm in size with an average of 2.3 cm.23For this reason, it may be reasonable to approach ureteral calculi of this or larger size with primary ureterolithotomy. Ureteral stones that are relatively large and are likely to be impacted also may be considered for primary ureterolithotomy, because these stones may be difficult to treat endoscopically without incurring an increased risk for ureteral injury or perforation. Endourologic treatment failures for renal calculi accounted for 17% of the indications for open surgery at the authors’ institution.u This includes failures of percutaneous nephrolithotomy alone or in combination with ESWL. Failure of endourologic management of renal calculi usually implies failure on multiple attempts, because most urologists would persist in trying to remove a complex renal stone with more than one attempt through a percutaneous tract before moving on to open surgery. Again, this goes to the-question of what is a reasonable number of attempts with percutaneous treatment or ESWL, which must be determined in each individual case by the urologist and the patient. Anatomic Abnormalities
Urinary-tract anatomic abnormalities can predispose the stone-forming patient to recurrent stone disease after initial successful treatment and eradication. Intrarenal and collecting-system abnormalities also can complicate the surgical approach. In addition to breaking up or removing the stone, the anatomic defect must be treated in order for the procedure to be deemed a success. Additional endourologic surgical expertise and instruments are required to correct these defects through the existing endourologic access sites. Because of the additional complexity that arises with concomitant anatomic abnormalities, the likelihood of open stone surgery rises with the presence of an anatomic defect. Specific anatomic abnormalities that can complicate the stone process include congenital and acquired ureteropelvic-junction (UPJ) obstruction, calyceal diverticulum, infundibular stenosis, and ureteral stricture. At the authors’ institution, 24% of the patients requiring open stone surgery had an anatomic abnormality that necessitated combined open stone removal with correction of the anatomic defect.23
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Renal calculi and concomitant UPJ obstruction certainly can be approached percutaneously, either in the same setting or in a staged procedure. Most renal stones are amenable to percutaneous lithotripsy, and percutaneous endopyelotomy can be performed through the same percutaneous tract, either at the same time (for primary UPJ obstruction) or delayed (if there is concern that the UPJ obstruction could be secondary to edema from the calculus). For simple or small renal pelvic stones, the combined percutaneous approach would seem to be the treatment of choice. As the stone burden increases or if there are confounding anatomic factors, more contemplation may be given to a combined open approach to the coexisting problems. Complex stones, the presence of a crossing vessel, or the presence of a large dilated renal pelvis are relative indications for open surgery. In the authors’ series, of the patients undergoing combined open stone removal and UPJ repair, one had failed previous percutaneous stone removal, another had a horseshoe kidney, and a third patient was younger than 1 year of age. From the authors’ experience, they advocate giving strong consideration to a combined open approach for patients with a large or complex stone burden or confounding anatomic factors related to the UPJ obstruction. For patients with mild to moderate stone burden and a straightforward UPJ obstruction, the percutaneous approach should be considered the first-line treatment. Stones in calyceal diverticula, or associated with stenotic or obstructed infundibula, can be approached percutaneously to eradicate the stone and to obliterate the diverticulum or perform infundibuloplasty. Most of these stones can be treated successfully in this combined manner. There are situations, however, in which open surgery can be considered. In the authors‘ series, there was one patient who had failed previous percutaneous treatment secondary to a narrow diverticular neck, another patient with a diverticulum associated with an anterior calyx, and a third patient with a large stone filling a dilated diverticulum who were successfully treated with open surgery. Surgeon experience with the endourologic techniques also may factor into the decision making. Ureteral stricture or obstruction distal to a ureteral calculus precludes simple ESWL or ureteroscopic lithotripsy. One must treat successfully the obstructing process as well as
the stone to promote drainage of fragments and prevent recurrent stone formation secondary to obstruction or urinary stasis. Ureteral strictures can be treated with endoscopic dilation concomitantly with stone removal or fragmentation. In one of the authors’ patients, a 2-cm ureteral stone, as well as stricture of the distal ureter, were treated successfully with combined ureterolithotomy and ipsilatera1 ureteroneocystostomy. The approach in these patients needs to be individualized, and certain circumstances, such as large stone burden or stricture length or certain locations may dictate the preference for an open surgical approach.
Patient Anatomy Certain factors relating to patient anatomy can interfere with or preclude endourologic access or ESWL therapy. Obesity is probably the most commonly encountered anatomic factor. Morbidly obese patients with stones present a difficult challenge no matter what treatment modality is implemented. Percutaneous access, tract length, and patient positioning are problems frequently encountered in obese patients. Percutaneous nephrolithotomy, however, has been shown to be a successful treatment method in obese patients by Carson et a17 and Hoffman and Stoller.16 ESWL can be technically difficult or impossible if the stone cannot be positioned within the focal point of the lithotripter or if the patient is too heavy for the table. Any open surgery in an obese patient can be more difficult secondary to body habitus and limitations in surgical exposure, and also because of the higher risk of complications. In certain patients, endourologic procedures and ESWL may be technically impossible or carry a significantly increased chance of failure or complications for any of the previously stated reasons, so that open surgery is preferred, even with only a moderate stone burden, which usually would be treated with a lesser invasive modality. In the authors’ experience, open stone surgery was performed in 10% of patients because of morbid obesity, and all were treated successfully with minimal morbidity.u Other anatomic or body habitus considerations include severe limb contractures or the inability to position in the prone position secondary to pulmonary disease.ls Ectopic kid-
IS THERE A ROLE FOR OPEN STONE SURGERY?
neys or malrotation also can limit or interfere with access. Open surgery may be indicated in these cases; however, percutaneous access still can be achieved successfully with adjunctive methods such as laparoscopic assistance. Transplanted kidneys present anatomic considerations in stone management. The location of the transplant kidney or the surrounding anatomy may dictate the need for an open procedure; however, successful treatment also can be achieved with percutaneous access or ESWL.6 Comorbid Disease
The presence of significant comorbid medical diseases and advanced age can factor into the decision making on how to treat the stone-forming patient. The ideal therapy for such patients takes into consideration the desire to achieve a stone-free state with the avoidance of significant morbidity and complications, and the desire to avoid multiple or prolonged procedures. Despite the fact that the procedures may be considered less invasive, each procedure still requires some sort of anesthesia and its resultant risk. Sometimes these types of patients are served best by a single, uncomplicated open procedure to achieve all of these goals. Open surgery certainly carries higher anesthetic risks and requires generously sized incisions. There is great benefit, however, in avoiding the potential for multiple procedures and prolonged hospitalizations. In certain elderly patients or those with multiple medical problems, the benefits of achieving a stone-free state with one open procedure outweigh the risk involved with a major surgery and outweigh the potential risk for requiring multiple lesser invasive procedures leading to a more difficult, protracted treatment course. Despite that the stone itself may be very amenable to endourologic access or ESWL therapy, the goal of the physician is to treat the patient as a whole.
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ally nonfunctioning kidneys. These patients are candidates for simple nephrectomy as treatment of their stone disease. Occasionally, a renal stone is associated with a poorly functioning or nonfunctioning moiety of the kidney. It may be necessary in these cases to perform removal of the stone via partial nephrectomy, allowing simultaneous removal of the nonfunctioning and obstructed segment of the kidney. Partial nephrectomy also may be indicated if a stone is associated with an anatomic abnormality that cannot be treated by endourologic techniques.35The stone and the segment of the kidney associated with the abnormal intrarenal unit can be excised intact.
Patient Preference
The final consideration in choosing the appropriate treatment modality for the stoneforming patient always should be the preference of the well-informed, competent patient. This is certainly not the least important factor. After the other variables have been factored into the decision making, ultimately the patient must choose what type of treatment he or she is willing to undergo. It is the responsibility of the surgeon to ensure that the patient has been given all of the necessary information regarding the benefits, risks, and expectations of success or failure for each of the alternative therapeutic modalities available in the most unbiased manner possible. It is only then that the patient can make the most appropriate individual decision on treatment. The authors believe that, given the choice, a small percentage of patients prefers to undergo open surgery rather than take the risk of requiring more than one less-invasive procedure, despite the fact that the urologist may feel that the less-invasive treatment is the appropriate choice. In these select cases, as long as the patient is an appropriate surgical candidate, the authors believe his or her preference ultimately should be honored.
Nephrectomy
Patients who are recurrent stone formers with frequent renal parenchymal infections and chronic high-grade obstruction are prone to developing poorly functioning and eventu-
SUMMARY
Modern day urinary-stone treatment involves procedures and techniques that were
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not even available 20 years ago. The relatively rapid and sometimes explosive development of ESWL, percutaneous techniques, and ureteroscopy and intracorporeal lithotripsy has ushered in the era of minimally invasive stone management. In many regards, open surgery has such a limited role that its performance often is regarded as a sign of failure. To think of open stone surgery in this manner is likely to do a disservice to a small but important segment of the urinary-stone patient population. The critical responsibility of the urologist treating stone disease is to be able to recognize those clinical situations in which open stone surgery may represent at least a viable and reasonable alternative to less-invasive modalities. The duty of the surgeon is then to be able to present this option to the patient in an unbiased fashion and to effectively perform and implement this form of treatment if chosen. It is only with this approach that open surgery will continue to be correctly applied on those rare occasions and will not become a lost surgical art in the era of minimally invasive surgery.
References 1. Assimos DG, Boyce WH, Harrison LH, et al: The role of open stone surgery since extracorporeal shock wave lithotripsy. J Urol 142263-267, 1989 2. Assimos DG, Wrenn JJ, Harrison LH, et al: A comparison of anatropic nephrolithotomy and percutaneous nephrolithotomy with and without extracorporeal shock wave lithotripsy for management of patients with staghom calculi. J Urol 145:710-714, 1991 3. Boyce WH, EIkins IB: Reconstructive renal surgery following anatrophic nephrolithotomy: Followup of 100 consecutive cases. J Urol 111:307-312, 1974 4. Brannen GE, Bush WH, Correa RJ, et al: Kidney stone removal: Percutaneous versus surgical lithotomy. J Urol 1336-12, 1985 5. Brown MW, Carson C 111, Dunnick NR, et al: Comparison of the costs and morbidity of percutaneous and open flank procedures. J Urol 135:1150-1152, 1986 6. Caldwell TC, Burns J R Current operative management of urinary calculi after renal transplantation. J Urol 140:1360-1363, 1988 7. Carson C 111, Danneberger JE, Weinberth JL: Percutaneous lithotripsy in morbid obesity. J Urol 139243, 1988 8. Chaussy CG, Fuchs GJ: Current state and future developments of noninvasive treatment of human urinary stones with extracorporeal shock wave lithotripsy. J Urol 141:782-789, 1989 9. Chaussy C, Brendel W, Schmiedt E: Extracorporally induced destruction of kidney stones by shock waves. Lancet i3:1265-1268, 1980
10. Esen AA, Kirkali Z , Guler C: Open stone surgery: Is it still a preferable procedure in the management of staghorn calculi? lnt Urol Nephrol 26247-253, 1994 11. Femstrom I, Johannson B: Percutaneous pyelolithotomy: A new extraction technique. Scand J Urol Nephrol 10257-259, 1976 12. Gallegos C: Surgery for urinary tract stone disease. Practitioner 239:654456, 1995 13. Gillenwater J Y Editorial comment. J Urol 142267, 1989 14. Hauri D: The role of open surgery. Urol Res 18(suppl 1):57-60, 1990 15. Hauri D: Surgical therapy. Urol Int 41:385-386, 1986 16. Hoffman R, Stoller ML: Endoscopic and open surgery in morbidly obese patients. J Urol 148:1108-1111, 1992 17. Kahnoski RJ, Lingeman JE, Coury TA, et al: Combined percutaneous and extracorporeal shock wave lithotripsy for staghorn calculi: An alternative to anatrophic nephrolithotomy. J Urol 135579481, 1986 18. Kane CJ, Bolton DM, Stoller ML: Current indications for open stone surgery in an endourology center. Urology 45218-220, 1995 19. Karlsen S, Gjolberg T Branched renal calculi treated by percutaneous nephrolithotomy and extracorporeal shock waves. Scand J Urol Nephrol 23201-205, 1989 20. Kincaid-Smith P: Is surgery for renal calculi necessary in 1985? Med J Aust 143:136-137, 1985 21. Lam HS, Lingeman JE, Mosbaugh PG, et al: Evolution of the technique of combination therapy for staghom calculi: A decreasing role for extracorporeal shock wave lithotripsy. J Urol 148:1058-1062, 1992 22. Lingeman JE, Coury TA, Newman DM, et al: Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. J Urol 138:485-490, 1987 23. Paik ML, Wainstein MA, Spimak JP, et al: Current indications for open stone surgery in the treatment of renal and ureteral calculi. J Urol 1593374379, 1998 24. Preminger GM, Clayman RV, Hardeman SW, et al: Percutaneous nephrostolithotomy vs open surgery for renal calculi. JAMA 254:1054-1058, 1985 25. Rady MYA, Rady AM: Conventional open surgery for renal stones in the era of modem techniques. Br J Clin Pract 41:704706, 1987 26. Rocco F, Casu M, Carmignani L, et al: Long-term results of intrarenal surgery for branched calculi: is such surgery still valid? Br J Urol 81:79&800, 1998 27. Rodrigues Netto N, Jr, Lemos GC, Palma PCR, et al: Staghom calculi: Percutaneous versus anatrophic nephrolithotomy. Eur Urol 15:9-12, 1988 28. Schulze H, Hertle L, Kutta A, et al: Critical evaluation of treatment of staghorn calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J Urol 141:8224325, 1989 29. Segura JW: Current surgical approaches to nephrolithiasis. Endocrinol Metab Clin North Am 19:919935, 1990 30. Segura JW: The role of percutaneous surgery in renal and ureteral stone removal. J Urol 141:780-781, 1989 31. Segura JW, Preminger GM, Assimos DG, et al: Nephrolithiasis clinical guidelines panel summary report o n the management of staghorn calculi. J Urol 151:1648-1651, 1994 32. Snyder JA, Smith AD: Staghom calculi: Percutaneous extraction versus anatrophic nephrolithotomy. J Urol 136~351-354,1986 33. Spimak JP, Resnick MI: Stone treatment. In Gillen-
IS THERE A ROLE FOR OPEN STONE SURGERY? water JY, Grayhack JT, Howards SS, et a1 (eds): Adult and Pediatric Urology. St. Louis, Mosby, 1996, pp 695-747 34. Streern SB, Lammert G: Long-term efficacy of combination therapy for struvite staghorn calculi. J Urol 147:563-566, 1992 35. Timoney AG, Payne SR, Walmsley BH, et al: Partial
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nephrectomy: An option in calculus disease? Br J Urol 62511-514, 1988 36. Winfield HN, Clayman RV, Chaussy CG, et al: Monotherapy of staghorn renal calculi: A comparative study between percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J Urol 139:895-899, 1988 Address r e p i t i t requests to Martin I. Resnick, MD Department of Urology University Hospitals of Cleveland Case Western Reserve University School of Medicine 11100 Euclid Avenue Cleveland, OH 44106