Endoscopic Stone Removal

Endoscopic stone management consists of ureteroscopy and percutaneous nephrolithotomy, 2 robustly developed techniques in which the surgeon directly visualizes kidney stones to facilitate removal. Ureteroscopy is performed in retrograde fashion and can be used to clear smaller stones from the ureter and renal collecting system. Percutaneous nephrolithotomy involves percutaneous renal access, guided by either ultrasound or fluoroscopy, to identify, fragment, and remove large renal stones. A key aspect to performance of these 2 procedures is careful preoperative work-up, including urine culture, with positive cultures mandating treatment prior to definitive stone removal. Deciding which procedure to perform requires accounting for several factors including stone burden (based on preoperative imaging), anatomy, comorbidities, and patient preference. Many intra-operative techniques, such as wire use and coaxial advancement of sheaths and endoscopes, are analogous to those used in interventional radiology and vascular surgery. Stone ablation relies on the use of laser technology, though percutaneous nephrolithotomy for larger stones may also employ mechanical lithotripters. Postoperatively, a temporary ureteral stent or nephrostomy tube is often left in place to prevent acute obstruction from ureteral edema. It is recommended to obtain routine postoperative imaging following endoscopic stone management as renal obstruction due to residual stone fragments or ureteral stricture can be asymptomatic and result in significant loss of renal function. Overall, however, endoscopic stone management is safe, effective, and performed extensively worldwide.