KIDNEY STONES SURGERY

Kidney stones: open stone surgery
Indications
- Complex stone burden (projection of stone into multiple calyces, such that multiple PCNL tracks would be required to gain access to all the stone)
- Failure of endoscopic treatment (technical difficulty gaining access to the collecting system of the kidney)
- Anatomic abnormality that precludes endoscopic surgery (e.g. retrorenal colon)
- Body habitus that precludes endoscopic surgery (e.g. gross obesity, kyphoscoliosis open stone surgery can be difficult)
- Patient request for a single procedure where multiple PCNLs might be required for stone clearance
- Non-functioning kidney

Non-functioning kidney
Where the kidney is not working, the stone may be left in situ if it is not causing symptoms (e.g. pain, recurrent urinary infection, haematuria). However, staghorn calculi should be removed, unless the patient has comorbidity that would preclude safe surgery because of the substantial risk of developing serious infective complications. If the kidney is non-functioning, the simplest way of removing the stone is to remove the kidney.

Functioning kidneys options for stone removal
Small- to medium-sized stones
- Pyelolithotomy
- Radial nephrolithotomy

Staghorn calculi
- Anatrophic (avascular) nephrolithotomy
- Extended pyelolithotomy with radial nephrotomies (small incisions over individual stones)
- Excision of the kidney,  bench  surgery to remove the stones, and autotransplantation

Specific complications of open stone surgery
Wound infection (the stones operated on are often infection stones); flank hernia; wound pain. (With PCNL these problems do not occur, blood transfusion rate is lower, analgesic requirement is less, mobilization is more rapid and discharge earlier all of which account for PCNL having replaced open surgery as the mainstay of treatment of large stones.) There is a significant chance of stone recurrence after open stone surgery (as for any other treatment modality) and the scar tissue that develops around the kidney will make subsequent open stone surgery technically more difficult.