Minimally invasive stone surgery: percutaneous, ureteroscopic and extracorporeal approaches to renal and ureteral calculi.

The goal of treating renal and ureteral calculi is to achieve complete stone clearance with minimal morbidity. The treatment depends on various factors, including stone size, composition and location, clinical “patient factors”, availability of the equipment and the surgeon’s capability. Recent prospective trials suggest that ureteroscopy provides certain advantages over shock wave therapy (SWL) for the management of distal ureteral calculi.1 Nevertheless, several surgical options are available for the treatment of proximal ureteral calculi and renal calculi. Recent advances in both technology and physiologic understanding have led to improvements in the management of urinary stone disease and allow for a variety of surgical options with decreased patient morbidity. Calculus disease that requires surgical intervention is typically managed by three different modalities and is dependent on the factors stated above. Generally, ureteral calculi are managed either by SWL or ureteroscopy with lithotripsy (URS). Renal stones are typically managed by the above two modalities as well as percutaneous nephrosolithotomy (PNL). Medical expulsive therapy (MET) is defined as the use of pharmacologic means to facilitate passage of ureteral stones. These medications are typically alpha blockers with or without the addition of a steroid. This is an acceptable first line option for ureteral stones that are < 1 cm in size. This should be under close urologic supervision as rigorous imaging and evaluation of renal function are necessary to ensure that these patients do not develop renal insufficiency, obstruction, sepsis, or poorly controlled pain which would warrant urgent intervention.