Minimally Invasive and Surgical Management of Urinary Stonesmanagement of urinary lithiasis...

458 UROLOGIC NURSING / December 2005 / Volume 25 Number 6

Karen Hanson

T reatment of urinarystones was once entirelysurgical, but recent tech-nological advances allow

stones to be treated with less-inva-sive methods, including extracor-poreal shock wave lithotripsy,ureteroscopic and percutaneousprocedures. While many stonesusually pass without interven-tion, approximately 10% to 20%will require intervention for re-moval (Tolley & Segura, 2001).Surgical management of stonesbecomes necessary in the settingof symptomatic calculi, urinarytract obstruction, staghorn calculi(symptomatic or asymptomatic),stones in high-risk patients forinfection (for example, trans-plant or immunocompromisedpatients) (Tolley & Segura, 2001).During the past 20 years,advances in imaging modalities,and endoscopic devices andshock wave lithotripsy led to sig-nificant improvements in themanagement of stones. Preventionof progressive or recurrent stoneformation is best managed by diet,adequate fluid intake, and in somecases, dietary supplements ormedications. Comprehensivemanagement of urinary lithiasisnecessitates collaboration be-tween the urologist, urologyhealth care professionals, and

First-line therapy for urinary stones typically involves minimally inva-sive surgical procedures for obstructing stones that cause symp-toms and do not pass spontaneously in a reasonable time. Treatmentdecisions are based upon suspected stone type, size, location, renalanatomy, and renal function. Comprehensive management of urinarylithiasis necessitates collaboration between the urologist, urologyhealth care professionals, and medical colleagues that possessknowledge of medical treatment.

Karen Hanson, MS, CNP, is a NursePractitioner, Mayo Clinic, Rochester,MN.

Note: CE Objectives and EvaluationForm appear on page 465.

medical colleagues that possessknowledge of medical treatment.

Etiology Stones form in the collecting

system of the kidney due to a mul-titude of factors. Most often animbalance of an organic substancesuch as calcium, struvite, urate, orcystine due to an underlying meta-bolic disorder leads to matrix for-mation in the urine. Any obstruc-tion to urine flow can lead to stasisof the urine and increased risk ofstone formation. Reduced urinevolume and dehydration may tipthe balance in causing stone dis-ease due to supersaturation of theurine. Medical conditions such asCrohn’s disease lead to increasedlevels of certain substances thatmay predispose an individual tostone formation.

Hypercalciuria. Defined as aurinary calcium excretion > 200mg/day, it is seen most commonlywith increased absorption afterintestinal resections (absorptivehypercalciuria), Types I and II. It isalso present in primary hyper-parathyroidism or resorptivehypercalciuria (an increase in 1,25[OH2] vitamin D that leads toincreased intestinal absorption ofcalcium), and renal hypercalci-uria, in which the parathyroid hor-

mone increases secondarily andresults in increased 1,25 (OH2) vit-amin D production leading toincreased intestinal calciumabsorption. Excess vitamin D pro-duction can be seen in patientswith sarcoidosis and granuloma-tous disorders.

Hyperoxaluria. Primary hyper-oxaluria is due to an enzyme defi-ciency (glyoxalate carbogliase).However, this is usually sec-ondary to previous small bowelresection especially of the distalileum, pancreatic insufficiency,and dietary calcium restriction.Diets high in oxalate can exacer-bate this condition.

Hyperuricosuria. This is seenin cases of a primary defect inmetabolism such as gout or withexcess protein breakdown in cata-bolic or ketotic states. Uric acidstones always form more often inacidic urine (pH less than 5.5), andcan form in individuals withexcessive purine intake. Thesestones are radiolucent.

Cystinuria. Cystine is a by-product of protein metabolism. Anautosomal recessive congenitaldefect in enzyme transport willcause impairment in renal tubularreabsorption of cystine, which isrelatively insoluble.

Struvite. Considered “infec-

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tious stones,” they are composedof magnesium, ammonium, phos-phate, and carbonate. They occurin alkaline urine (pH > 7.2) and inthe presence of ammonia. Theyare caused by urease-producingbacteria such as Proteus mirabilisor Ureaplasma urealyticum.Struvite stones can grow largeenough to fill the collecting sys-tem and can compromise renalfunction.

Low levels of certain sub-stances in the urine, such as citrateand magnesium which act toinhibit stone formation, can alsolead to stone disease. A moredetailed discussion of the etiologyof kidney stones can be foundelsewhere in this issue.

EpidemiologyBetween 120 and 140 people

per 100,000 will develop urinarystones each year (Menon &Resnick, 2002). There is a 10%risk per year of developing a first-time stone. Risk for subsequentcalcium oxalate stones is 10% at 1year, 35% at 5 years, and 50% at 10 years (Menon & Resnick,2002). Prevalence of stone diseasein the United States has risen from 3.8% between 1976 to 1980to 5.2% between 1988 to 1994(Stamatelou, Francis, Jones,Nyberg, & Curhan, 2003).

Age and gender. With theexception of struvite and cystinestones, men are more likely thanwomen to develop stones by 3:1(Menon & Resnick, 2002). Womenmore commonly form struvitestones due to their increased riskof urinary tract infections. Cystinestones occur equally in both sexes.Peak incidence of stones is fromthe 2nd to 4th decade of life.

Genetic factors. Family histo-ry predisposes individuals tostone disease. Certain inheritedgenetic disorders can lead to stonedisease. For example, cystinuria isa hereditary disorder of the abnor-mal renal tubule transport thatcauses an increase in excreted cys-tine in the urine. Renal tubularacidosis is a familial disorder that

causes kidney stones in mostpatients with this disorder. Stonesare rare in Native Americans,African and American blacks, andnative born Israelis (Menon &Resnick, 2002).

Socioeconomic factors. Af-fluent societies have higher rates ofsmall upper tract stones whereaslarge struvite stones are more com-mon in developing countrieswhere malnourishment and infec-tion are common (Hess, 2002).Bladder stones tend to be morecommon in underdeveloped coun-tries, and may be related to dietaryhabits and malnutrition (Menon &Resnick, 2002).

Geography. Prevalence ofstone disease is high in mountain-ous, desert, or tropical areas.Countries with a high incidence ofstones are the United States,British Isles, Scandinavian coun-tries, Mediterranean countries,northern India and Pakistan,northern Australia, central Europe,Malayan peninsula, and China.Reasons for geographic and cli-mate variances are unclear (Menon& Resnick, 2002).

Climate. Urinary stone diseaseis more common in sunny warmclimates, and seasonally duringsummer months. Dehydration andincreased production of 1.25 dihy-droxyvitamin D3 (vitamin D pro-duced by the body) from sunexposure have been proposed aspossible causes.

Hydration. Stone formationincreases significantly when urinevolume is low because of super-saturation of the urine.

Diet. Dietary calcium, potassi-um, and total fluid intake reducethe risk of kidney stones in olderwomen and men, yet supplemen-tal calcium, sodium, animal pro-tein, and sucrose may increaserisk. In the Nurses’ Health Study, ahigher intake of dietary calciumalso decreased the risk in youngerwomen, although supplementalcalcium did not increase risk asseen in older women (Curhan,2004). Urinary stone disease hasrecently become more prevalent in

the United States, in part due to anaffluent society diet rich in refinedcarbohydrates, salt, and animalprotein and relatively low in fruitsand vegetables; low intake of cit-rus fruit can result in hypocitra-turia. Excess intake of dietary sodi-um, oxalate, calcium, and purinesincreases risk of stone disease.

DiagnosisUrinary lithiasis usually com-

monly presents as an acuteepisode of ureteral or renal colicrelated to an obstruction or irrita-tion of the urinary tract.Presentation may range from nosymptoms, to hematuria, to vagueflank pain, to severe colicky painthat is not relieved well with painmedication. For a stone to causesignificant pain it is usuallyobstructing urinary flow or pass-ing through the ureter. A stone inthe upper ureter can cause painthat radiates to the testicles orlabia; as the stone passes to thedistal ureter, the pain may contin-ue to radiate to the testicle or labiaand lead to urinary urgency, fre-quency, hematuria, and gastroin-testinal upset.

Stones may be an incidentalfinding on an abdominal imagingstudy. Most stone disease can beeasily diagnosed with spiral CT.Spiral CT can identify both radio-opaque and radiolucent stones(uric acid), and assess for intra-abdominal abnormalities andrenal anatomy. An excretory uro-gram or retrograde pyelogram maybe needed to further assess the col-lecting system, especially if mini-mally invasive or surgical inter-vention is planned. Intravenousurography can further assess therenal anatomy for abnormalitiessuch as horseshoe kidney, dupli-cation of the collecting system,caliectasis, and assess therenopelvic angle.

MINIMALLY INVASIVETREATMENT

A stone that causes symp-toms, obstruction or near obstruc-tion, or infection must be urgently

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managed either non-surgically orsurgically. Large stones that causeobstruction can lead to hydro-nephrosis and kidney damage aswell as increased risk of infection.

Shock Wave LithotripsyExtracorporeal shock wave

lithotripsy (SWL) is a minimallyinvasive treatment that was intro-duced in 1980 after years ofresearch between Dornier, Inc. andthe University of Munich. Thisnovel technology utilizes targetedshock waves or “high-energyamplitudes of pressure generatedin the air or water by an abruptrelease of energy in space” (Auge& Preminger, 2002, p. 1065).Shock waves are generated out-side the body by a lithotripter, andare then targeted to fragmentstones within the urinary tract.The three types of shock wavegenerators are electrohydraulic,electromagnetic, and piezoelec-tric. All lithotripters have an ener-gy source, a focusing device, acoupling mechanism, and a stonelocalization system using eitherfluoroscopy or ultrasound. Frag-mentation occurs through tensilestress that removes surface materi-al, and spalling or pulverization ofthe stone through the applicationof multiple shock waves and ulti-mately cavitation forces (seeFigure 1).

The number of shock wavesrequired for adequate stone frag-mentation depends on the compo-sition of the stone, the focal pres-sure, energy density, and fluidinterface. Stones that fragmenteasily include calcium oxalatedihydrate, uric acid, and struvite.Stones that are difficult to frag-ment include calcium oxalatemonohydrate, cystine, and calci-um phosphate (brushite). The useof shock wave lithotripsy isdependant on the size, position,and anatomic features of the stone;SWL is less effective with largestones and in obese patients due todifficulty in getting the stone intothe focal point. Once a stone isadequately treated, the fragments

can then be passed spontaneouslyfrom the urinary tract.

The first lithotripter, DornierHM-3, used a water bath intowhich the patient was suspendedfrom a ceiling-mounted gantry,and required general anesthesiabecause powerful shock wavesproduced intolerable discomfort.Newer devices use a water-filledcushion placed in contact with thepatient’s body to provide a cou-pling mechanism, use less-intenseshock waves, and typically requireonly conscious sedation. Thesenewer lithotripters are probablysafer than the original devices, butare also somewhat less efficacious

(Menon & Resnick, 2002). Complications include acute

damage to adjacent renal tissuesthat can lead to hematuria, sub-capsular hematoma, infectioncaused by bacteria liberated dur-ing SWL, or obstruction and/orcolic caused by passage of stonefragments. Some renal injuriesmay be irreversible (Menon &Resnick, 2002). Potential long-term adverse effects include ele-vated systemic blood pressure,decreased renal function, andincreased risk of stone recurrence(Menon & Resnick, 2002). Gastricand duodenal erosions are themost common extrarenal compli-

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Adapted with permission from Tolley & Segura, 2001.

Figure 1.Stone Fragmentation Using Extracorporeal Shock

Wave Lithotripsy

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cation of SWL. Risk factors forinjury with SWL and potentialcontraindications include age(both young and old), obesity,coagulation disorders, solitary kid-ney, thrombocytopenia, diabetesmellitus, coronary artery disease,and hypertension (Menon &Resnick, 2002). A double pigtailstent may be placed for stoneslarger than 6 mm to preventobstruction. The stent is removedat a followup visit. Renal or ureter-al colic is painful and can be treat-ed with antispasmodics.

Nursing care. Shock wavelithotripsy is commonly an outpa-tient procedure and recovery israpid. It is minimally invasive andcan be delivered under local anes-thesia or intravenous sedation;typically parenteral sedatives andnarcotics such as alfentanil, mida-zolam, and propofol are used.Topical anesthetics such as EMLA(a mixture of lidocaine and prilo-caine) can reduce anesthesiarequirements; this topical agent isapplied at least 45 minutes prior toSWL. The procedure lasts approx-imately 30 to 50 minutes. Cardiacmonitoring during the procedureis required to synchronize theshock waves with the patient’sEKG rhythm to prevent cardiacarrhythmias. Patients are encour-aged to ambulate and increasefluid intake to flush out stone frag-ments. Stone passage may contin-ue for up to 3 months after SWL(Tolley & Segura, 2001).

UreteroscopyRigid ureteroscopy has been

used since the 1980s and was ini-tially indicated for management ofdistal ureteral stones. The devel-opment of smaller semi-rigidureteroscopes and more recently,flexible deflectable ureteroreno-scopes, allows routine endoscopicevaluation of the entire urinarycollecting system. Both rigid andflexible ureteroscopy are used forstone diagnosis and treatment,investigation of gross hematuriaand positive urine cytology, fulgu-ration of epithelial tumors and

management of ureteral strictures,obstructed calices, and uretero-pelvic junction (UPJ) obstruction(see Figure 2).

Indications for uteroscopicstone management include SWLfailures, lower pole stones, obesi-ty, musculoskeletal deformitiessuch as scoliosis, coagulation dis-orders, associated obstruction,horseshoe or ectopic kidney, or asan adjunct to percutaneous ne-phrolithotomy (Busby & Low,2004). Small stones in the lowerureter (less than 7 mm in diame-ter) can be extracted by a basket orforceps passed through a rigidscope that has been passed over aworking guidewire or alongside asafety guidewire. If the lumen ofthe ureter is narrow, it can be dilat-ed with a self-dilating (tapered)ureteroscope, by coaxial dilationthat uses larger catheters sequen-tially placed over smaller ones, orby balloon dilation in which a bal-loon catheter is placed over aworking wire and then inflated.Contraindications to this surgerywould be large ureteral orintrarenal stones.

Larger ureteral and intrarenalcalculi can be treated with electro-hydraulic or laser intracorporeallithotripsy to fragment the stone(s)prior to passage or removal.Electrohydraulic lithotripsy withsmaller caliber 1.9 Fr probesallows success in fragmentingureteral and renal stones with lessmorbidity. Laser lithotripsy usingthe holmium:yttrium-aluminum-garnet technology is the treatmentof choice for ureteral stones formost urologists. The more expen-sive holmium laser also allows fortissue cutting and coagulation andhas largely replaced the pulsed-dye laser. Lower ureteral stoneremoval is effective in almost100% of cases and slightly lesseffective for upper ureteral stones.

Complications are rare; how-ever, ureteral perforation canoccur during manipulation of aguidewire or basket and can leadto extravasation of contrast dye orurine. Significant bleeding is rareduring ureteroscopy, but can occurafter more traumatic procedures ordifficult stone extraction. In-struments can break during proce-


Figure 2.Flexible Ureteroscopy of Entire Renal Collecting System

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dures, so all ureteroscopes shouldbe carefully inspected. Stricturesoccur infrequently, usually incases of excessive manipulation ofthe ureter. Other complicationsinclude thermal injury and ureter-al avulsion. Ureteral avulsion israre but is among the most seriouscomplications of ureteroscopy. Itcan occur during basket extractionof large stones without prior frag-mentation. Urine must be drainedproximally through a percuta-neous nephrostomy if avulsionoccurs, and ureteral reconstruc-tion is subsequently performed.

A 4.8 to 7.0 Fr pigtail ureteralstent is left indwelling for a mini-mum of 48 hours after routineureteroscopy. This stent helpsfacilitate urine flow and preventsedema from causing obstruction orureteral colic that may occur withpassage of a stone or clot. Stentsrange in length from 8 cm to 30cm, and most are made ofpolyurethane. They generallyneed to have a hydrophilic coatingto ease insertion, biodurability toresist degradation, biocompatibili-ty with the patient’s body, and areradio-opaque for radiographicvisualization (Brownlee, 1999).Most stents are coated with a sub-stance such as phosphorylcholine, a naturally occurring sub-stance that alters the surface of redblood cells to reduce the risk ofencrustation (Tolley & Segura,2001). Some stents have anattached “suture” that allows easyremoval by the patient.

Nursing care. Patients shouldbe assessed preoperatively for his-tory of stone disease, allergies tocontrast dye, and sensitivity toshellfish. Equipment should beinspected in advance and dispos-able items such as graspers, bas-kets, and stents should be readilyavailable. Antibiotics may beadministered during the perioper-ative period. Anticoagulated pa-tients may not need to discontinuetheir medications. Postoperativecare for patients who have under-gone ureteroscopy includesinstruction to strain all urine for

stone fragments, direction regard-ing suture care if it is externalized,and information about diet, med-ications, and drinking fluids.

Patients should be advisedthat symptoms of dysuria, termi-nal hematuria, and flank discom-fort with urination can be expect-ed. This is due to the fact that thestent interferes with the ability ofthe ureter to prevent reflux ofurine, because the stent is posi-tioned through the ureteropelvicjunction. Patients who complainof discomfort from stents can beinstructed to try a hot bath; theymay also be prescribed antispas-modics and/or anti-inflammatorymedication.

PercutaneousNephrolithotomy

Endoscopic or intracorporealmanagement of stones through apercutaneous tract into the renalcollecting system is called percu-taneous nephrolithotomy (PNL).This technique was developed in1975 by Fernstrom and Johanson(Tolley & Segura, 2001). It can beused for most renal and proximalureteral stones (such as stoneswithin the lower pole calyx, with-in a calyceal diverticulum or astaghorn calculi) but is used most-ly for large stones (>2 cm) that arenot easily managed by SWL orureteroscopy, and as a salvage pro-cedure for failed SWL

A percutaneous nephrostomytract is established under localanesthesia or intravenous sedationthrough an upper, middle, orlower pole posterior calyx underfluoroscopic or ultrasound guid-ance. A recent survey showed thatonly 11% of urologists obtainedpercutaneous access alone; inabout 90% of cases, the tract isestablished by the attending radi-ologist (Bird, Fallon, & Winfield,2003). The patient is placed in aprone, semi-prone, or flank posi-tion. A guidewire is then passedand the tract is dilated with gradu-ated plastic dilators or a balloondilator. A hollow plastic sheath isplaced through the tract through

which a rigid or flexible nephro-scope is passed (see Figure 3).Stones less than 1 cm in size canbe manually extracted through theplastic sheath using a grasping for-ceps.

The surgical procedure itselfis commonly performed undergeneral anesthesia. If the stonesare larger than 1 cm, intracorpore-al lithotripsy using ultrasonic,electrohydraulic, or laser lithotrip-sy is performed. Ultrasonic litho-tripsy is used for large renal stonesthrough a rigid scope. A recentreview by Leveillee and Lobik(2003) showed that ultrasoniclithotripsy is preferred by urolo-gists when using rigid scopes witha high fragmentation rate and 94%stone-free rate. Ultrasonic litho-tripsy is the procedure of choicefor fragmentation of large stonesduring PNL. Occasionally, a stagedprocedure is required for largestones in which ultrasonic litho-tripsy may serve to debulk thestone burden which can then betreated with SWL.

Electrohydraulic lithotripsy(EHL) is reserved for fragmenta-tion of very hard stones or thosenot within reach of the ultrasoundrigid scope. More commonly, elec-trohydraulic lithotripsy is usedextensively for bladder stones, butEHL can fragment all types of uri-nary calculi including hard cys-tine, uric acid, and calciumoxalate monohydrate stones.Unfortunately, EHL cannot effi-ciently remove stone fragmentsand the particles need to bewashed out during intraoperativeirrigation, or grasped with a for-ceps. Pneumatic lithotripsy, on theother hand, produces the leastamount of urothelial injury and itis considered among the most effi-cient form of intracorporeal stonefragmentation.

Laser lithotripsy is used simi-larly to EHL, but mostly is used forretrograde ureteroscopic fragmen-tation of calculi. Holmium:YAGlaser lithotripsy is the preferredmethod when using flexibleendoscopy, and is able to fragment

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all stone types with a nearly 100%stone-free rate (Leveillee & Lobik,2003).

Once the stone is removed,inspection for residual stones isperformed under fluoroscopicguidance. A nephrostomy tubethat can be from 22.0 to 26.0French is usually left in place tem-porarily to ease re-instrumentationif needed, to tamponade bleeding,and to allow proper drainage ofurine. Tubeless PNL has been usedfor many years in select cases, anda recent study suggested that“tubeless” PNL, in which nonephrostomy tube is placed post-operatively, can be used inpatients with minimal to moderatestone burden without increasedcomplications (Limb & Bellman,2002).

Minor complications occur in

11% to 25% of patients, whilemajor complications occur in upto 7% (Menon & Resnick, 2002).The most significant complicationof PNL is blood loss from damageto an intrarenal artery, with occursin approximately 0.8% of cases,usually due to an arteriovenousmalformation (Kessaris, Bellman,Pardalidis, & Smith, 1995).Symptoms include significantgross hematuria and managemententails blood transfusion and arte-riographic embolization of thedamaged vessel.

Renal veins may be damagedas well. This is usually obviousduring the procedure and is oftentreated by plugging the nephrosto-my tube for 30 to 40 minuteswhich provides tamponade to thecollecting system, and administra-tion of mannitol or another diuret-

ic concomitantly. Another compli-cation is extravasation of the irri-gating fluid. Differences of morethan 500 ml between the volumeof fluid infused and drainage col-lected through the tubes and onthe drapes raise concerns aboutpossible intravascular extravasa-tion into the retroperitoneum.Irrigation should be performedusing sterile saline to preventhyponatremia, and this solutionmay be warmed as well.

Adjacent organ damage canoccur, particularly to the colon, inabout 1% of cases (Menon &Resnick, 2002), and less often tothe duodenum, spleen, or liver.Colon perforation is suspectedwhen intraoperative hema-tochezia, peritonitis, or sepsis ispresent, or when passage of flatusor feces from the nephrostomytube occurs. This is usually man-aged by diverting colostomy andinternally diverting urine using adouble pigtail stent and Foleycatheter. Every attempt is thenmade to separate the urinary andgastrointestinal tract to prevent fis-tula formation. Broad-spectrumantibiotics are given and radi-ographic studies through thecolostomy are performed 7 to 10days later to assure no communi-cation (in other words, no fistulaor sinus tract connection to thegastrointestinal and urinary sys-tems) before the tube is pulled.Duodenal perforation can occurduring right kidney PNL and isusually treated with placement ofa nephrostomy tube and nasogas-tric tube to divert gastric secre-tions. Spleen injury may occur incases of splenomegaly, and maylead to exploratory laparotomyand splenectomy. Risk of liverinjury is rare but increases withhepatomegaly; treatment is usual-ly conservative.

Nursing care. Patients sched-uled for PNL should have urinecultures preoperatively to rule outurinary tract infection. Imagingstudies are completed to verifystone location and kidney anato-my. If a struvite stone is suspected,


Figure 3.Percutaneous Nephrolithotripsy

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treatment for 2 weeks with abroad-spectrum antibiotic is rec-ommended; antibiotics may alsobe recommended in patients witha history of recurrent urinary tractinfections, or those requiring apostoperative indwelling stent.

Nonsteroidal anti-inflammato-ry medications (NSAIDS) andaspirin should be avoided for 10 to14 days prior to procedure.Patients should have blood typedand screened. PNL is done undergeneral or epidural anesthesia, andpatients are usually hospitalizedfor 1 to 3 days and recover quickly.PNL is effective in up to 95% to99% of cases, with lower successrates in patients with staghorn cal-culi or difficult access (Tolley &Segura, 2001). A nephrostomytube may be left in place for 1 to 5days, then removed and the sitecovered with a bulky bandage.Pain with the nephrostomy tube islessened with a smaller size butmay require narcotic medication.Good fluid intake is encouraged.

SURGICAL MANAGEMENT

Open LithotomyOnly 1% to 5% of stones

require an open procedure forremoval. Open procedures havebeen largely replaced by SWL,ureteroscopy, and PNL due todecreased postoperative morbidi-ty, more rapid recovery, and short-er hospitalizations and compara-ble success rates. In the past, obe-sity was an indication for opensurgery, although development oflonger nephroscopes makes percu-taneous procedures possible ineven the morbidly obese individ-ual. One study of 223 patientsshowed no difference in durationof operation, hemoglobin levels,postoperative pain medication,length of hospital stay, or stone-free rates in obese (BMI > 30) ver-sus normal weight patients (BMI <25) undergoing PNL (Koo, 2004).Most often open lithotomy isreserved for patients who havefailed SWL or PNL or who haveabnormal anatomy. Branched orlarge stones may necessitate open

surgical removal, while stones thatmay require multiple SWL or PNLprocedures may be better man-aged with open surgery in selectcases. Lastly, patients requiringpartial or total nephrectomy for anonfunctioning kidney, repair ofureteropelvic obstruction or steno-sis, or in need of other nonurolog-ic surgery may be candidates foropen surgery.

Nursing care. Patients are hos-pitalized for 3 to 4 days. Oraland/or intravenous fluids shouldbe increased to 3 L to 4 L daily ifpossible in the postoperative peri-od. Urine output should be at least0.5 ml/kg/hr (Bernier, 2005).Patients may require bladder irri-gations and straining of all urinepostoperatively. If a ureteralcatheter is in place, output of atleast 0.25 ml/kg/hr is expected.Ureteral catheters are kept openand may require irrigation whenthere is mucous, blood clots, andsediment in the urine. Irrigationsare completed with 3 ml to 5 ml ofsterile saline by gravity flow.Postoperative assessment includesmonitoring bowel sounds andvital signs, and administration ofantibiotics and pain medication asordered. Patients may have painrequiring narcotic medication.

ConclusionFirst-line therapy for urinary

stones typically involves minimal-ly invasive surgical procedures forobstructing stones that causesymptoms and do not pass sponta-neously in a reasonable time.Treatment decisions are basedupon suspected stone type, size,location, renal anatomy, and renalfunction. Morbidity, hospitaliza-tion, and cost are often reducedsignificantly with minimally inva-sive treatments such as shockwave lithotripsy, ureteroscopy,and percutaneous nephrolitho-tripsy; open surgical lithotomy israre but indicated in select cases.Patients recuperate more quickly,have a quicker return to normalactivity with the less-invasive sur-gical options that are available. •

ReferencesAuge, B., & Preminger, G. (2002). Surgical

management of urolithiasis. Endo-crinology and Metabolism Clinics,31(4), 1065-1082.

Bernier, F. (2005). Management of clientswith urinary disorders. In J. Black & J.Hawks (Eds.), Medical-surgical nurs-ing: Clinical management for positiveoutcomes (7th ed.) (pp. 857-911).Philadelphia: Saunders.

Bird, V., Fallon, B., & Winfield, H. (2003).Practice patterns in the treatment oflarge renal stones. Journal ofEndourology, 17(6), 355-363.

Brownlee, N. (1999). Taking the mysteryout of uteroscopy. Association ofPerioperative Nurses, 69(1), 162- 171.

Busby, J., & Low, R. (2004). Uteroscopictreatment of renal calculi. UrologicClinics of North America, 31(1).

Curhan, G. (2004). Dietary factors and therisk of incident kidney stones inyounger women: Nurses’ HealthStudy II. Archives of InternalMedicine, 164(8), 885-891.

Hess, B. (2002). Nutritional aspects of stonedisease. Endocrinology and Meta-bolism Clinics, 31(4), 1017- 1030.

Kessaris, D., Bellman, G., Pardalidis, N., &Smith, A. (1995). Management ofhemorrhage after percutaneous renalsurgery. Journal of Urology, 153(3),604-608.

Koo, B. (2004). Percutaneous stone surgeryin the obese: outcome stratifiedaccording to body mass index. BJUInternational, 93(9), 1296-1299.

Leveillee, R., & Lobik, L. (2003).Intracorporeal lithotripsy: Whichmodality is best? Current Opinion inUrology, 13(3), 249-253.

Limb, J., & Bellman, G. (2002). Tubelesspercutaneous renal surgery: Reviewof first 112 patients. Urology, 59(4),527-531.

Menon, M., & Resnick, M. (2002). Urinarylithiasis: Etiology, diagnosis, andmedical management. In P. Walsh(Ed.), Campbell’s urology (8th ed.)(pp. 3230-3437). Philadelphia: Saun-ders.

Stamatelou, K., Francis, M., Jones, C.,Nyberg, L., & Curhan, G. (2003). Timetrends in reported prevalence of kid-ney stones in the United States: 1976-1994. Kidney International, 63(5),1817-1823.

Tolley, D., & Segura, J. (2001). Urinarystones. Oxford: Health Press.

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