Lithotripsy and surgery.

Advances in surgical techniques have dramatically altered the management of patients with symptomatic urolithiasis requiring intervention. Extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, and ureteroscopy allow virtually any stone to be removed from the upper urinary tract without resorting to open surgical techniques. Extracorporeal shock wave lithotripsy is the preferred initial treatment for approximately 80% to 85% of calculi. Percutaneous nephrolithotomy is the preferred approach when dealing with more voluminous stone material (ie, > 2 cm). Ureteroscopy is generally reserved for distal ureteral calculi, although the recent advent of small flexible ureteroscopes have extended ureteroscopic techniques effectively into the proximal ureter and even the kidney. Staghorn stones are usually best managed initially with percutaneous nephrolithotomy followed by the addition of extracorporeal shock wave lithotripsy, if necessary. The relative advantages, disadvantages, and complications of extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, and ureteroscopy will be reviewed.