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9. Medical and Surgical Management of Nephrolithiasis


  • Renal stone disease is a common illness, affecting one in ten individuals at some time in their life.
  • Although the pain can be excruciating, 85 % of the stones will actually pass spontaneously. The management of the rest of the patients can be completed using relatively new endoscopic and minimally invasive techniques, resulting in open surgery being reserved for exceptional cases.
  • This module will review the current status of medical and surgical treatment of urolithiasis and its prevention.

Training Requirements

9.1 Medical Expert

Cognitive Skills

Required reading

  • Campbell’s Urology, Volume 1, Nephrolithiasis
  • Need nephrology text or some other text on medical workup and management
  • American Urologic Association Guidelines Committee report on Management of Urolithiasis

Optional Reading

  • AUA Updates on Stone Surgery
  • Journal of Endourology

Residents will participate in a lecture series which will cover the following topics:

  • Physiology of Stone Formation — biochemistry of stone formation, role of the inhibitors, formation and chemistry of all types of stones
  • Medical Work-up of the recurrent stone former and the Prophylaxis of further Stone Disease — to include a critical assessment of the role for medical management in 2003, work-up of the patient with recurrent stones , dietary management and review of medications available to aid in prevention of stones
  • Management of Renal stones — to include a discussion of asymptomatic renal stones, Extracorporeal Shock Wave Lithotripsy, Percutaneous Nephrolithotripsy and Open Surgery.
  • Management of Upper Ureteral Stones — to include a discussion of flexible ureteroscopy, role of ESWL and its success rate, antegrade ureteroscopy and ureterolithotomy. The different modalities used to fracture stones in the ureter will be reviewed at this lecture.
  • Management of the Lower Ureteral Stone — to include a discussion of indications for surgery, rigid ureteroscopy, and a review of the potential complications of ureteroscopy and their management.
  • Radiology of Stone Disease — to include a discussion of the role of Intravenous Pyelogram, CT scan, ultrasound and Retrograde Pyelogram in the management of stone disease. The radiologic anatomy of the kidney and the procedure of percutaneous nephrostomy tube insertion will be reviewed. Contrast toxicity in the renal failure patient will be reviewed.
  • Endourologic Procedures for non-Stone related Conditions — this lecture will discuss endopyelotomy, management of calyceal diverticlum, endoureterotomy and other options in the management of ureteral strictures.

Lectures will be provided to review the physics of lasers and discuss laser physics as part of a laser safety course which will result in certification.


Technical Skills

Core Program Rotations — Residents should focus on the following areas:

  • Develop a working knowledge of the cystoscopes, ureteroscopes and nephroscopes used in completing these procedures
  • Understand the differences in guidewires, stents and baskets and in particular the different characteristics of the materials used in these disposable items.
  • Develop a working knowledge of the anatomy of the urinary tract and understand the passage of catheters and guidewires from the ureteric orifice to the kidney.
  • Residents should appreciate the role of fluoroscopy and how to safely utilize imaging with the minimum in radiation exposure.
  • Insertion of ureteric stents and catheters following endoscopic procedures and for the diversion of urine where an obstruction is present

Urology — PGY3, 4, 5

Residents will learn:

  • To access the lower ureter with rigid and flexible ureteroscopes and determine when dilitation of the intramural portion of the ureter is indicated.
  • How to pass the endoscope to the level of the stone and then determine whether it can be removed primarily or if some form of fragmentation is indicated.
  • To safely fragment the stone and remove the fragments if indicated. Later in their training they will learn to access intra-renal stones and to fragment these in-situ or by moving them to the renal pelvis.
  • Dilatation of a percutaneous nephrostomy tube tract for the purpose of completing percutaneous nephrolithotripsy. They will learn to access the various regions of the calyceal system and then fragment the stone and remove it. Principles of drainage and indications for stenting will also be reviewed.

Senior residents will:

  • Learn the indications for open stone surgery and develop an approach to the collecting system and ureter if this form of stone extraction is indicated.
  • Visit an ESWL facility and observe the procedure. They will review the need for ancillary procedures with this modality and the management of steinstrasse.

Faculty for Cognitive and Surgical Skills

  • Dr. J. Paul Whelan and Dr. Edward Matsumoto: Endourology and Physiology of Stone Development
  • Dr. David Churchill: Medical Management of Stones
  • Dr. Julian Dobranowski: Radiology of the Urinary Tract

9.2 Communicator

General Objectives

  • Develop a therapeutic relationship with patients and their families and obtain information in an effective and caring manner.

Specific Objectives

  • As many of these patients will be in significant pain, the resident should be able to assess the analgesic needs of the patient and whether this needs to be addressed before a detailed interview is to occur.
  • The resident should be able to assess the location and severity of the pain and any associated symptoms such as fever or hematuria.
  • They should also learn to assess the frequency of stone passage and any family history of stones.
  • Residents should be able to record the data from the history, laboratory work and radiologic investigations in an effective manner and communicate it to others in order to develop a management plan.
  • The resident will learn to communicate the management plan to the patient and their family in a manner that facilitates patients’ willing participation.

9.3 Collaborator

General Objectives

  • Consult and work with physicians and other health care team members to resolve the acute and long term problems with urolithiasis.

Specific Objectives

  • Interact with dieticians, nephrologists and endocrinologists to deal with issues related to the prevention of stone disease.
  • Arrange for patients to be properly prepared for transfer to an ESWL unit for treatment and to complete instructions from the treating urologist.
  • Assess and review new technologies in stone disease and make appropriate recommendations to hospitals regarding acquisitions.

9.4 Manager

General Objectives

  • Utilize information technology and meetings to facilitate life long learning in the area of Urolithiasis.
  • The resident will learn to organize a practice and work effectively within a health care organization.

Specific Objectives

  • The resident will learn to develop a system of prioritizing patients for surgery.
  • They will learn to assess new technologies for diagnosis, treatment and prevention of stones.

9.5 Health Advocate

General Objectives

  • Identify the factors predisposing to this condition in their patients.
  • Contribute to the prevention of urolithiasis and advocate for better treatment options.

Specific Objectives

  • Understand the risk factors for urolithiasis and how they may impact on individuals within a community.
  • Understand the role of the Canadian Urologic Association and other organizations in providing guidelines for treatment of stones and patient education information

9.6 Scholar

General Objectives

  • Develop and implement a continuing personal learning strategy in the field of Urolithiasis.
  • The resident will critically appraise the information and facilitate the education of others (housestaff, patients, staff, and other health professionals).

Specific Objectives

  • The resident will evaluate their own capabilities and limitations in the field of stone surgery and determine a course to improve and refine their skills and knowledge base.
  • They will demonstrate an ability to research a topic using available data bases and critically evaluate the studies they find.
  • They will maintain an inquisitive attitude and may pursue the development of research protocols. If they pursue this they will be aware of the ethics of human and animal experimentation

9.7 Professional

General objectives

  • The resident will learn to deliver the highest quality care with integrity, honesty and compassion.
  • They will practice ethically and demonstrate appropriate behaviour for a Urologic Consultant.

Specific Objectives

  • The resident will demonstrate personal responsibility by maintaining confidentiality, being available and being sensitive to the patient’s level of physical and emotional comfort.
  • They will be aware of best practice and where appropriate refer to a centre of excellence.
  • They will understand the process of informed consent, delegated consent and informed decision making as it applies to stone surgery.

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