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Open Surgery

The surgical treatment of nephrolithiasis has changed dramatically in the last 20 years. Previously the majority of patients requiring stone removal were subjected to open surgery. Advances in endoscopic management of calculous disease, in the form of ureteroscopy as well as percutaneous nephrolithotomy initially promoted a rapid decrease in the use of this approach. The subsequent introduction of extracorporeal shock wave lithotripsy furtherreduced the incidence of open surgery. In the current age of minimally invasive therapy open surgical procedures for calculous removal are still performed.

Despite refinement of endourological technology, increasing technical expertise, and development of improved retrograde and antegrade endoscopic techniques there are still individuals who are best treated by open surgical stone removal. Patients who are potential candidates for this approach include those with large volume, staghorn calculi in complex collecting systems, or large volume calculi in anterior caliceal diverticula or in cavities communicating with the central portion on the renal collecting system. Patients with calculi and concomitant ureteropelvic junction obstruction who are not expected to have good results with endopyelotomy, or those who harbour stones in a nonfunctioning kidney or non functioning polar region may also be considered for this approach. Finally, patients in whom endourological treatment has failed may achieve a favourable outcome with an open surgical procedure. In current practice this latter indication should be extremely rare. Recent advances in laparoscopic techniques have made many of these indications for open surgical procedures indication for laparoscopic intervention. There have been reports of the successful performance of every type of "Lithotomy"procedure using a laparoscopic approach except anatrophic nephrolithotomy, the latter being accomplished in a porcine model. In the future, as more urologist become facile with laparoscopic techniques and procedures, the incidence of open surgery is likely to decline further. Ultimately, the only patients under going open stone surgery will likely be those with calculous disease requiring complex anatrophic nephrolithotomy treatment or those withxanthogranulomatous pyelonephritis requiring nephrectomy.

PCNL was started in 1987, URS was started in 1988, ESWL was in 1986. Over last 10-12 years, there is a steady fall in open surgery for stone. At present the only indication for open surgery are.
* Very large stone (Wickham grade IV stone).
* Patient wish.
* Accidental injury/inability to create an adequate access to PC system.
* Inadvertent major complication in form of bleeding, injury or vessels/renal unit.
* Nonavailability of instruments or expertise