Management of Caliceal Stones Resistant to Extracorporeal Shock Wave Lithotripsy

Abstract

Although extracorporeal shock wave lithotripsy (ESWL) is the treatment of choice for many caliceal stones, a noteworthy percentage of stones, mostly those situated in inferior calices, are resistant to ESWL, in that, after one or two sessions the stone appears to be intact or the calix is full of fragments that cannot come out. For caliceal stones, we recommend the following protocol. Stone-containing caliceal diverticula or stones in calices with a very narrow ostium should be treated percutaneously with a 24F or 27F nephroscope. All other caliceal stones should be treated first with ESWL alone. Those stones that appear unchanged after ESWL should be approached by retrograde dilation of the caliceal ostium and ESWL with continuous irrigation of the calix. Finally, stones that are fragmented but cannot be passed should be approached percutaneously. A preliminary attempt should be made simply to puncture the calix and wash out the fragments under local anesthesia. If this fails, calicoscopy with a 17F instrument is the best method for the removal of the fragments and for the fragmentation of the remaining stones. The authors describe these minimally invasive techniques, with which 40 of 43 patients with caliceal stones resistant to ESWL alone were made stone free.