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INTRODUCTION
Kidney stone are the most common pathology in all sites on the
urinary tract. Although treatment of kidney stons has been
progressive, but still challenging for urologists. Open surgery to
remove stone only accounts for less than 10% in developed countries.
The incidence of residual stone in open surgery is dependent on the
complex or simple stone. According to the study of Nguyen Hong
Truong (2007), the rate of residual stone was 34.6%; Tran Van Hinh
was 47.22%; Huynh Van Nghia (2010) was 17%.
In order to limit the rate of residual stone, many domestic and
foreign authors have studied and used many ways to open the renal
pelvis of kidney parenchyma or use different supporting techniques
to remove all stones and reduce the damage of parenchymal or vessel
such as: x-ray application, ultrasound or endoscopic surgery,
application of bio-glue. The study results, although there are many
incentives, but not meet the practical requirements.
The technique of flexible endoscopy has been applied in kidney
stones since the beginning of the 21st century, has quickly proved
many advantages in urinary calculi. Renoendoscopy with a flexible
scope assisted in open-surgery for complex kidney stones is a modern
technique that has the advantage of allowing access to stones in
kidneys without opening kidney parenchymal, thus reducing the rate
residual stone and increasing the conservation of kidney. Studies of
this technical application are still in the early stages and not much.
In such circumstances, we carried out the study: "Evaluating the
results of open pyelolithotomy with endoscopic support to treat
multiple kidney stones" with 2 objectives:
1. To evaluate the results of open pyelolithotomy with endoscopic
support to treat multiple kidney stones at Thanh Nhan Hospital.
2. To understand some factors related to the results of open

pyelolithotomy with endoscopic support to treat multiple kidney
stones at Thanh Nhan Hospital.


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New contributions of the thesis:
The study was conducted in 55 patients with 56 kidneys,
diagnosed multiple kidney stones, within 5 years (32012 to 72017) at
Thanh Nhan Hospital in Hanoi, patients were followed after surgery
for 1 month, 3 months. The study has analyzed and evaluated in
detail the effectiveness, safety and preservation of renal parenchyma
in surgery.
Research has shown the superiority of flexible endoscopy
supporting open surgery to remove multiple kidney stones.
The thesis also analyzed and found some related factors affecting
treatment results such as: age, shape of stone, position and number of
stones, the angle between ureteropelvic axis and lower calyx axis …
Renoendoscopy with flexible scope assisted in open surgery to treat
multiple kidney stones is a modern technique with advantages,
allowing to access to stones in calyx without opening the kidney
parenchyma, thus reducing the rate of residual stone and increasing
the conservation of kidney tissue.
Structure of the thesis:
The thesis consists of 120 pages (Introduction 2 pages, Overview
30 pages, Subjects and methods 22 pages, Results 25 pages,
Dicussion 39 pages, Conclusion 2 pages), with 45 tables, 6 graphs.
The thesis also used 120 references, 18 references. in Vietnamsese
and 102 references. in English.
CHAPTER 1. OVERVIEW
1.1. Surgical anatomy of kidney

1.1.1. Classification of stone:
According to Rocco F., C (Calculi): describes the morphology,
size and topography of the stone in five descriptive categories :
- C1: simple pelvic stone.
- C2: pelvic stone with multiple small stone in calices.


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- C3 (borderline): simple pelvicaliceal stone (1 calyx), with or
without small stones in other calices.
- C4: complex pelvicaliceal stone (2 calices), with or without
small stones in other calyx.
- C5: complete staghorn calculi.
1.2. Treatment of Kidney Stones.
1.2.1. Extracorporeal ShockWave Lithotripsy
Due to the less invasive and gentle of extracorporeal shockwave
lithotripsy (ESWL), some authors have indicated ESWL to treat
kidney stones. ESWL treated 70-75% of patients, however, it had to
be done in several phages with an average of 3-4 times, in addition to
using other support methods 17-57%.
1.2.2. Pure Percutaneous Nephrolithotomy and PCNL with ESWL
Like ESWL, PCNL has also been applied to treat staghorn
calculi, but it is not an easy technique. Many authors are hesitant to
make more tunnel into kidneys because they believe this will increase
complications.
To reduce the damage that the standard PCNL technique causes,
a smaller device called minimally invasive PCNL or mini-PCNL has
been used to limit bleeding, kidney parenchymal injury and safer.
1.2.3. Open surgery
Open surgery is still necessary in the following cases:

- Struvite stone causes hydronephrosis or infected hydronephrosis
- Stone with abnormal urinary anatomy.
- Giant stone.
- Fail to PCNL and/or ESWL.
1.3. Pyelolithotomy
There have been many studies in the world as well as in the
Vietnam about methods of treating kidney stones. However, despite
the introduction of any new therapies, they are all aimed at: 1remove all stones, restore normal urinary tract circulation; 2- resolve
kidney infections, and 3- conserve or improve kidney function.


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Open pyelolithotomy is a technique of choice because: it is
relatively simple, less bleeding, does not cause tissue damage, does
not affect kidney function and morphology, and less complications.
1.4. Researches in reducing residual stone in open surgery
Surgery for complex kidney stones is difficult, the major concern
of the surgeons is the residual stones after surgery, and then the
bleeding during and after surgery. Complicated kidney stones often
come with many small stones in the kidneys, these small stones are
easy to miss in surgery, especially when the kidney tissue is thick, the
neck of calyx is narrow, surgery has a lot of bleeding. The residual
stones cause many complications such as urine leakage, urinary tract
infections ... The measures to support the prevention of stones used in
kidney stone surgery include:
1.4.1. Using intra-operative X-rays
Using X-rays taken in surgery to define small stones that have
been in use since the 1980s of the last century. Currently, due to the
development of the X-ray with C-arm, it is more effective to use this
method because it not only indicates the focal area of the stones in

the upper or middle calyx, but when the arm rotation can indicate the
front or back sides of the kidney.
1.4.2. Using intra-operative ultrasound
Schlegel J.U. (1961) used ultrasound during process of operation
to find small stones in calices. Similarly, Sigel et al. (1982) used
ultrasound in surgery to find small stones in calices; and by
ultrasound, the incision through the parenchymal entered directly
stones. According to the authors, stone-free was 15/16 patients.
1.4.3. Intra-operative reno-endoscopy
In 1964 Victor F. Marsall used a flexible endoscope to visualize
the ureters and renal pelvis. In 1980, Zingg E.J. and CS used a rigid
endoscope in the operation of staghorn calculi, detected over 60% of
small stones in calices in which they would remain in the kidney after
surgery. Then Terris M.K. in the open surgery for staghorn calculi has


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been used flexible or rigid scope, even cystoscope to check, locate
and remove some small caliceal stones.
In 2004 Unsal A. used a pneumatic energy passing the incision
of the pelvis to frag caliceal stones after removing the pelvic stone.
Traxel O. and CS (2008) used flexible scope and laser energy to find
and frag small stones in the kidney.
1.5. The results of applying the flexible scope and laser energy in
the treatment of kidney stone
The application of flexible endoscopy to handle small stones
scattered in calices in the treatment of multiple kidney stones are of
particular interest to domestic and foreign authors. The authors
believe that all case need for active treatment, remove all stones as
soon as possible, resolve for kidney infections, need to intervene

before chronic renal pelvio-nephritis is too severe due to infection.
According to Ono Y. et al., the factors related to residual stone:
number and shape of stone (staghorn calculi combined with multiple
stone, stones scattered in many calices), shape of the pelvis and
calices pelvis (small pelvis with caliceal neck stenosis and dilated
calices), thick parenchyma and surgical techniques are also factors
that affect the rate of remnant stones.
Therefore, many less invasive techniques are implemented and
bring very positive and encouraging results such as: not to incise
renal tissue and conserving kidneys, passing postoperative period
easily, shortened hospital stay ... However, each technique has its
advantages and disadvantages.
1.5.1. Laparoscopic lithotomy combined with flexible scope
Initially, post- or transperitoneal laparoscopic surgery is
indicated for simple upper ureteral stones, or pelvic stone which is
outside the renal hilum.
Thanks to the development and improvement of the flexible
scope, the surgeons have treated the stones deep in the kidneys, the


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stones in the renal calices, which had previously been removed with
incision of renal parenchyma.
In Ramakumar's et al. report, the rate of stone-free in three months in
19 patients underwent laparoscopic surgery and flexible endoscopic
surgery is 90%. Similar results were reported recently by Srivastava et al.,
Wang X. et al. with stone-free rates of 75% and 80%.
1.5.2. Retrograde ureterorenoscopy with flexible lithotripsy
Before the introduction of flexible scope with small caliber, the
role of retrograde ureteroscopy in the treatment of kidney stones was

very limited, in which the rate of complications was high.
The progress of retrograde ureteroscopy technique with flexible
scope has helped urologists to access the entire ureter and renal pelvis
system, but the indicatin is still much debate.
1.5.3. Percutaneous nephrolithotomy with flexible scope
The improvement of flexible endoscopy helped many urologists
in the treatment of kidney stone. Its application in PCNL has brought
many encouraging results. PCNL has treated complex stone,
however, the residual stone also affects the quality of treatment.
Recently, many authors in the world have actively used flexible
endoscope to treat remnant stones in the time of operation and have
good results.
1.5.4. Open surgery combined with flexible endoscope
Open surgery for staghorn calcili is difficult, a large stone often
accompany with small fragments in calices, easy to miss in surgery
especially when the kidney tissue is thick, caliceal neck stenosis,
bleeding. Characteristics of stone: scattered all 3 groups of calices.
Surgery to preserve renal parenchyma is very concerned by the
urologists, how to get all the stones in surgery and reduce the damage
to kidney tissue, relieve the phenomenon of urinary obstruction. If
you leave small stones in surgery, there will be many complications
such as urinary tract infection, urine leakage, stone recurrence…


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To overcome these factors, many authors used flexible scope in
the same operation to remove all the remaining stones scattered in
calices. In 2006, Terris M.K. has taken open surgery combined with
flexible, rigid scope or even a cystoscopy to check, locate and take
some small stones in the calices.

Traxel O. et al. (2008) used flexible scope and laser energy to
frag small stones in the kidney. Traxel O. et al. (2010) performed
surgery for 17 patients of staghorn calculi on horseshoe kidneys
flexible scope in combination with holmium laser from December
2004 to May 2009 for results 15/17 patients (88.2%) of stone-free,
02/17 patients (11.8%) with residual stone.
1.5.5. Role of Holmium laser
Holmium Laser's efficiency on stone fragment depends on the
energy of the emitted pulse and the diameter of the optical wire, with
the wire type 365µm and 550µm, while the 200µm wire has a better
"drilling" effect. Types of 365µm and 550µm will be easier to push
up stone than 200µm conductors. There is no need to use eye
protection when fragment; for example, if the energy is below 15W,
the surgeon's conjunctiva and cornea are damaged only when the
distance of the laser head is less than 100mm from the eye.
Laser fiber type: Holmium Laser conductor has the following
diameter: 200, 230, 272, 365, 550 and 1000 µm.
CHAPTER 2. SUBJECT AND METHOD
2.1. Subject
Including 55 patients diagnosed multiple kidney stones, underwent
open pyelolithotomy in combination with flexible endoscopy in Thanh
Nhan hospital, Hanoi from March 2012 to July 2017.
There was 1 patient who has been undergone bilateral kidney
stones, in which each side of the kidney ensures the research criteria
Therefore, there would be 56 surgeries performed in the study.


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2.1.1. Criteria of selection
- Multiple kidney stones: 1 pelvic and at least 2 caliceal stones.

- Open pyelolithotomy.
- Using flexible intra-operatively to reveal and remove caliceal stones.
- Patients agree to voluntarily participate in the study.
- Sufficient records to conduct data analysis and statistics.
2.1.2. Criteria of exclusion
- Severe hydronephrosis, thin renal parenchymal.
- Open pyelotomy combined with parenchymal incision.
- Do not found caliceal stones with endoscopy.
2.2. Sample size formula
n=

Z12−α / 2 p (1 − p)
d2

2.3. Research method
Prospective longitudinal followup study.
The data were prepared according to the study design, collecting
and analyzing the results based on the follow-up, describing the
research index over the longitudinal follow-up time.
2.4. Index of study
2.4.1. Clinical characteristics
Age and sex; BMI index; systemic diseases.
2.4.2. Para-clinical characteristics
* Blood test:
- Blood tests were done in Thanh Nhan hospital.
- Classification of renal failure according to KDIGO.
* Urine test.
- Total urine analysis.
- Urine culture and microbiology report.
* Ultrasound: to evaluate the pelviocaliceal dilation (4 grades)

* Plain X-ray film (KUB), to evaluate:
- Unilateral of bilateral kidney stones.
- Number of stones: monolithic stone of multiple stones.


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- Size of caliceal stones.
- Site of caliceal stones: Select only C3, C4, C5 stones into the study.
* Intravenous Urography (IVU), CT-Scan: assessing renal
excretory function in kidney of stone and opposite site; kidney
dilatation and thickness of kidney parenchyma; location of stone and
caliceal anatomy.
2.4.3. Process of open pyelolithotomy in combination with flexible
endoscopy to remove caliceal stones.
2.4.3.1. Indication of surgery:

- Age: 18 year old or older; BMI < 30.
- History of stone operation: unilateral or bilateral kidney stone.
- Stone characteristics: 1 pelvic stone and at least 2 caliceal stones.
+ Pelvic stone: C3, C4, C5 according to Rocco’s classification.
+ Size of caliceal stone: < 20 mm/stone.
+ Pelvis shape: B2, B3 and B4.
+ Angle between ureteropelvic axis and lower calyx axis ≥ 30o.
* Anesthesia: general or epidural anesthesia.
* Patients positioning: lateral position on a flexed operation table.
2.4.3.2. Technique operation

Step 1: Pyelolithotomy
- Flank incision, access the pelvis.
- Simple pyelotomy, or Gil-Vernet incision.

- Remove the pelvic stone.
Step 2: Flexible endoscopy
- Karl Storz’s setup of laparoscopic surgery.
- Flexible scope 10Fr (Olympus CYF-4).
- Instrument: 272µm laser fiber, triprong forcep, Dormia basket.
Technique:
- Irrigate the pelvis and calices with NaCl 0.9%; total sutures the
incision of pelvis with Vicryl 4/0, except a hole for scope passing by.
- Using flexible scope 10Fr, visualize: pelvis, upper calyx,
middle calyx and lower calyx, respectively; seek and remove caliceal


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stones with Dormia basket or triprong forcep. In case of large stone
not pass throung the caliceal neck, laser holmium was used to
fragment stone.
The 272 µm fiber, energy was set at 2 level:
+ ‘Soft’ stone: 1.2J, 10Hz frequency.
+ ‘Hard’ stone: 1.4 – 1.6J, 12-14Hz frequency.
- Do the last check all the peviocaliceal system to avoid remnant.
- Remove the scope, place a JJ-stent into the ureter, close the
pelvis completely with Vicryl 4/0 running or simple suture.
2.4.3.3. Criteria for evaluating surgical result.

- Result of open pyelolithotomy
- Classification postoperative results and related factors.
+ Success and failure, related factors.
+ Duration of endoscopic lithotripsy for each calyx.
+ Hospital stay, time of remove JJ-stent.
+ Evaluate the results at 1 month and 3 month after discharge.

2.4.3.4. Evaluate the intra-operative complications

* Intra-operative bleeding: severe, moderate, mild.
Seek the relation between the grade of bleeding and pelvis.
2.4.3.5. Evaluate the post-operative complications

* Color of urine.
* Bleeding.
2.4.3.6. Evaluate the surgical results

* At the time of discharge.
- Stone-free, residual stone.
- Residual stone: location, size, number; if stone ≤ 4mm, left to
free naturally; if stone ≥ 10mm, applying ESWL.
* Evaluate at 1 month after surgery: urinary ultrasoud, plain Xray (KUB), blood test (ure and creatinin).
+ Intra- and post-operative complications.
* Evaluate the additional therapy for residual stone.
* Evaluate at 3 month after surgery:


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- Good: stone-free at discharge, stone-free after ESWL for
residual stone; kidney function improvement (for patient with kidney
failure prior to surgery); no intra- or post-operative somplications.
- Moderate: fragment stone < 5mm after ESWL for residual
stone; sustentive kidney function (kidney failure prior to surgery).
- Bad: residual stone but fail to ESWL; early stone formation
(recurrence); increasing the level of kidney failure (kidney failure
prior to surgery); infected hydronephrosis or giant hydronephrosis
requiring to re-operate.

2.5. Moral research
- The research protocol was adopted by the Scientific Council of
Military Medical Academy.
- Patients were thoroughly explained before taking part in the
study and were completely voluntary with the attached application.
- The data and medical records were kept in compliance with the
regulations of the Ministry of Health and the provisions of law.
2.6. Data analysis
- The data are managed and analyzed by SPSS 22.0 software.
CHAPTER 3. RESULTS
3.1. Clinical and paraclinical characteristics related to surgery
Table 3.1. Mean age 54 ± 12 (26 – 81).
Graph 3.1. Male/female ratio 3/2.
Table 3.2. Flank pain 94.6%; hematuria 1.8%; accidental stone 1.8%.
Table 3.3. Disease time: 1 year 46 patients (83.6%), 1 - 3 year 8
patients (14.5%), 1 pt over 3 year (1.8%).
Table 3.4. Diabetes 7 patients (12.7%), Hypertension 1 pt
(1.8%), History of pulmonary tuberculosis 1 pt (1.8%).
Table 3.5. History of stone surgery: 45 patients no history of
intervention 81.8%, 3 patients stone recurrence after surgery 5.5%; 2
patients with ureteral stone in the same side 3.6%; 3 patients with
ureteral stone in the opposite side 5.5%.


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Table 3.6. Mean BMI index 54.5%.
Table 3.7. Preoperative ure and creatinin.
Table 3.8. Preoperative creatinin clearance.
Table 3.9. Evaluate the grade of kidney failure: 80% in normal
range; 4 patients stage 1 of failure (7.3%); 6 patients stage 2 (10.9%),

and 1 pt stage 3 (1.8%).
Table 3.10. Urine culture positive in 3 patients (5.4%).
Graph 3.2. Hydronephrosis: 25% grade 1, 8.9% grade 2, and
3.6% grade 3.
Graph 3.3. Kidney stone: right 57.1%, left 42.9%.
Graph 3.4. Classification of kidney stone according to Rocco F:
C3 32.1%, C4 51,8%, C5 16.1%.
Table 3.11. Stone location: middle-lower calices 42.9%, all
calices 16.1%.
Table 3.12. There are 272 stones on 56 kidney, 4.9 stones each
kidney on average.
Table 3.13. Stone size ≤ 10 mm (62.5%), 20 mm (37.5%).
Table 3.14. Renal excretion: 52 kidneys in good 92.9%, 4 kidney
on moderate 7.1%.
Table 3.15. Stones: B2 26.8%, B3 16.1%, B4 57.1%
Table 3.16. Angle between ureteropelvic axis and lower calyx
axis: 5 patients ≤ 450 (13.2%), 33 patients ≥ 450 (86.8%).
3.2. Surgical results
Table 3.17. Simple pyelolithotomy 19.6%; standard Gil-Vernet
pyelotomy 53.6%; non-standard Gil-Vernet 26.8%.
Table 3.18. Pumped pelvis and calices, took out 96 stones/47
kidneys (83.9%).
Table 3.19. 51 operation in which flexible scope accessed all
calices 91.1%; 5 operations the scope could not accessed lower calyx.
Table 3.20. Treated caliceal neck stenosis successfully with
dilatation in 4 cases (7.1%), unsuccessful in 2 cases (3.6%).


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Table 3.21. There were 157 stones: 35 stones in upper calyx

(22.3%), 74 in middle (47.1%), and 48 in lower calyx (30.6%).
Table 3.22. Stone removed with instruments: upper calyx 29.8%,
middle calyx 55.3%, lower calyx 14.9%. Stone fragment by laser:
upper calyx 19.8%, middle calyx 43.8%, lower calyx 36.5%.
Table 3.23. Stones migrated from upper to lower calyx in 2
patients (3.6%).
Table 3.24. Time of laser lithotripsy: upper calyx 31 minutes, middle 33 – 40
mins, and lower calyx 39 – 50 mins, ≥ 4 stones 80 mins.
Table 3.25. Relation between laser lithotripsy and number of
stones: 63 minutes on average in 21 patients with 1 – 2 stones
(37.5%); 69 minutes in 25 patients with 3 stones (44.6%); 82 minutes
in 7 patients with 4 stones (12.5%); 87 minutes in 3 patients with
more than 4 caliceal stones (5.4%).
Table 3.26. Reason of flexible renoendoscopy: pelvic rupture and
caliceal neck injuries in 4 patients (7.1%); the scope did not access to
lower calyx in 3 patients (5.4%) due to angle between ureteropelvic
axis and lower calyx axis < 450; 2 patients with caliceal neck stenosis
so that the scope did not pass by.
3.3. Analyze the relative factors
Table 3.27. High success rate 94.3% in patients with stone ≤ 10
mm, differred from patients with stones 11 – 20 mm statistically
significant.
Table 3.28. The relation between number of stones and was
significantly different with p <0.05.
Table 3.29. The rate of technical failure in patients with lower
caliceal stones was higher than no lower caliceal stone, sig.
statistically (p <0.05).
Table 3.30. The rate of technical failure in patients with angle
between ureteropelvic axis and lower calyx axis < 450 was higher
than the angle ≥ 450, sig. statistically (p < 0.05).

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Graph 3.6. Intraoperative bleeding: 4 patients due to pelvic rupture
and caliceal neck injuries; 3 patients due to large and hard stones.
Table 3.31. Rupture of peritoneum and pleura in 3 patients with
history of stone surgery.
3.4. Follow-up and postoperative complications
Table 3.32. Postoperative care: red urine in 14 patients (25%);
pink urine in 42 patients (75%).
Table 3.33. Mean hospital stay 11.6 days.
Table 3.34. Stone-free rate 71.4%; residual stone 28.6%.
Table 3.35. Location of residual stones: lower calyx 62.5%,
upper and lower calyx 6.3%, middle and lower calyx 12.5%.
Table 3.36. There were 20 residual stones with diameter < 10
mm (62.5%), 12 others ≥ 10mm (37.5%).
Table 3.37. The postoperative grade of peviocaliceal dilatation
decreased in compare to preoperative statistically significance (p < 0.05).
Table 3.38. The difference of the rate of kidney failure between
preoperative and 1 month after surgery was not significant (p > 0.05).
Table 3.39. Additional therapy: 3 patients not to require additional treatment
(18.8%), 13 patients was treated by ESWL (81.3%).
Table 3.40. 3 free of stone kidneys was classified in good result
(23.1%), 7 kidneys in moderate results (53.8%), 3 kidneys in bad
condition (23.1%).
Table 3.41. Results at 3 months after surgery: good 82.2%;
moderate 12.5%, and bad 5.3%.
Table 3.42. The grade of peviocaliceal dilatation 3 month after
surgery decreased in compare to preoperative grade with statistical
significance (p < 0.05).

Table 3.43. After surgery, stage of kidney failure improved
significant statistically (p < 0.05).


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CHAPTER 4. DISCUSSION
4.1. Discussion on indication and results of open
pyelolithotomy with endoscopy assisted in the
treatment of multiple kidney stones
4.1.1. Indication of flexible in open stone surgery
The application of flexible endoscopy in open stone surgery is
depended on following factors: stone characteristics, pelvis and
calices charateristics, stone pathology, clinical features and patient
performance status.
4.1.1.1. Clinical characteristics
* Age, sex, BMI index and history of stone surgery.
The age of the most infected is 41 – 60 years old, accounted for
50.9%, the youngest is 26 and the oldest at 81 (Table 3.1). According to
Nguyen Ky et al., the most common age of patients with urolithiasis is
31 - 60 years old. Tran Van Hinh also found that the age of patients was
concentrated in the age of 20 – 60 (91.78%). The incidence between
men and women is 3/2, which is different from the research of some
other authors, the rate of male and female patients is similar.
BMI is also a factor to be considered when applying flexible
endoscopy in open surgery to assist in the treatment of residual stones.
* Reason of admission and comorbidity.
The rate of flank pain was 94.6% (52/55 patients), lower than
Nguyen Ky’s report (96.28% on 2316 patients with kidney stone) and
Tran Van Hinh’s report (90%).
The rate of comorbidity was 16.4% (9 patients), in which 7

diabetes (12.7%), 1 hypertension (1.8%) and 1 history of pulmonary
tuberculosis 1.8% (Table 3.4).
According to Martin’s report (2014), 10 patients with incidental
kidney stones (13.6%), 12 patients with flank pain (16.4%), 4
patients with hematuria (5.4%), 39 patients with renal colic (53.4%).
4.1.1.2. Stone characteristics


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The characteristic of kidney stones is the most important factor
affecting the indication of surgery. This is a procedure that is used for cases
of multiple kidney stones, not only for pelvic stones but also for caliceal
stones with high risk of leaving out in case of open surgery alone.
The some previous studies, the rate of residual stone after open
surgery was quite high: 34.6% according to Nguyen Hong Truong’s
report (2007), 47% in Tran Van Hinh’s report (2011).
However, using flexible endoscope is a difficult technique, only
bleeding caused by a tearing of the mucosa or caliceal neck is seriously
affecting the field of vision, even unable to be examined. Therefore, the
characteristics of both renal pelvic stones as well as caliceal stone stones
affect the indication of this endoscopic technique.
* Pelvic stone characteristics
Graph 3.4 showed that, there were 9 kidneys with enough 3
stone branches in 3 upper, middle and lower calices; there were 47
kidneys with stone in 2 caliceal groups.
In order to get the percentage of kidney stones and many such
stones, we actually excluded from the study the cases of open surgery
with incision the renal parenchyma to remove stones. If these cases
are selected, the number of our study patients will be higher. And this
also limits the number of study patients to 55 with 56 operated

kidneys. It requires rigor in indication.
* Number, location and size of caliceal stones:
- Number and location of stones on KUB: excepted for pelvic
stones with branches, there were 216 caliceal stones.
- Location of caliceal stones was showed in Table 3.11, in
details: 42.9% stone in middle and lower calyx (24/56 kidneys). In 9
kidneys with enough 3 stone branches in 3 upper, middle and lower
calices accounted for 16.1%.
The total number of stones on the KUB film is 272 stones/56
kidneys, on average each kidney has 4.9 stones (Table 3.12).


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In a total of 216 caliceal stones, distributed in calices as follows:
20 kidneys with 3 stones accounted for 35.7%; 23 kidneys with 4
stones accounted for 41.1% and 12 kidneys with 5 stones accounted
for 21.5%.
- Stone size on KUB:
+ Stone with 20 mm diameter in 21 kidneys (37.5%).
+ Stone with 10mm diameter in 35/56 kidneys (62.5%) (Table
3.13). There was no patient with stone 30mm or above whom
indicated flexible renoendoscopic lithotripsy.
4.1.1.3. Renal pathology and renal excretory
In our study, the grade 1 of dilatation was in 14 patients,
accounted for 25%; grade 2 in 5 patients accounted for 8.9%; grade 3
in 2 patients accounted for 3.6%; other 34 patients accounted for
62.5% with no renal dilatation (Graph 3.2).
Assesment on IVU and CT-Scan, there were 52 kidneys in good
infusion (92.9%), 4 kidneys in medium infusion (7.1%) (Table 3.14).
We evaluated the pelvic morphology according to Nguyen The

Truong (B1, B2, B3, B4, B5): There were 15 renal pelvis in the renal
hilum (B2) accounted for 26.8%, 9 medial renal pelvis (B3)
accounted for 16.1%, 32 cases of renal pelvis outside the renal hilum
(B4) accounted for 57.1%.
4.1.1.4. Paraclinical characteristics

* Blood test: Evaluate pre-operative stage of kidney failure
followed KDIGO (2017).
In the study, there were 44 cases of renal function within normal
range, accounted for 80%; 4 cases of renal impairment at stage 1
accounted for 7.3%; 6 renal failure at grade 2 accounted for 10.9%
and 1 case of renal failure at level 3 accounted for 1.8%. No patients
with renal failure at stage 4.
The rate of renal failure is similar to that of Tran Van Hinh
(2001), Huynh Van Nghia’s report (2010).
* Creatinin clearance


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All 55 cases in the study were evaluated creatinin clearance
before surgery; 7 of which had low clearance accounted for 12.7%,
the remain had the clearance within normal range.
According to Nguyen Buu Trieu (1984), after surgery of
staghorn calculi by modified Gil-Vernet technique, kidney function
improved (based on creatinin clearance). In Tran Van Hinh’s report
(2001), the change of clearance before and after surgery was not
statistically significant.
Our results are similar to those of the authors.
* Urine analysis and culture
34 patients with micro hematuria in urine accounted for 63.6%; 3

patients with leucocytes accounted for 5.5% and 15 cases with
proteinuria accounted for 27.3%.
There were 3/55 patients with bacteruria accounted for 5.4%,
whom treated by abtibiotics preoperatively based on microbiologic
report and then took the second urine culture. Surgery only be
perform in case of negative urine with bacteria.
4.1.2. Discussion on process surgery
4.1.2.1. Anesthesia and Incision
We conducted general anesthesia with endotracheal control for
55 patients (98.2%); 1 patient was given epidural anesthesia (1.8%)
because of history of pulmonary tuberculosis.
We applied two incision to access the stone: simple pyelotomy
(for 11 kidneys – 19.6%) and Gil-Vernet pyelotomy (for 45 kidneys –
80.4%), in which:
+ 15 kidneys in B2 group were openned by modified Gil-Vernet
pyelotomy, accounted for 26.8% (Table 3.17).
+ 30 kidneys in B3 and B4 group were openned by standard GilVernet, accounted for 53.6% (Table 3.17).
In this study, we only selected patients who obtained stones
through the open renal pelvis (not parenchyma). The rate of multiple
kidney stones is 56/56 surgeries, in which: 9 cases have branched


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into all 3 caliceal groups (16.1%) (Graph 3.4). In fact, these are cases
where stone branches are often shallow and uncomplicated, with no
sub-branches.
4.1.2.3. Technique to remove caliceal stone through pyelotomy
After pelvic stone removed, we irrigated pelvis with NaCl 0.9%
and a tube 14Fr to take out ‘easy’ stones first. So we took out 96
stones in 47 operations, excepted 9 cases.

After that, we proceeded to suture renal pelvis with Vicryl 4/0
and conduct flexible endoscopy to treat the remaining stones.
4.1.2.4. Flexible endoscopy technique
* Instrument: A flexible probe was used in the study, which was
type 10F of Olympus, 1 channel for operation and irrigation. The
auxiliary tools in endoscopy were baskets and triprong forceps. The
source of energy used in the study was a 30W Sphinx JR Laser
Holmium machine of Lisa Laser Co. (Germany), with a fibre of
272µm diameter.
* Steps of caliceal flexible endoscopy: from upper calyx, to
middle and lower; could be supported by widened caliceal neck.
* Laser energy level often used: 1.2J, 10Hz frequency.
4.1.3. Results of open pyelolithotomy in combination with flexible
endoscopy to remove caliceal stones
4.1.3.1. Results of intra-operative endoscopy
Table 3.19 showed that, flexible probe could access caliceal
stone in 51 cases, acoounted for 91.1%; in which 47 cases with laser
lithotripsy completely.
There were 4 cases despite of stone access but bleeding due to
caliceal neck injuries.
However the scope could not reach the lower calyx in 5
surgeries; because of a/ the acute angle between ureteropelvic axis
and lower calyx axis in 3 cases, caliceal neck stenosis in 2 cases.


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4.1.3.2. Number of caliceal stones
We counted the number of caliceal stones during the operation
under the visual of scope. There were total 157 stones: 35 stones in
upper calyx (22.3%), 74 stones in middle calyx (47.1%) and 48

stones in lower calyx (30.6%) (Table 3.21).
4.1.3.3. Handle stones in endoscopy
- Handling stones with instruments:
We took out 47/157 stones on 34 kidneys, accounted for 29.9%
(Table 3.22). Terris M.K. in the open surgery for staghorn calculi has
been used flexible or rigid scope, even cystoscope to check, locate
and remove some small caliceal stones.
- Handling stones with holmium laser energy.
For 110/157 stones remained after handling with instrument, we
used holmium laser to fragment in 96/110 stones (61.1%) (Table 3.22).
Unsal A. (2004) used a pneumatic energy passing the incision of the
pelvis to frag caliceal stones after removing the pelvic stone.
4.1.3.4. Time of handling caliceal stones
After determining the number of caliceal stones, assessing the
size of stones, we proceeded to use tools to get the stones that were
easy to advance. For large stones that cannot be obtained by tools, we
conduct holmium laser lithotripsy.
The processing time of kidney stones is not the same, depending
on the number and location of caliceal stones. Table 3.24 showed that
the average time lithotripsy in the caliceal groups had a statistically
significant difference (p < 0.05).
Relevant time of lithotripsy with the amount of stones was
shown (Table 3.25). The operation time increased significantly when
the number of stones from 4 or more (82 – 87 minutes) compared to
the group with only 1 – 2 stones (63 minutes).
The average time of operation (from skin incision to skin suture)
was 140 minutes, the fastest was 100 minutes, the longest is 200


21

minutes. Results of Unsal A. the average operation time was 190
minutes (135 – 285 minutes).
4.2. The technical failure and related factors (Table 3.2.6)
There were 4 cases of renal pelvis in the sinuses (B2), when the
stones were handled, there were such a lot of bleeding that we must
be placed surgicel and the gauze inserted into the renal pelvis and the
caliceal neck to stop bleeding. The flexible probe was reinserted into
the calyx, but when it was ready to access stones, bleeding was
forced to stop the operation.
There were 2 cases of failure, failing to bring scope through the
caliceal neck to access stones, accounted for 3.6%. The main reason
is that because of the chronic inflammation of the caliceal neck, the
process of widening has failed.
There were 3 cases whom could not put the scope into the lower
calyx because of the acute angle between ureteropelvic axis and
lower calyx axis, accounted for 5.4%.
4.2.1. Shape of pelvic stones
The study founded 15 cases of stones in the group (B2) with the
rate of 26.8%, of which there were 4 cases (7.1%) of rupture of renal
pelvis due to small renal pelvis and narrow hilum, inflammation of
stones adhering to the pelvic mucosa (Table 3.26). Huynh Van Nghia
(2010) 5 cases (5%) of rupture of renal pelvis.
4.2.2. Stone size
The stone size is a factor that is strongly related to postoperative stone-free
rate. The bigger the stone, the lower stone-free rate after surgery.
We took the stone’s largest size to make research landmarks. We
divided patients based on the stone size into 2 groups, including group of
stone ≤ 10 mm and group > 10 mm (Table 3.27). The results showed a
higher failure rate in the group with size > 10mm (p < 0.05).
4.2.3. Number of stone

When dividing the group of stones by 1 kidney into 2 groups,
group ≤ 3 stones and group ≥ 4 stones (Table 3.28), we found that the
failure rate was higher in the group of 4 or more stones (33.3%)
compared to the group with ≤ 3 stones (9.8%).


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Flexible endoscopy used in kidney stone surgery is a difficult
technique, if not said it is very difficult. Therefore, if the more
number of stones, the more difficult to control the entire
pelviocaliceal system. The risk of bleeding and residual stone will
also be higher.
4.2.4. Location of stone
Studying the relationship between stone position and success
rate, failure of flexible endoscopy, we found that the stone of lower
calyx was significantly related to the failure rate of the technique.
Table 3.29 showed us that 9 cases of failure in the study had 7
cases of stones in the lower calyx. It may be either alone or in
combination with the remaining calices. The success rate in the group
of patients with stone in lower calyx accounted for only 81.6%.
4.2.5. Angle between ureteropelvic axis and lower calyx axis
The angle between ureteropelvic axis and lower calyx axis has
been studied by many authors in the world, especially in ESWL, the
authors believe that the anatomical characteristics of lower calyx and
renal pelvis contribute an important part in the elimination and
clearance of stones.
In our study, although open surgery in combination with flexible
endoscopy to get the remaining stones in calices, there were many
difficulties, common causes due to the small, acute angle between
ureteropelvic axis and lower calyx axis, so the probe could not be

passed through the caliceal neck. We chosed 45 0 for this angle
according to Resorlu et al. (2012) (Table 3.30).
4.2.6. Approach stone
In the study, the caliceal stone were immediately accessed and
completely removed in 47 cases; 4 patients accessed the stones but
only partially managed the remnants; 5 patients accounted for 8.9%
the stones could not be accessed.
There were 6 patients who had caliceal neck stenosis, much
edema due to long-term stone occupied, accounted for 10.7% (Table
3.20), we had to carry out the dilatation with the tip of the probe into
the calyx to access the stones. Also in this study, caliceal neck of 2
cases were completely stricture, unable to put the scope through,
accounted for 3.6%.


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4.4. Postoperative results
4.4.1. Evaluate the results at the time of discharge
The patients were examined at the 7th day or 10th day after surgery.
Table 3.34 showed the evaluation of the residual stone; there
were 40 patients with complete stone-free (71.4%); 16 patients with
residual stones (28.6%). The position and size of residual stones are
shown in Table 3.35 and 3.36.
4.4.2. Hospital stay
The patient had the shortest post-operative hospital stay of 6 days, the
longest was 35 days. The hospital stay was an average of 11.4 days. Unsal’s
report had an average hospital stay of 4.2 days (3 – 7 days).
4.4.3. Results after 3 months
There were 13/16 patients with residual stones treated by ESWL
at 1 month after surgery. The results were shown in Table 3.40:

+ Stone-free: 3 patients, accounted for 23.1%.
+ Remnant fragment < 5mm: 7 patients, accounted for 53.8%.
+ Stones were not broken: 3 patients, accounted for 23.1%
CONCLUSION
1. Evaluate results of open pyelolithotomy with endoscopy
assisted in the treatment of multiple kidney stones
- The flexible endoscopy were performed on 56 patients, in
which laser lithotripsy was completely successed on 47 patients
(83.9%), failed to fragment stone in 4 patients (5.6%), and stones
could not be accessed in 5 patients (10.7%).
- Pumped pelvis and calices, took out 96 stones on 47 kidneys (83.9%).
- There were 157 stones: 35 stones in upper calyx (22.3%), 74 in
middle (47.1%), and 48 in lower calyx (30.6%).
+ With instruments, we took out 47/157 stones (29.9%).
+ Holmium laser lithotripsy in 96/110 stones (61.1%).
- Intraoperative complications: rupture of peritoneum 1.8%, rupture
of pleura 1.8%. Postoperative complication: wound infection 3.6%.


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- Stone-free 71.4%; there were 32 residual stones in 16 kidneys.
- Results at 1 month after surgery:
+ The stone was spontaneous passage after JJ-stent removed in 3
patients, although no sign of sign on KUB and ultrasoud (18.8%).
+ ESWL for 13 patients with residual stones: stone-free in 3
patients (23.1%), remnant fragment < 5mm in 7 patients (53.8%), but
stones were not broken in 3 patients (23.1%).
- - Results at 3 month after surgery: good 46 patients (82.2%),
medium 7 patients (12.5%), and bad 3 patients (5.3%).
2. Understand factors related to the results of open

pyelolithotomy with endoscopic support to treat
multiple kidney stones
- The preoperative assessment of pelvic stone and removing intact,
without tearing the renal pelvis or damage to the caliceal neck, also
determined the success of the surgery. The study founded 15 cases of
stones in the group (B2) with the rate of 26.8%, of which there were 4
cases (7.1%) of rupture of renal pelvis and caliceal neck injuries.
- The stone size was a factor that is strongly related to
postoperative stone-free rate. The bigger the stone, the lower the rate
of stone-free after surgery.
- The number of stones was also significant to surgical success. We
found that the failure rate was more common in the group of 4 stones or
more (33.3%) compared with the group with ≤ 3 stones (9.8%).
- The success rate of flexible endoscopy in cases with the acute
angle between ureteropelvic axis and lower calyx axis was not high.
The success rate in the group of patients with stones in lower calyx
accounted for only 81.6%.
- Assessing stones and managing remnants in calices was also a
problem because the stones were in the calices for a long time,
causing inflammation or narrowing of the caliceal neck. In the study,
we encountered 6 cases of caliceal neck stenosis, high mucosal


25
edema, accounted for 10.7%. We treated successfully with dilatation
in 4 cases (7.1%), unsuccessful in 2 cases (3.6%).