Treatment options for kidney stones have evolved considerably over the past several decades, where almost any stone can now be considered for treatment with a noninvasive or a minimally invasive approach including shock wave lithotripsy, ureteroscopy or percutaneous nephrolithotomy. However, open stone surgery is stil required for certain indications. Stone disease is often associated with anatomic and metabolic anomalies or infection, and stone reccurrence risk is high in pediatric age groups [15]. For these reasons and also have a long life expectancy ,the treatment of pediatric stone disease is important, and minimally invasive procedures must be preferred in the pediatric age group. Advances in extracorporeal shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotripsy (PNL) have rarely led to the need for open surgery. With the increase in endoscopic intervention experience, the need for open surgery is gradually decreasing. In addition, with the increase in endoscopic intervention experience, open surgery indications also change.
The indications of open stone surgery include complex stone burden, treatment failure of ESWL and/or PNL, or failed ureteroscopic procedure, intrarenal anatomical abnormalities: infundibular stenosis, stone in the calyceal diverticulum, PUJ obstruction, stricture, skeletal deformity, contractures and fixed deformities of hips and legs, comorbid medical disease, concomitant open surgery, non-functioning lower pole (partial nephrectomy), nonfunctioning kidney (nephrectomy), patient’s choice following failed minimally invasive procedures; the patient might prefer a single procedure and avoid the risk of needing more than one PNL procedure, stone in an ectopic kidney where percutaneous access and ESWL might be difficult or impossible.
While our open surgery rate was 25% in the period when our endoscopic experience was limited in our series, it decreased to 1.5% with the increase of experience. In the period when experience is limited, open surgical intervention is preferred for cases with staghorn stones and multiple stones, while it is seen that cases with high stone burden can be treated minimally invasively with the increase of endoscopic intervention experience. The indications for open surgery included complex stone burden (44%), failed endoscopic procedures 40%), anatomical abnormalities (12%) at begining. Anatomical abnormalities were PUJ obstruction (one), unavailability of minimally invasive therapies (two). The parents' preference for open surgery was an important factor in selecting this method. Open procedures, 50% were driven by failed endoscopic procedures, 25% anatomical indications after increase of endourologic experience.
Cases with staghorn stoneand/ormultiple stone are managed by endourologic procedures after increased experience. However, another problem arises here. With the increase of endoscopic procedures, especially the residents' open surgery experience becomes insufficient. This situation reveals the necessity of performing the cases requiring open surgery in time only in certain centers with experience.
The most important disadvantage of endoscopic stone treatment is high rate of the need for repeated procedures. High repetitive operation rate appearsto be a factor that increases the cost. The patient and parents should be informed about the need for repetitive procedures. The next step in the learning curve should be reducing the number of repetitive processes.
In RIRS application, especially if jj stent is required for passive dilatation, and if mucosal damage is suspected and jj stent is placed again after the procedure, anesthesia should be taken at least three times. The rate of passive dilation before RIRS with jj stent was 46.5% previous study (12). There was no statistical relationship between the age and the use of preoperative JJ stents.
While the stone-free rate is high in stones smaller than 1 cm, sandwich technique or more than one endoscopic intervention is required to ensure stone cleaning in stones between 1–2 cm. In the PNL procedure, th emost important reason for the decrease in the stone-free rate and the need for additional interventions is the high stone burden, trying not to exceed 90 minutes in the operation time, avoiding the application of multiple accesses in the same session for stone-clearence.