Most kidney ureteral stones smaller than 6 mm do not require surgical treatment! Stones can be removed on their own by drinking plenty of water, standing upside down, running, jumping, and by taking oral diuretic and lithotriptic medications. Sometimes severe lower back and abdominal pain in patients with small stones is good news and indicates that stones are being removed. Larger stones require surgical intervention or operation, especially those with obstructive nature need early treatment to avoid heavy fluid retention and infection, kidney failure and uremia. The specific stones that require surgical treatment and how to deal with them are the issues of concern. The following is a brief summary for sharing. Li Daobing, Department of Urology, Affiliated Hospital of Zunyi Medical College, advantages and disadvantages of extracorporeal shock wave lithotripsy. The early extracorporeal lithotripters had more complications because of the energy and voltage and capacitance were not easy to grasp. After modification of modern extracorporeal lithotripter extracorporeal lithotripsy is basically non-traumatic, no wound, no major impact on daily work. Indications for extracorporeal lithotripsy: kidney preferably with single stones, best in diameter from 8mm to 2cm; kidney stones less than 6mm do not need lithotripsy; upper ureteral stones with obstruction time less than 2 months can be considered for lithotripsy; ureteral multiple stones can also try to break the lowermost stones first. The prerequisite for extracorporeal lithotripsy is the absence of infection and obstruction. Advantages: new lithotripters have stable voltage, good operability, little damage to the body and good lithotripsy effect; domestic lithotripters or old imported lithotripters have poor voltage capacitance control, which can easily lead to kidney rupture and perirenal hematoma. Stones smaller than 6mm do not need extracorporeal lithotripsy! Most small stones can be removed on their own by taking medication or drinking more water. For obstructed ureteral stones (such as stricture or twist, adhesions, etc.) lithotripsy is not effective. If there is an infection, the infection should be controlled before lithotripsy. If the renal pelvic stone or ureteral stone is combined with infection or fever, it is better to drain the stone first and wait for the infection to be controlled before lithotripsy. Isolated kidney stones need to be lithotripped carefully! Extracorporeal lithotripsy is not recommended for young unmarried men and women with lower ureteral stones, otherwise there is a risk of damaging the ovaries, fallopian tubes or vas deferens and seminal vesicles, which may lead to infertility. Nowadays, many private hospitals have purchased lithotripters, which is a good thing in itself, but in order to increase their income, the physicians in private hospitals also take extracorporeal lithotripsy for 3-4mm kidney stones, or the patients themselves do not have stones and are fooled into doing an ultrasound for free to say that they have stones, and the patients undergo extracorporeal lithotripsy and “package”, in fact, such physicians The conscience is too bad! Also, to perform extracorporeal lithotripsy on both kidney stones at the same time or to repeatedly lithotripsy within 1 week is against the scientific law and should be condemned by conscience. The second time after extracorporeal lithotripsy should be at least 1 week between lithotripsy, the third time after at least 2 weeks, and the fourth time after at least 1 month. Domestic charges are about 600 RMB per visit. Advantages and disadvantages of ureteral rigidoscopy. Ureteral rigidoscopy can enter the ureter through the urethra for examination and lithotripsy. The best indications are middle and lower ureteral stones and urethral stones, small bladder stones, tumor biopsy of the ureter, etc.; if a blocker is applied at the same time, it can also be used for upper ureteral stones, but the position of ureteral stones is too high and lithotripsy through ureteral rigidoscopy is not recommended. The advantages are that there is no wound outside the body, the stone can be removed by itself after lithotripsy, and some small stone particles can be removed immediately by ureteroscopy. Disadvantages: unskilled technique may easily cause ureteral injury, perforation or even avulsion; if combined with infection, it may bring sepsis, infectious shock or even death to the patient after the operation. Therefore, patients with combined infections are best drained first, and antibiotics must be infused before and during surgery, and anti-inflammatory treatment must be strengthened or infection controlled before ureteroscopic lithotripsy and stone extraction. Domestic charges are within 10,000 RMB (about 30,000 USD in the US). Advantages and disadvantages of ureteroscopic lithotripsy. Ureteroscopy can also be performed via the urethra into the ureter and the pelvis and calyces, and can deal with stones in the upper ureter and stones in the pelvis and calyces. The best indication is small to medium-sized stones in the pelvis and calyces, less than 3 cm in diameter. Stones that are too large and take too long to lithotripsy through flexible scopes may cause water toxicity, sepsis, infectious shock or even death in patients. After lithotripsy, most of the stones are turned into powder and flushed out of the body directly, while small particles of stones can be drained by themselves. However, the time of stone removal is often longer and the rate of residual stones is too high. The recurrence rate is higher than that of percutaneous nephrolithotomy and requires extracorporeal lithotripsy or other methods to deal with the residual stones. Sometimes it causes ureteral obstruction and other complications that need to be treated by ureteral rigidoscopy again. In addition, the cost of flexible microscopy is expensive and the fee varies from place to place. Some major cities in China charge more than 100,000 RMB (about 160,000 USD in the US), while third-tier or fourth-tier cities charge only 20-30,000. At present, many hospitals in China perform a lot of soft microscopic lithotripsy. Percutaneous nephrolithotomy. It is a procedure of direct lithotripsy and stone extraction by puncturing from the lumbar region into the target calyces of the kidney to establish a channel. Advantages: just 1 cm or less incision, direct access to lithotripsy for kidney stones or upper ureteral stones and immediate removal of stone particles, if combined with stenosis the stenosis can be treated at the same time. The traditional position is prone, which poses a greater cardiopulmonary risk to the patient, requires the health care provider to turn the patient over and over, and is troublesome for the anesthesiologist to observe the resuscitation. In our hospital, we all adopt the truncated oblique position, which does not require repeatedly swinging the position, the patient is relaxed, there is no risk of cardiopulmonary compression, the kidney stone and ureteral stone can be treated at the same time, the surgeon can sit and operate, and it is easy to observe and resuscitate. Advantages: direct stone extraction and management of strictures, just under 1 cm wound. Disadvantages: possible hemorrhage, but most do not bleed profusely and only rarely require arterial embolization; high residual stone rate if the calyces are too large or too long, but most do not require second-stage stone retrieval; complications include perforation, perforation injury, renal laceration, other organ damage, parenchymal infection, perirenal infection, and high residual stone rate due to too many branches in the calyces. Distantly, arteriovenous fistulas, micro aneurysms, and obstruction due to downward migration of the residual stone into the ureter may occur, but all can be managed. The biggest concern is postoperative hemorrhage or renal cortical infection, which may cause death. Therefore, smaller hospitals are advised not to perform such procedures easily. Laparoscopic pelvic dissection for stone extraction or parenchymal dissection for stone extraction. This is possible, but laparoscopy requires three holes in the skin and requires a larger area of the kidney to be freed. If the renal parenchyma is cut, there may be more bleeding, leaving synthetic clips to stop the bleeding, etc. The advantages are only slightly better than open surgery. Disadvantages: high trauma, high residual stone rate, heavy perinephric adhesions, and only lumpectomy can be performed to remove stones if they appear later. Robotic lithotripsy. Robotic stone extraction is currently an experiment, an operation that relies on the manual operation of a keyboard to direct the robot arm. The price is very expensive, more than 200,000 per operation, which is unacceptable to the general public. A few hospitals in China are experimenting with robotic surgery, and it is not appropriate to promote it. Open surgery for stone extraction. Open surgery to remove stones, if the ureteral stones are too long, combined with stenosis and distortion may require open surgery. Large kidney stones without effusion or isolated kidney stones of excessive size, combined with ureteral malformation, stenosis, torsion or pelvic outlet stenosis may require open surgery. The cost of open surgery is usually less expensive than lumpectomy, but recovery is slower after surgery and urine leakage and extravasation may occur after surgery. The rate of residual stones may be high, especially in patients with thick renal parenchyma; if stones are present in all calyces, the surgical damage may be high. Bladder stones: Bladder stones less than 4 cm can be removed by transurethral nephrolithotomy; stones over 4 cm are recommended to be removed by open surgery. Patients with frequent bladder stones should address the cause of the stone, such as prostatic hyperplasia or urethral stricture. Urethral stones: stones near the external urethra can be removed by clamping; stones far from the external urethra can be removed by ureteroscopic lithotripsy; stones in the posterior urethra can be pushed into the bladder and then removed by ureteroscopic lithotripsy. This article is authorized by Dr. Daobing Li.