الفهرس 
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Abstract
compared with PCNL for managing moderate size kidney stones measure between 100 and 300 mm2 in area.
This study was conducted at Menoufia teaching hospital, urology department , Menoufia University between December 2013 and February 2015 . The study included all patients with moderate size renal calculi (range 1-3 cm) who were planned for management of renal calculi either with percutaneous nephrolithotomy (PNL) or extra corporeal shock wave lithotripsy (ESWL).
The study exclude Patients with anatomical abnormalities (Ureteropelvic junction obstruction, Caliceal diverticulum , Infundibular stenosis). Patients with co morbidity that will affect the management plan (abnormal body habitus or body mass index , Patients with coagulopathies.), radiolucent renal stones and patients with cystinuria, kidney transplant and pregnancy.
All patients were subjected to preoperative evaluation by history and physical examination.
Pre-operative laboratory investigations were done for all patients in the form of urine analysis, urine culture and sensitivity,complete blood count (CBC),coagulation profile, blood glucose.urea, serum creatinine,erum uric acid and Liver functions test .
Additional investigations were ordered as necessary for example serum sodium (Na), serum potassium (k), serum calcium(Ca) and acid base balance studies for patients with uremic manifestations.
Preoperative radiological studies were done in the form of abdominal ultrasonography (U/S), intravenous pyelography ( IVP )and computed tomography (CT) .
The results of the study were as follows:
30 patients underwent percutaneous nephrolithotomy and 40 patients underwent ESWL were 49 (70%) males and 21 (30%) females , 29 (41.4%) right-sided stones and 41 (58.5%) left sided stones , with mean age of 34.1 years and body mass index of 29.0 kg/m. The mean operative time in our study was 2.36 (± 0.8) hours.
The main presenting symptom was loin pain in 70 patients (100%) in the form of; right loin pain 29 patients (41.4%),left loin pain 41patients (58.5%),. The loin pain was associated with other symptoms. These symptoms were in the form of haematuria 19 patients (27.1%), irritative symptoms 51 patients (72.8%), and fever 14 patients (20%).
Urine culture & sensitivity was done for all patients , 47 patients (67.1%) showed positive growth while 23 patients (32.8%) had negative cultures.
In this study radiological investigations used were abdominal ultrasonography and plain x-ray KUB for all patients. Intravenous pyelography (IVP) was done for 8 patients, computed tomography (CT abdomen pelvis was done for 62 patients. The side, site, size and radiological appearance of stones were recorded.
o Side of the stone:
Stones were 29 (41.4%) right-sided stones and 41 (58.5%) left sided stones
o Site of the stone:
39 patients (55.7%) stones were in renal pelvis, in 17 patients (24.2%) stones were middle calyceal, 10 patients (14.2%) stones were middle calyceal and 4 patients (5.7%) stones were lower calyceal
o Radiological appearance of the stone:
The stones were radiopaque in all patients (100%).
Ureteral catheters were fixed in all patients of PCNL (100%), DJ stents were fixed in 3 patients (10%) of PCNL due to perforation of collecting system and extravasation of contrast. The ureteric stent was usually removed in the 2nd or 3rd day postoperatively. DJ stent was usually removed after 6 weeks.
Access was done through; lower calyx in 24 patients (80%). In 5 patients (16.6%) middle access was used. In only one patient (3.3%) two access tracts were used in the form of middle and lower accesses.
In PCNL group complete stone clearance in 28 patients (93.3%). This was confirmed with routine plain urinary tract (PUT) which was done on the first postoperative day. In 2 patients (6.6%) there were residual stones that were treated by URS, in ESWL group complete stone clearance was recorded in24 patients (60%). This was confirmed with routine plain urinary tract (PUT) which was done on after one week. In 16 patients (40%) there were residual stones that were treated by second session of SWL
Single treatment success rates were significantly better for PCNL at 93.3% vs 60% for SWL, respectively P<0.01.while with two session of SWL treatments success rate improved to 77.5% and if three SWL treatments were administered, success rates improved further to 85.0%,more than two sessions of ESWL show comparable results to PCNL,P=0.66.
Auxiliary treatments, defined by repeating the initial treatment modality or progressing to other modalities, were more common after SWL (42.5%) vs ( 6.6%) in PCNL groups, respectively.
Complications were equivalent across treatment groups, as classified by the Clavien grading system. Complications were classified by Clavien grade, such that Clavien grades I to II complications were considered minor and Clavien grades III to V complications were major. All minor complications in the SWL arm were in patients who returned to either the clinic or emergency department with renal colic secondary to steinstrasse (n=4), postoperative fever (n=4) and postoperative infection (n=3) . In the PCNL group, there were complication that consisted of a minor bleed from the access tract (n=5) that necessitated neither a blood transfusion nor embolization, and minor complications that consisted of postoperative fever (n=17) and postoperative infections (n=8).