The surgical management of urinary-stone disease has undergone dramatic changes and seen the implementation of technological innovations that are unsurpassed in the field of urologic surgery over the past 20 years. Before these advancements of the past two decades, open surgery was the only surgical option for urolithiasis. The introduction and development of percutaneous renal surgery, the significant achievement of extracorporeal shock-wave lithotripsy (ESWL) (Dornier Medical Systems, Marietta, Georgia), the refinement of ureteroscopy, and technical advancements in the available modalities for intracorporeal lithotripsy have led to a revolution in the manner in which urinary-stone disease is managed surgically. The indications for open stone surgery have been narrowed significantly, and for the most part open surgery has become a second- or third-line treatment option.

The surgical removal of renal stones was documented in the ancient Greek and Roman civilizations but is more detailed in the literature dating back to the 1500s and 1600s. During this time period and for years thereafter, stone operations were performed only in the setting of infected, obstructed kidneys. Ingalls is credited with the first planned nephrolithotomy in the United States in 1872, and Morris is credited with performing the first nephrolithotomy in the setting of an uninfected kidney in England in 1880.<sup>33 Spirnak J.P., Resnick M.I. Stone treatment Adult and Pediatric Urology. St. Louis: Mosby (1996).  695-747

Haga clic aquí para ir a la sección de Referencias</sup> Further advancements were made this century, with respect to surgical approaches to the kidney and collecting system, as surgeons arrived at a better understanding of the anatomy of the intrarenal vasculature.

The development of ESWL has been, since its introduction by Chaussy et al in 1980,<sup>9 Chaussy C., Brendel W., Schmiedt E. Extracorporally induced destruction of kidney stones by shock waves Lancet 1980 ;  ii : 1265-1268  [cross-ref]

Haga clic aquí para ir a la sección de Referencias</sup> probably the most significant factor responsible for the precipitous decline in the use of open surgery for stone treatment. No other single achievement has revolutionized the discipline of stone treatment. In 1989, Chaussy and Fuchs<sup>8 Chaussy C.G., Fuchs G.J. Current state and future developments of noninvasive treatment of human urinary stones with extracorporeal shock wave lithotripsy J Urol 1989 ;  141 : 782-789

Haga clic aquí para ir a la sección de Referencias</sup> estimated that 70% of urinary stone patients could be treated with ESWL monotherapy, with an additional 25% able to be treated by ESWL in combination with endourologic modalities. Most of the remaining credit for the vast reduction in open stone operations during this time period can be attributed to the development of percutaneous nephrolithotomy, first introduced in 1976 by Fernstrom and Johannson.<sup>11 Fernstrom I., Johannson B. Percutaneous pyelolithotomy: A new extraction technique Scand J Urol Nephrol 1976 ;  10 : 257-259

Haga clic aquí para ir a la sección de Referencias</sup> Segura<sup>30 Segura J.W. The role of percutaneous surgery in renal and ureteral stone removal J Urol 1989 ;  141 : 780-781

Haga clic aquí para ir a la sección de Referencias</sup> reported that percutaneous lithotripsy was the preferred treatment modality in 15% to 20% of stone patients. The development of smaller-caliber semirigid ureteroscopes and flexible ureteroscopes, along with the parallel advances in intracorporeal lithotripsy devices, has accounted for the infrequent performance of ureterolithotomy in contemporary stone management.

With all of these technologic advancements and the resultant change in philosophy in the surgical management of urinary stone disease, one is left to wonder what exactly is the role of open stone surgery in contemporary stone management. As the newer, lesser invasive modalities have taken over stone treatment, urologists, especially recently trained practitioners and those who will enter the field in the future, are and inevitably will be less thoroughly trained in the techniques of open stone procedures. As the use of open stone surgery has diminished with time, it has become increasingly more difficult, in this era of minimally invasive surgery, to properly define the role of open surgery and the acceptable indications to resort to open procedures in the management of renal and ureteral calculi. In this article, the authors attempt to better define the acceptable indications for open stone surgery, to review the commonly accepted advantages of open stone procedures, and to establish the expected results and outcomes following open surgery for stone disease.