Urolithiasis is a condition with a historical footprint spanning millennia, with surgical interventions described as early as the Sushruta Samhita. While the 20th century witnessed a paradigm shift toward minimally invasive procedures like ESWL and PCNL, open surgery retains a specific and critical role in urological practice. It is particularly indicated for complex staghorn calculi, anatomical abnormalities, or in healthcare settings where advanced endourological equipment is unavailable. The pathogenesis of renal stones is multifactorial, involving supersaturation of urine, dietary habits, and environmental factors such as water quality. This study aims to analyze the demographic profile, etiological factors, and surgical outcomes of patients undergoing open nephrolithotomy in a contemporary tertiary care setting.

Study Design and Setting This prospective non-randomized observational study was conducted at the Department of General Surgery, Sheth L.G. Municipal General Hospital, Ahmedabad, over a 12-month period from March 1, 2024, to February 28, 2025. Study Population The cohort consisted of 30 patients diagnosed with renal calculi. ● Inclusion Criteria: Patients aged >10 years with confirmed unilateral or bilateral renal stones. ● Exclusion Criteria: First-trimester pregnancy, severe bleeding diatheses, congenital renal abnormalities, or refusal to consent. Methodology All participants underwent a comprehensive workup including: 1. Clinical Assessment: Detailed history of dietary habits and water sources. 1. Laboratory Evaluation: Urinalysis, renal function tests, and metabolic profiling (Serum Calcium, PTH, Uric Acid). 1. Imaging: Ultrasonography (USG) and X-ray KUB were standard. Plain CT KUB or CT IVP were utilized for inconclusive cases or surgical planning. Surgical Protocol Standard open surgical approaches were utilized, primarily the flank incision involving the 12th rib. Procedures included Pyelolithotomy, Nephrolithotomy, and Nephrectomy based on stone burden and renal function.

3.1 Demographics and Etiology The study population (N=30) exhibited a peak prevalence in the 30–40 year age group, consistent with periods of high metabolic activity. Males were more frequently affected than females (60% vs. 40%). Figure 1: Age Distribution of Patients Age Group (Years) Number of Patients Percentage 10–20 0 0% 20–30 6 20% 30–40 9 30% 40–50 6 20% 50–60 5 16.7% 60–70 4 13.3% Diet and Water Consumption: The majority of patients (66.7%) followed a vegetarian diet. Notably, 83.3% of patients consumed water from sources with high mineral content (Borewell: 43.3%, Surface water: 40%), suggesting a strong environmental correlation with stone formation. 3.2 Clinical Presentation Renal pain was the universal presenting symptom. ● Renal Pain: 100% of patients. ● Nausea/Vomiting: 60%. ● Burning Micturition: 43.3%. ● Hematuria: Gross hematuria was observed in 10% of cases, while microscopic hematuria was prevalent (mean RBC 6/hpf). 3.3 Surgical Management The surgical approach was tailored to the stone burden. Pyelolithotomy with DJ stenting was the predominant procedure. Figure 2: Types of Surgical Procedures Performed Procedure n (N=30) Percentage Indication Pyelolithotomy + DJ Stenting 25 83.3% Pelvic/Staghorn calculi Total Nephrectomy 4 13.3% Non-functioning kidney Nephrolithotomy 1 3.3% Intrarenal/Calyceal stones 3.4 Complications ● Intraoperative: 83.3% of surgeries had nil complications. Minor bleeding occurred in 3 cases (10%) and peritoneal rent in 2 cases (6.7%), all managed intraoperatively. ● Postoperative: The majority (73.3%) had an uneventful recovery. Minor complications included transient pain (10%) and fever (6.7%).

Demographic Patterns The age distribution in this study mirrors global trends described in Campbell-Walsh-Wein Urology, where the third to fifth decades of life represent the peak risk for nephrolithiasis. The absence of pediatric patients (10–20 years) likely reflects a preference for minimally invasive therapies like ESWL in younger demographics. Environmental Influence A significant finding is the high reliance on borewell and surface water among patients. These water sources typically contain high Total Dissolved Solids (TDS), including calcium and magnesium. This aligns with the "supersaturation theory" of stone formation, where chronic intake of mineral-rich water exacerbates crystalluria. The Role of Open Surgery Despite the advent of PCNL, this study validates the continued relevance of open pyelolithotomy. With a success rate of 83.3% for pyelolithotomy with stenting, the procedure ensures complete clearance of large stone burdens, such as staghorn calculi, which might otherwise require multiple sessions of PCNL or ESWL. The use of the Gil-Vernet extended pyelolithotomy technique facilitates the removal of complex stones while preserving renal parenchyma. Safety Profile The low complication rate (73.3% complication-free postoperative course) underscores the safety of open surgery when performed with meticulous technique. The average hospital stay (discharge by POD 6–8) remains acceptable, particularly given the cost-effectiveness compared to multiple endourological procedures.

This prospective study concludes that open surgical management for renal stones is a definitive, safe, and effective treatment modality. It is particularly valuable for: 1. Complex Stone Burdens: Large staghorn or pelvic calculi. 2. Resource Optimization: Providing high clearance rates in a single setting, making it cost-effective for developing regions. 1. Renal Salvage: Effective management of anatomical variations and preservation of function in salvageable kidneys. While endourology remains the first line for many cases, open surgery retains an indispensable position in the urologist's armamentarium.

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