Staghorn calculi in solitary kidneys

Treatment of complete staghorn stones: a prospective randomized comparison of open surgery versus percutaneous nephrolithotomy

PURPOSE

We studied the role of open surgery versus percutaneous nephrolithotomy (PCNL) in the treatment of complete staghorn stones in a prospective randomized manner.

MATERIALS AND METHODS

A total of 79 patients with 88 complete staghorn stones, defined as filling the entire collecting system or at least 80% of it, were prospectively randomized for PCNL (43) or open surgery (45). Intraoperative and postoperative morbidity, operative time, hospital stay, and stone clearance at discharge home and followup were compared for both methods. Patients with significant residuals in both groups were subjected to extracorporeal shock wave lithotripsy (Dornier Medical Systems, Inc., Marietta, Georgia) on an outpatient basis. Followup was completed for all cases with a mean duration +/- SD of 4.9 +/- 2.5 months (range 3 to 14). Renal function was evaluated by Tc-mercaptoacetyltriglycine renogram before and after treatment in both groups.

RESULTS

Intraoperative complications in terms of bleeding requiring blood transfusion, and pleural, vascular or ureteral injuries were recorded in 7 patients (16.3%) in the PCNL and 17 (37.8%) in the open surgery groups, a difference of significant value (p <0.05). Major postoperative complications including massive hematuria requiring blood transfusion, septicemia, urinary leakage and wound infection were observed in 8 patients (18.6%) in the PCNL group and in 14 (31.1%) in the open surgery group, a difference of no significant value. PCNL was associated with shorter operative time (127 +/- 30 vs 204 +/- 31 minutes, p <0.001), shorter hospital stay (6.4 +/- 4.2 vs 10 +/- 4.2 days, p <0.001) and earlier return to work (2.5 +/- 0.8 vs 4.1 +/- 1 weeks, p <0.001). On the other hand both treatment groups were comparable in regard to stone-free rates at discharge home (49% vs 66%) and at followup (74% vs 82%). At followup renal function improved or remained stable in 91% and 86.7% in the PCNL and open surgery groups, respectively.

CONCLUSIONS

PCNL is a valuable treatment option for complete staghorn stones with a stone-free rate approaching that of open surgery. Moreover, it has the advantages of lower morbidity, shorter operative time, shorter hospital stay and earlier return to work.

Modified anatrophic nephrolithotomy for management of staghorn calculi: is renal function preserved?

PURPOSE

We report the results of modified anatrophic nephrolithotomy in select patients with complex staghorn calculi.

MATERIALS AND METHODS

From 1987 to 1997 modified anatrophic nephrolithotomy, including 1 bilateral procedure, was performed in 15 patients at San Francisco General Hospital. Preoperative imaging included excretory urography, sonography and computerized tomography. Preoperative and postoperative quantitative renal function was assessed with 99mtechnetium dimercapto-succinic acid renal scintigraphy and serum creatinine measurements.

RESULTS

Mean patient age was 42 years and 11 of the 15 patients were male. Bilateral nephrolithotomy was performed in 1 patient on separate occasions. Average surgical time was 3.7 hours with blood loss of 325 ml. Length of hospital stay averaged 4 days. Residual stones were present after 3 procedures, and 1 of these patients required a secondary procedure. There were no other short-term complications. Renal function was not significantly altered.

CONCLUSIONS

Modified anatrophic nephrolithotomy for staghorn renal stones rendered most patients stone-free with concomitant preservation of renal function. Because of its safety, efficacy and simplicity we believe that continued use of this procedure is warranted in select patients with complex renal stone disease.

Staghorn calculi

Struvite staghorn calculi are infected stones that represent a real threat to the kidney and to the patient and are an indication for active treatment in most individuals. SWL, PL, combined PL and SWI, and open surgery are all viable treatment options for these patients. Most patients should be treated with combined therapy, reserving SWL for small-volume stones and open surgery for difficult situations that do not lend themselves to combined treatment.

Combination therapy for staghorn calculi in solitary kidneys: functional results with long-term followup

A total of 10 patients with staghorn calculi in a solitary kidney was managed with endourological sandwich therapy consisting of primary percutaneous debulking followed by extracorporeal shock wave lithotripsy (ESWL*) of residual inaccessible stones. Secondary percutaneous procedures, ESWL and chemical dissolution were used as necessary in a vigorous attempt to render each patient stone-free. As such, these 10 renal units underwent 21 percutaneous procedures through 13 tracts, 17 ESWL treatments and 3 courses of hemiacidrin. No patient required open operative intervention or dialytic support. With 4 to 57 months (mean 31.6) of followup, renal function for the group as a whole improved as evidenced by a decrease in mean serum creatinine levels from 3.1 mg./dl. before treatment to 2.2 mg./dl. at latest followup. More importantly, renal function has remained stable or improved in 9 of the 10 patients individually. We conclude that an aggressive, combined endourological approach to the management of staghorn calculi provides long-term preservation of function in the affected kidney.

Staghorn calculi--long-term results of management

We have treated 167 patients with staghorn calculi. Conservative therapy was used in 61 patients who have been followed up for 1 to 18 years (average 7.8). Chronic renal failure occurred in 22 of these patients and 7 died from uraemia. The causes of chronic renal failure were bilateral staghorn calculi, staghorn calculi and contralateral urinary calculi, and chronic pyelonephritis of the contralateral kidney. The morbidity and mortality rates following conservative treatment were higher than those following surgical management. The pathological findings in 47 kidneys after nephrectomy showed severe hydronephrosis, renal abscess and xanthogranulomatous pyelonephritis. These results indicated that staghorn calculi destroyed the kidney and early complete removal of these stones is advisable.

Endoscopic removal of staghorn calculi in patient with high urinary diversion

The treatment of recurrent renal calculi in patients after ureteroileal urinary diversion is difficult, especially when urinary stones are formed in the presence of urinary tract infection. In many cases, these patients already have undergone multiple renal operations and more surgery could pose difficult technical problems. We report on a patient with a high urinary diversion in whom bilateral staghorn renal calculi developed, and then were endoscopically removed. The conversion of ureteroileocutaneous diversion to a high pyeloileocutaneous diversion is recommended in selected cases as alternate treatment for patients with recurrent stone formation.

The renal quantitative scintillation camera study for determination of renal function after anatrophic nephrolithotomy

The effect of hypothermic anatrophic nephrolithotomy was evaluated in 13 patients by comparing preoperative and postoperative renal quantitative scintillation camera studies. Total renal function as measured by effective renal plasma flow remained normal postoperatively. However, the operated kidney had a significant loss of function with a proportionate compensatory hypertrophy of the contralateral kidney. This finding explains the normal total renal function, the good end results of the operation being stable renal function if stones do not recur.

Anatrophic nephrolithotomy for removal of staghorn or branched renal calculi

Forty anatrophic nephrolithotomies were performed in 38 patients between November, 1965, and December, 1977, to remove staghorn or branched renal calculi. Thirty-six (95 per cent) of the patients' preoperative urine cultures were infected, and postoperatively 35 of the cultures (88 per cent) were sterile. Magnesium ammonium phosphate calculi were present in the majority of patients (67 per cent). In 6 patients (15 per cent) transient nephrocutaneous fistulas developed. Thirty-six of the 40 renal units (90 per cent) had improved or stable intravenous pyelograms postoperatively. The patients had been followed for an average of twenty months (four to one hundred and twelve months). In 6 patients (15 per cent) recurrent renal calculi developed, and 3 patients (8 per cent) had residual calculi during this period.

Anatrophic nephrolithotomy: experience with a simplication of the Smith and Boyce technique

The anatrophic nephrolithomty procedure described by Smith and Boyce is a safe, effective method to remove dendritic renal calculi. Two major departures from their surgical technique have simplified the procedure in our hands. Our experience with 56 consecutive cases treated with the simplified technique is reported.

Operative versus non-operative management of patients with staghorn calculi and neurogenic bladder

During the last 5 years 22 patients have been treated at our hospital for staghorn calculi and neurogenic bladder. In 17 patients an operation was done soon after discovery of the calculi, while 5 patients were followed non-operatively. The latter 5 patients had a rapid downhill course marked by sepsis and renal function deterioration and an operation was necessary in 4 of the 5 cases. Injudicious non-operative therapy only prolongs the relentless effects of staghorn calculi in patients with spinal cord pathology.

Retrospective study of 95 patients with staghorn calculus disease

Medical records were reviewed for 95 consecutive patients hospitalized with a diagnosis of staghorn calculus disease. Of those patients in whom a conservative, non-operative approach was taken 30 per cent ultimately died of renal failure and/or sepsis. It is concluded that surgical intervention is the treatment of choice for patients with staghorn calculus disease.

Extensive nephrolithotomy in previously operated solitary kidneys

The surgical management of 2 patients with large dendritic calculi in previously operated solitary kidneys is presented. Complete nephrolithotomy was accomplished in situ using the anatropic nephrotomy technique of Smith and Boyce. Postoperatively a circle tube nephrostomy was used. The surgical management as described is recommended as an alternative to extracorporeal nephrolithotomy with autotransplantation or simple nephrectomy and dialysis.