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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 1  |  Page : 47-53
Percutaneous Nephrolithotomy for Complete Staghorn Renal Stones


1 Department of Urology, Armed Forces Hospital, Dhahran, Saudi Arabia
2 Deparment of Urology, Benin University, Benin, Nigeria
3 Department of Urology, Riyadh Medical Complex, Riyadh, Saudi Arabia

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   Abstract 

To evaluate the effectiveness of percutaneous nephrolithotomy (PNL) in the management of patients with complete staghorn stones, a retrospective study was conducted on 110 patients at the Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia. The study was performed between September 1990 and September 1999. 144 procedures were performed on 119 renal units including 22 units (18.5%) that needed more than one sitting. Of them, 85 units (71.4%) were completely cleared after PNL and 11 units (9.2%) were left with insignificant residual fragments (< 4 mm). This gives a success rate of 78.6% for PNL as a monotherapy. Twelve patients with significant residual fragments required Extracorporal Shock Wave Lithotripsy (SWL) in addition to PNL. The overall success rate after PNL and SWL in 108 renal units was 89.4%. We found PNL useful in the management of patients with complete staghorn stones, either as monotherapy or in combination with SWL. It was associated with little morbidity and the procedure can be instituted even in centers with limited facilities.

Keywords: Staghorn calculi, Percutaneous nephrolithotomy,.Extracorporal Shock Wave Lithotripsy, Riyadh

How to cite this article:
Koko AH, Onuora VC, Al-Turkey MA, Al Moss M, Meabed AH, Al Jawani NA. Percutaneous Nephrolithotomy for Complete Staghorn Renal Stones. Saudi J Kidney Dis Transpl 2007;18:47-53

How to cite this URL:
Koko AH, Onuora VC, Al-Turkey MA, Al Moss M, Meabed AH, Al Jawani NA. Percutaneous Nephrolithotomy for Complete Staghorn Renal Stones. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Nov 22];18:47-53. Available from: http://www.sjkdt.org/text.asp?2007/18/1/47/31845

   Introduction Top


The management of complete staghorn stones remains one of the difficult tasks for the urologist. Open surgical procedures such as anatrophic nephrolithotomy [1] remained unchallenged untill the introduction of percu­taneous nephrolithotomy (PNL) as an acceptable method of treating renal stones. [2],[3] Subsequently, with the introduction of Extracorporeal Shock Wave Lithotripsy (SWL), it became popular to combine PNL and SWL in treating such difficult cases. [4] We present our experience in the management of 110 patients with complete staghorn stones.


   Patients and Methods Top


Between September 1990 and September 1999, 167 patients with staghorn calculi were subjected to PNL in the Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia. Of them, 110 patients were found to have complete staghorn stones and their records were reviewed. Their ages ranged between 15 and 65 years with a mean age of 38.2 years. There were 92 males and 18 females (ratio 5:1). The stones were found on the left side in 51 patients, on the right side in 46 patients and were bilateral in 13 patients. 72.7% of the stones were radio-opaque and 27.3% were radiolucent. Mid-stream urine cultures were positive in 19 patients (17.3%); all of whom were treated with appropriate antibiotics before surgery. All patients received prophylactic antibiotics prior to surgery and the antibiotics were continued after surgery until the nephrostomy tube was removed. All procedures were performed by a urologist in the operating theater.

A preliminary cystoscopy and retrograde catheterization of the affected side was done initially. This was followed by the puncture and estabishment of the percutaneous access under combined ultrasound and fluroscopy guidance or fluroscopy alone, after opaci­fication of the pelvicalyceal system. Ultra­sound and electrohydraulic lithotripsy were used in the early stages of the study for contact lithotrips, but were subsequently replaced with the pneumatic lithotriptor (Swiss lithoclast). DJ stents were inserted whenever significant fragments (> 4 mm) were left behind, which in turn were treated with Extracorporal Shock Wave Lithotripsy (SWL) utilizing a Siemens Lithostar plus lithotriptor. Monotherapy with PNL failed in some patients, either due to failed access or failure of stone disintegration. Prior to the installation of the lithotriptor in our institution, these patients were managed with open surgery under the same anesthesia.

Plain radiograms, antegrade urograms and ultrasound were used to assess the residual fragments during the hospital stay and in the stone clinic at follow-up. All patients were followed until they were free of stones or left with insignificant residual fragments.


   Results Top


144 procedures were performed on 119 renal units including 22 units (18.5%) that needed more than one sitting. [1],[2],[3],[4] Complete clearance of stones was achieved in 85 renal units (71.4%) and 11 units (9.2%) were left with insignificant fragments (< 4 mm). This gives an overall success rate of 80.6% for PNL as monotherapy for complete staghorn stones. 12 patients with significant residual stones were further managed successfully with SWL. Overall, the success rate of PNL and SWL in 108 renal units was 90.8%. PNL failed in 11 cases (9.2%) and they were managed with open surgery [Figure - 1]. The average hospital stay was 9.7 days, and the mean time to a stone-free state or stone-free with insignifcant residual fragments was 23 days (7-157 days).

Complications were encountered in nine cases (8.2%). Three cases developed sepsis and were treated conservatively with appropriate antibiotics. There were two cases of hemorrhage. One patient experienced uncontrollable primary bleeding and required nephrectomy; while another patient with secondary hemorrhage was managed conservatively. One patient had right colonic injury and failed access and was managed by open nephrolithotomy and repair of the right colon. Three cases developed steinstrasse and were managed by ureteroscopy.

Stone analysis revealed that 30 patients (27.3%) had pure uric acid stones, 38 (34.5%) had calcium oxalate and uric acid calculi, nine (8.2%) had calcium oxalate and phosphate stones, 15 (13.6%) had calcium oxalate stones, and 18 patients (16.4%) had magnesium ammonium phosphates (struvite) stones [Figure - 2].


   Discussion Top


The issue of how to treat patients with staghorn stones still remains unanswered. Open surgical management, PNL mono­therapy, combined PNL and SWL, SWL monotherapy and watchful waiting are still in practice depending on the urologist's preference and experience, presence of faci­lities and patient preference and his/her general health. Our policy for patients with staghorn stones who are fit for active stone management is to initiate treatment with PNL unless the patient is unwilling. Open surgical removal of such stones is a major surgical procedure and complete clearance is possible in only 65-76% of cases. [ 5],[6] SWL, on the other hand, has been shown to clear only about 50% of these cases [7] PNL is much less invasive than open surgery and the clearance rate is in the range of 71 - 78%. [8],[9] Combination of debulking PNL followed by SWL is the most frequently used and the best modality and was reported to be associated with stone-free rates of 78.5 - 89%.[9],[10],[11],[12] We believe that if the surgeon intends to clear the kidney and is familiar with the procedures, the results will be better. Percutaneous-based management is more cost-effective than SWL monotherapy in the management of staghorn stones as pointed out by Parmjit and Chandhoke. [11]

Our results of a 71.4% stone-free rate and 78.6% with clinicaly insignificant fragments following PNL monotherapy and 89.4% for the combined PNL and SWL therapy compares favorably with the results of others [10],[12] [Figure - 3][Figure - 4]. Although radiologists and urologists have an advantage by working together in managing such cases, this ideal situation is not always possible in a busy general hospital setting. We found that a one-stage procedure by the urologist is convenient for both the urologist and the patient since the puncture is performed under anesthesia and a nephrostomy set is saved. Again, we believe that insertion of a nephrostomy should be mastered by a urologist. It might be a good policy for urologists interested in percutaneous renal surgery to undergo some training in interventional radiology. Currently, we use the Swiss Lithoclast and have found it very efficient relative to the ultrasonic and electrohydraulic contact lithotripsy. [13] Evacuation of the small fragments after removal of the larger ones by forceps is problematic. We irrigated the kidney using a size-12 Fr Nelaton catheter through the Amplantz sheath and found this to be extremely helpful. In dilated systems, the use of an Ellic evacuator and nephroscope sheath after manual occlusion of the space between the nephroscope sheath and the Amplantz sheath is also effective in removing the tiny fragments.

The hospital stay in our study was 9.7 days and is within the range reported by others.Our failure rate was 9.2%, which is high compared with 1.7 to 8% that has been reported by other centers. It was mainly due to access failure or stone disintegration problems before the use of the Swiss Lithoclast at our center. Another factor was that many urologists with varying levels of experience were involved in the mangement of our patients. Our complication rate of 8.2% was in the range of 3.2 to 13.2% [14], [15], which has been reported in the literature [Figure - 5].

Urinary infection is a common finding in patients with staghorn stones. 17.3% of our patients were found to have a positive mid­stream urine culture, all of whom were treated with appropriate antibiotics. Prophylactic antibiotics were used routinely in all cases to cover the procedure and the early post-operative period. We had to perform a nephrectomy in one patient who had uncontrollable primary hemorrhage. Embolization could be attempted in such cases, but we did not have the technology. Colonic injury can occur in PNL, and when recognized can be managed conservatively by stenting the ipsilateral kidney, administering broad-spectrum antibiotics and decompressing the gastrointestinal tract [16] or by colonic repair, as was the case in one of our patients. We encountered three cases of significant steinstrasse after PNL and SWL. These were successfully managed by ureteroscopy. We routinely stent patients with large residual fragments and have found this useful in the prevention of morbidity caused by ureteric obstruction.

The high prevalance of uric acid stones in our series (27.3%) as compared to the 1.2 - 9% prevalence reported elsewhere [17] may be due to the hot climate in this area and the high ingestion of purines in our population.

In conclusion, our results show that the use of PNL for the management of staghorn stones is associated with good results, even in a general hospital setting with relatively limited facilities.

 
   References Top

1.Smith MJ, Boyce WH. Anatrophic nephrotomy and plastic calyrhaphy. J Urol 1968; 99, 521 - 7.  Back to cited text no. 1    
2.Alken P, Hutschenreiter G, Gunther R, Marberger M. Percutaneous stone manipulation. J Urol 1981; 125:463- 6.  Back to cited text no. 2  [PUBMED]  
3.Segura JW, Patterson DE, LeRoy A, May GR, Smith LH. Percutaneous lithotripsy. J Urol 1983; 130:1051- 4.  Back to cited text no. 3    
4.Segura JW, Patterson DE, LeRoy A. Combined percutaneous ultrasonic lithotripsy and extracorporeal shock wave lithotripsy for struvite staghorn calculi. World J Urol 1987; 5: 245 - 7.  Back to cited text no. 4    
5.Wickham JE, Coe N, and Ward JP. One hundred cases of nephrolithotomy under hypothermia. J Urol 1974;112: 702 - 5.  Back to cited text no. 5    
6.Giulani L, Puppo P, Bottino P, et al. 1988 staghorn stones: surgery or PCN and ESWL In Giuliani L, Pappo PP. (eds) controversies in the management of urinary stones. 156­162. Basel Karger.  Back to cited text no. 6    
7.Gleeson MJ, Griffith DP. Extracorporeal shock wave lithotripsy monotherapy for large renal calculi. Br J Urol 1989;64:329 -32.  Back to cited text no. 7  [PUBMED]  
8.Chibber PJ. Percutaneous nephroli­thotomy for large and staghorn calculi. J Endourol 1993; 7 (4): 293 - 5.  Back to cited text no. 8    
9.Rodrigues Netto N Jr, Claro J de A, Ferreira U. Is perctaneous monotherapy for staghorn calculus still indicated in the era of extracorporeal shock wave lithotripsy? J Endourol 1994 ;8(3): 195-7.  Back to cited text no. 9    
10.Schulze H, Hertle L, Graff J, et al. Combined treatment of branched calculi by perctaneous nephro-litho­tomy and extracorporeal shock wave lithotripsy. J Urol 1986; 135:1138-41.  Back to cited text no. 10  [PUBMED]  
11.Chandhoke PS. Cost-effectiveness of different treatment options for staghorn calculi. J Urol 1996;156 (5):1567 -71.  Back to cited text no. 11    
12.Segura JW, Preminger GM, Assimos DG et al. Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. J Urol 1994;151: 1648 - 51.  Back to cited text no. 12    
13.Denstedt JD. Use of Swiss Lithoclast for percutaneous nephrolithotripsy. J Endourol 1993; 7 (6): 477 - 80.  Back to cited text no. 13    
14.Segura JW, Patterson DE, LeRoy A, et al. Percutaneous removal of kidney stones: review of 1000 cases. J Urol 1985; 134:1077 - 81.  Back to cited text no. 14    
15.Jones DJ, Russell GL, Kellett MJ, et al. The changing practice of percutaneous stone surgery. Review of 1000 cases. 1981 - 1988. Br J Urol1990; 66:1 - 5.  Back to cited text no. 15    
16.el-Kenawy MR, el-Kappany HA, el­Diasty TA, Ghoneim MA. Percutaneous nephrolithotripsy for renal stones in over 1000 patients. Br J Urol1992;69:470 - 5.  Back to cited text no. 16  [PUBMED]  
17.Sharma RN, Shah I, Gupta S, Sharma P, Beigh AA. Thermogrovimetric ananlysis of urinary stones. Br J Urol1989; 64:564-6.  Back to cited text no. 17  [PUBMED]  

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Correspondence Address:
Abdelmoniem H Koko
Department of Urology, Armed Forces Hospital, Dhahran P.O. Box 70370, Al Khobar 31952
Saudi Arabia
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PMID: 17237891

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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

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    Patients and Methods
    Results
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