| Abstract|| |
Between 1990 and 1999 a total of 186 patients with staghorn renal stones were treated in our unit. Of them, 76 patients were managed by extra-corporeal shockwave lithotripsy (ESWL) alone using a third generation Siemen's Lithostar Plus lithotriptor. Sixty-one of these patients who completed a follow-up of 41 months formed the subjects of this study. ESWL was done after routine stenting of the affected side in all cases except one. The mean number of ESWL sessions was 5.2, delivering an average 15,940 shocks per patient. The average hospital stay was 21.68 days and the duration of the treatment was 1-41 months (mean 6.75 months). Significant complications occurred in 35 patients (57.4%) eight of whom sustained multiple significant complications. A total of 162 auxiliary procedures were used in conjunction with ESWL and in the management of complications. The stone free rate at three months was 18%, but rose by the end of the treatment period (41 months) to 63.9%. Our study indicates that ESWL monotherapy is associated with high morbidity rates, high rates of unplanned invasive procedures as well as prolonged treatment periods and hospitalization. Thus, ESWL monotherapy is not adequate for the management of staghorn calculi.
Keywords: Extracorporeal shockwave lithotripsy, Staghorn calculi, Monotherapy.
|How to cite this article:|
Koko AK, Onuora VC, Al Turki MA, Mesbed AH, Al Jawini NA. Extracorporeal Shockwave Lithotripsy Monotherapy is not Adequate for Management of Staghorn Renal Calculi. Saudi J Kidney Dis Transpl 2003;14:487-91
|How to cite this URL:|
Koko AK, Onuora VC, Al Turki MA, Mesbed AH, Al Jawini NA. Extracorporeal Shockwave Lithotripsy Monotherapy is not Adequate for Management of Staghorn Renal Calculi. Saudi J Kidney Dis Transpl [serial online] 2003 [cited 2021 Mar 6];14:487-91. Available from: https://www.sjkdt.org/text.asp?2003/14/4/487/32914
| Introduction|| |
Combination percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy (ESWL) is currently the most widely accepted management modality for staghorn renal calculi. ,,, Controversy over the use of ESWL monotherapy in the management of staghorn calculi still persists. There are many reports both for , and against ,, this form of treatment. We reviewed our experience with ESWL monotherapy in the management of staghorn stones to contribute data to this argument.
| Patients and Methods|| |
Between 1990 and 1999, a total of 186 patients with staghorn stones were treated in our unit. Of them, 76 were initially managed by ESWL alone utilizing a third generation Siemen's Lithostar Plus lithotripter. A total of 61 of these patients were regularly followedup and their records were analyzed in this study. Their ages ranged between 14 and 73 years with a mean of 41.2 years. There were 51 males and 10 females with male to female ratio of 5:1. An intravenous urogram (if no contraindication), renal and coagulation profiles and mid-stream urine bacterial cultures were done routinely. Stones were found on the right side in 32 and on the left side in 29 patients. The stones were classified into partial and complete staghorn stones according to Rocco et al.  Partial staghorn (Rocco C4) was defined as a stone filling the renal pelvis and at least one calyceal group, and complete staghorn (Rocco C5) filled the renal pelvis and all calyces. There were 37 partial and 24 complete staghorn calculi. Twenty patients were found to have positive mid-stream urine bacterial cultures; all were treated with appropriate antibiotics before ESWL. All patients except one were subjected to double pigtail stenting of the affected side, and all, in addition, received antibiotics prior to the procedure which was continued in the immediate post treatment period. Intravenous narcotic analgesia was used in these patients and ESWL was performed with the patient in supine position. Follow-up treatment was carried out in the stone clinic until stone clearance and the time taken to achieve this status was noted. Stone clearance was defined as complete absence of any fragments or the presence of fragments less than four mm in size. The treatment outcome variables of the two sub-groups (partial and complete) were compared, and tested for statistical significance using Student's t test. (Independent samples test for unequal variances).
| Results|| |
The average number of shocks administered was 15,940 (3000-50000), delivered in a mean of 5.2 sittings (range 1-15). The mean hospital stay was 21.86 days (range 4-120) and significant complications occurred in 35 patients (57.4%). Nineteen patients developed steinstrasse with ureteric obstruction, four had neglected double J catheters; three patients developed severe deterioration of renal function during the treatment period, three cases developed septicemia, one patient each developed severe hematuria, peri-nephric hematoma, chronic renal failure, hypertension and bladder calculus while tachyarrhythmia occurring during the procedure was noted in one patient [Table - 1].
A total of 162 auxiliary procedures were used; 108 double J stents, 14 ureteroscopies, 18 ureteric catheterizations for ESWL in cases of radiolucent or very faint stones, 10 percutaneous nephrostomies, nine percutaneous nephrolithotomies, one cystolitholapexy, and two open pyelonephrolithotomies [Table - 2]. A total of 29 patients (47.5%) required multiple invasive interventions and multiple sittings of anesthesia due to complications or treatment failure.
Patients with complete staghorn calculi had a significantly longer cumulative hospital stay (31.2 days) compared to those with partial staghorn calculi (15.5 days; P = 0.026). The total number needed of invasive procedures, as well as the number of unplanned auxiliary procedures, was also significantly higher in patients with complete versus partial staghorn calculi, (P = 0.003 and 0.004 respectively). There was no statistically significant difference found between the two groups in terms of complications, number of shocks, number of sittings and duration of the treatment [Table - 3].
Treatment with ESWL failed to fragment the stones in three patients (4.9%), four cases (6.5%) failed to pass the stones, while 13 cases (21.3%) were left with significant retained fragments in the lower calyx.
Stone analysis showed that 25 patients (41%) had calcium oxalate stones, 15 (24.6%) had uric acid stones, 16 (26%) had infection-related stones and in five (8.2%), no results were available in their records.
| Discussion|| |
The success rate of ESWL monotherapy in this series was 18% at three months. It, however, rose gradually to 63.9% by the end of the study at 41 months [Table - 4]. Success rates of 22-76% have been reported by others. ,,,
Successful outcome was defined as complete absence of stones on radiological assessment, or presence of residual fragments of four mm or less in size in the absence of infection or infection-related stones.
The best modality to treat the majority of staghorn calculi is the combination of percutaneous nephrolithotomy (PNL) and ESWL.  It is also the most cost-effective method of treatment as pointed out by Chandokhe.  The use of ESWL monotherapy in the management of these cases has been reported with conflicting results. Reports are still emerging recommending ESWL monotherapy in the management of staghorn stones. , On the other hand, there are several reports against the use of ESWL alone in these cases. ,,
There is no agreement among urologists concerning the definition of the successful outcome following ESWL. Some insist on the complete clearance of all fragments, while others consider that fragments less than five mm in diameter are clinically insignificant. Streem et al  stated that the term clinically insignificant fragments is a misnomer, since a sizeable number of these patients will require intervention or have symptoms within two years.
The overall cumulative hospital stay in our study was high (21.86 days) compared to 8.8-12.6 days in other series. ,, This was greatly due to the high incidence of complications and the need for unplanned invasive procedures.
Significant complications were encountered in 23 patients (37.7%). The commonest complication was ureteral obstruction and this occurred despite routine stenting prior to ESWL. Three patients developed severe deterioration (<20%) of function of the affected kidney. All these patients did not attend followup for long periods of time, and when they showed up, they had poorly functioning renal units and encrusted neglected double J stents. The high incidence of complications and failure of some patients to pass the stones after successful fragmentation, together with cases where there was failure to fragment stones with ESWL, led to an unacceptably high incidence of unplanned secondary invasive procedures in 29 patients (47.5%) compared to 25% and 12% reported from elsewhere. ,
Significant differences were found in the hospital stay and the use of auxiliary procedures between partial and complete staghorn calculi. We think this is most probably related to the bulk of the stones.
| Conclusions|| |
ESWL monotherapy is associated with high morbidity rates, high rates of unplanned invasive procedures as well as prolonged treatment periods and hospitalization. Thus, this form of treatment is not adequate for the management of staghorn calculi.
| References|| |
|1.||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. [PUBMED] |
|2.||Chandhoke PS. Cost effectiveness of different treatment options for staghorn calculi. J Urol 1996;156(5):1567-71. |
|3.||Meretyk S, Gofrit ON, Gafni O, et al. Complete staghorn calculi: random prospective comparison between extracorporeal shock wave lithotripsy mono-therapy and combined with percutaneous nephrostolithotomy. J Urol 1997;157(3): 780-6. |
|4.||Lam HS, Lingeman JE, Barron M, et al. Staghorn calculi: analysis of treatment results between initial percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy monotherapy with reference to surface area. J Urol 1992; 147:1219-25. [PUBMED] |
|5.||Yamaguchi A. Extracorporeal shock wave lithotripsy monotherapy for staghorn calculi. Eur Urol 1994;25(2):110-5. |
|6.||Bruns T, Stein J, Tauber R. Extracorporeal piezoelectric shock wave lithotripsy as mono and multiple therapy of large renal calculi including staghorn stones in unanaesthetized patients under semi-ambulant conditions. Br J Urol 1995; 75:435-40. [PUBMED] |
|7.||Rocco F, Mandressi A, Larcher P. Surgical classification of renal calculi. Eur Urol 1984;10:121-3. [PUBMED] |
|8.||Delaney CP, Creagh TA, Smith JM, Fitzpatrick JM. Do not treat staghorn calculi by extracorporeal shock wave lithotripsy alone. Eur Urol 1993;24:355-7. [PUBMED] |
|9.||Coz F, Orvieto M, Bustos M, et al. Extracorporeal shock wave lithotripsy of 2000 urinary calculi with the Modulith SL-20: success and failure according to size and location of stones. J Endourol 2000; 14:239-46. [PUBMED] |
|10.||Streem SB, Yost A, Mascha E. Clinical implications of clinically insignificant stone fragments after extracorporeal shock wave lithotripsy. J Urol 1996;155:1186-90. [PUBMED] |
|11.||Rassweiler JJ, Renner C, Eisenberger F. The management of complex renal stones. BJU Int 2000;86:919-28. [PUBMED] [FULLTEXT]|
|12.||Ackermann D, Griffith DP, Dunthorn M, et al. Calculation of stone volume and urinary stone staging with computer assistance. J Endourol 1989;3:355. |
Abdelmoniem K Koko
Department of Urology, Riyadh Medical Complex, P.O. Box 92025, Riyadh 11653
[Table - 1], [Table - 2], [Table - 3], [Table - 4]