From the Guidelines
Percutaneous nephrolithotomy (PNL) should be the first treatment utilized for most patients with prominent staghorn calculus in the right renal pelvis, due to its higher stone-free rates and lower morbidity compared to other treatment options. This approach is supported by the American Urological Association (AUA) guideline on management of staghorn calculi, which recommends PNL-based techniques as the preferred treatment for most patients 1. The guideline cites a randomized, prospective trial comparing PNL to shock wave lithotripsy (SWL) for staghorn stone management, which demonstrated stone-free rates with PNL-based therapy to be more than three times greater than with SWL monotherapy 1.
Some key points to consider when treating prominent staghorn calculus in the right renal pelvis include:
- PNL-based therapy has advantages over open surgery, including lower morbidity, reduced convalescence, and shorter hospitalizations 1
- Combination therapy, which includes percutaneous nephroscopy, endoscopic removal, and SWL, may be necessary for some patients, but PNL should be the primary approach 1
- SWL monotherapy should not be used for most patients, as it produces significantly lower stone-free rates than PNL-based approaches 1
- Open surgery should not be used for most patients, as it is associated with longer incisions, hernia, and eventration of flank musculature, and has similar stone-free rates to PNL-based therapy 1
In terms of treatment specifics, PNL involves making a small incision in the back, creating a tract into the kidney, and using specialized instruments to fragment and remove the stone. For large staghorn calculi, multiple PNL sessions may be necessary, sometimes combined with flexible ureteroscopy to reach branches of the stone. Prior to surgery, a course of appropriate antibiotics is essential, as these stones are often infection-related. Complete stone removal is crucial to prevent recurrence and ongoing infection. Following treatment, metabolic evaluation is recommended to identify underlying causes, and long-term preventive measures often include increased fluid intake, dietary modifications, and sometimes medications depending on stone composition. Regular follow-up imaging is important to monitor for recurrence, as staghorn calculi have high recurrence rates if risk factors aren't addressed.
From the Research
Treatment Options for Prominent Staghorn Calculus
- The gold standard treatment for staghorn calculi is percutaneous nephrolithotomy (PCNL) 2, 3, 4, 5, 6
- PCNL can be performed in supine or prone position according to surgeon's experience 2
- In cases of impossible percutaneous renal access, anatrophic nephrolithotomy is an alternative 2
- Shockwave lithotripsy and flexible ureteroscopy are useful tools to treat residual fragments that can be left after treatment of complete staghorn renal stone 2
- Retrograde intrarenal surgery (RIRS) is a safe and effective treatment of staghorn calculi with the presence of urinary tract deformation 3
Preoperative and Postoperative Care
- Preoperative computed tomography scan and careful evaluation of all urine cultures made prior surgery are essential for a well-planning surgical approach and a right antibiotics choice 2
- Long-term or short-term antibiotic therapy is recommended and regular control imaging exams and urine culture should be done 2
- To check postoperative stone-free status, computed tomography is the most accurate imaging exam, but ultrasound combined to KUB is an option 2
- Intra-operative high-resolution fluoroscopy and flexible nephroscopy have been described as an alternative for looking at residual fragments and save radiation exposure 2
Complications and Management
- Common and notable intraoperative complications include bleeding, renal collecting system injury, injury of visceral organs, pulmonary complications, thromboembolic complications, extrarenal stone migration, and misplacement of the nephrostomy tube 4
- Postoperative complications include infection and urosepsis, bleeding, persistent nephrocutaneous urine leakage, infundibular stenosis, and death 4
- Recommendations regarding troubleshooting measures that can be used to identify and characterize these complications, as well as management strategies for complications associated with PCNL for staghorn calculi, have been reported 4