What is the treatment for staghorn calculus pyelonephritis?

From the Guidelines

The treatment for staghorn calculus pyelonephritis should prioritize percutaneous nephrolithotomy (PCNL) as the first-line surgical approach, combined with broad-spectrum antibiotics to control the infection, as recommended by the American Urological Association (AUA) guidelines 1.

Initial Management

The initial management of staghorn calculus pyelonephritis involves starting broad-spectrum intravenous antibiotics immediately to control the infection, typically including agents like piperacillin-tazobactam, a carbapenem, or a third-generation cephalosporin plus an aminoglycoside. These antibiotics should be adjusted based on urine culture results and continued for at least 1-2 weeks, followed by oral antibiotics for a total of 4-6 weeks.

Definitive Treatment

For definitive treatment, percutaneous nephrolithotomy (PCNL) is the gold standard surgical approach once the acute infection is controlled, usually performed 2-4 weeks after the infection resolves. In some cases, a temporary nephrostomy tube may be placed for drainage during the acute phase. For complex stones, a staged approach with multiple procedures might be necessary. Extracorporeal shock wave lithotripsy alone is generally insufficient for staghorn calculi.

Post-Treatment Care

Following stone removal, metabolic evaluation and long-term antibiotic prophylaxis may be needed to prevent recurrence, along with increased fluid intake of at least 2-3 liters daily. This comprehensive approach is necessary because staghorn calculi are typically composed of infection-related struvite or calcium phosphate, creating a cycle where bacteria become embedded in the stone, making both the infection and stone difficult to eradicate without addressing both components.

Key Considerations

• PCNL has emerged as the treatment of choice for the management of patients with staghorn calculi based on superior outcomes and acceptably low morbidity 1.
• Combination therapy using both PNL and SWL may be necessary for some patients, but PCNL should be the initial approach, and percutaneous nephroscopy should be the final procedure in combination therapy 1.
• Open surgery should not be used for most patients due to its higher morbidity compared to PNL-based therapy 1.

From the Research

Treatment Options for Staghorn Calculus Pyelonephritis

• The ideal treatment for staghorn calculi is maximal surgical removal 2.
• Percutaneous nephrolithotomy (PCNL) is the gold standard surgical technique for treating staghorn renal stones 3, 4.
• In cases where percutaneous renal access is impossible, anatrophic nephrolithotomy is an alternative surgical approach 3.
• Shockwave lithotripsy and flexible ureteroscopy are useful tools for treating residual fragments that can be left after treatment of complete staghorn renal stone 3.

Preoperative and Postoperative Care

• Preoperative computed tomography scan and careful evaluation of all urine cultures made prior to surgery are essential for a well-planned surgical approach and the right antibiotic choice 3.
• Long-term or short-term antibiotic therapy is recommended to prevent infection and recurrence 3.
• Regular control imaging exams and urine culture should be done to monitor the patient's condition 3.
• Tranexamic acid can be used to avoid bleeding during PCNL 3.

Complications and Management

• Common complications associated with PCNL for staghorn calculi 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.
• Troubleshooting measures and management strategies are necessary to identify and characterize these complications 4.

Metabolic Evaluation and Medical Management

• Metabolic evaluation with directed medical management is recommended for all staghorn stone formers, as the majority of staghorn stones are metabolic in etiology 2.
• Even infection stones are usually associated with metabolic abnormalities, making metabolic evaluation and medical management essential for preventing recurrence 2.