From the Guidelines
A large renal calculus in the renal pelvis with pelvocaliectasis is a significant stone blocking the kidney's collecting system, causing dilation of the renal pelvis and calyces due to urine backup, and requires prompt treatment, typically through surgical intervention, with percutaneous nephrolithotomy (PCNL) being the preferred approach for most patients, as recommended by the American Urological Association (AUA) guidelines 1.
Diagnosis and Treatment
The condition is characterized by a large stone in the renal pelvis, which can cause severe pain, nausea, and vomiting, and if left untreated, can lead to serious complications such as kidney damage, infection, and sepsis.
- The AUA guidelines recommend PCNL as the first-line treatment for most patients with staghorn calculi, due to its higher stone-free rates and lower morbidity compared to open surgery and shock wave lithotripsy (SWL) monotherapy 1.
- PCNL involves making a small incision in the back to directly access and remove the stone, and has been shown to be effective in achieving stone-free status in patients with large and complex stones 1.
- SWL monotherapy may be considered for patients with small volume staghorn calculi and normal collecting-system anatomy, but is not recommended for most patients due to its lower stone-free rates and higher risk of complications 1.
- Open surgery may be considered for patients with extremely large stones, complex collecting system issues, or excessive morbid obesity, but is rarely needed and is associated with higher morbidity and longer recovery times 1.
Pain Management and Follow-up
- Pain management typically includes NSAIDs like ketorolac (10-30 mg IV or 10 mg orally every 6 hours) or opioids if needed.
- Patients should increase fluid intake to 2-3 liters daily to help flush out stone fragments.
- Temporary drainage with a nephrostomy tube or ureteral stent may be needed if infection is present or kidney function is compromised.
- After treatment, stone analysis is important to determine composition, and preventive measures like dietary modifications and medications may be recommended based on stone type to prevent recurrence 1.
From the Research
Definition and Implications
- A large renal calculus in the renal pelvis refers to a kidney stone that has formed in the pelvis of the kidney, which is the area that collects urine and passes it to the ureter 2.
- Pelvocaliectasis is a condition where the renal pelvis and calyces become dilated due to obstruction, in this case, caused by the large renal calculus 3.
- This obstruction can lead to acute renal failure, recurrent urinary tract infections, and lower abdominal pain [(3,4)].
Treatment Options
- Percutaneous nephrostolithotorny (PCNL) is the standard treatment for large staghorn renal calculi 2.
- However, a staged ureteroscopic approach can be effective in treating stones as large as 5 cm 2.
- Extracorporeal shockwave lithotripsy (ESWL) is considered a first-line treatment for renal calculi, except for stones larger than 30 mm in diameter 5.
- Surgical intervention, such as cystolithotomy or endoscopic cystolithotripsy, can achieve satisfactory results for large bladder stones [(3,4)].
Considerations and Complications
- Close follow-up is mandatory due to the high recurrence rate of urolithiasis in patients with voiding problems and recurrent urinary infections [(3,4)].
- Bladder outlet obstruction should be treated simultaneously with the removal of the stone [(3,4)].
- In rare cases, a giant renal calculus can be associated with metastatic carcinoma 6.