What is the management and treatment of staghorn calculi?

Management and Treatment of Staghorn Calculi

Percutaneous nephrolithotomy (PCNL) should be the first-line treatment for most patients with staghorn calculi due to superior stone-free rates and acceptably low morbidity compared to other treatment modalities. 1

Initial Evaluation

• Stone characteristics assessment:

  • Determine if partial or complete staghorn (affects treatment outcomes)
  • Measure stone burden (size and volume)
  • Evaluate stone composition if possible

• Renal function assessment:

  • Evaluate kidney function of affected unit
  • Check for presence of obstruction or infection
  • Consider nephrectomy if kidney has negligible function 1

Treatment Algorithm

First-line Treatment:

• PCNL monotherapy for most staghorn calculi 1, 2
  • Offers superior stone-free rates (>3× higher than SWL monotherapy)
  • Associated with acceptable morbidity
  • Recent advances in instrumentation and techniques have improved outcomes
  • Flexible nephroscopy during initial PCNL helps remove stones remote from access tract

Alternative Approaches Based on Specific Scenarios:

1. For small volume staghorn calculi (<500 mm²) with normal collecting system:

   • SWL monotherapy may be considered
   • Must establish adequate drainage via ureteral stent or nephrostomy tube before treatment 1

2. For extremely large and complex staghorn calculi:

   • Open surgery (anatrophic nephrolithotomy) when stone removal unlikely with reasonable number of less invasive procedures
   • Consider in patients with unfavorable collecting system anatomy or extreme obesity that precludes fluoroscopy 1, 3
   • Laparoscopic anatrophic nephrolithotomy is emerging as a minimally invasive alternative 3

3. For staghorn calculi in kidney with negligible function:

   • Nephrectomy should be considered
   • Especially when kidney is source of persistent morbidity (recurrent UTIs, pyelonephritis, sepsis)
   • Laparoscopic nephrectomy is an option unless there's intense perirenal inflammation 1

4. For cystine staghorn calculi:

   • SWL monotherapy should NOT be used
   • PCNL is preferred approach 1, 4

5. For children with staghorn calculi:

   • Either SWL monotherapy or PCNL-based therapy may be considered
   • Stone-free rates with SWL in children approach 80% (higher than in adults)
   • Consider bioeffects of SWL on developing kidney 1

Combination Therapy Approach:

If combination therapy is undertaken:

1. Begin with percutaneous debulking
2. Follow with SWL for residual stones
3. Complete with percutaneous nephroscopy ("sandwich therapy")
4. Critical point: Percutaneous nephroscopy should be the LAST procedure to ensure stone-free status 1

Medical Management

• All staghorn stone formers should undergo metabolic evaluation 5
• Directed medical management based on stone composition:
  • Infection stones: appropriate antibiotics for urease-producing bacteria
  • Metabolic stones: targeted therapy based on specific abnormalities
  • Cystine/uric acid stones: consider alkalization therapy 5, 4

Complications Management

Common complications of PCNL for staghorn calculi include:

• Bleeding: may require transfusion (<20% of cases)
• Infection/sepsis: requires prompt antibiotic treatment
• Collecting system injury: may require longer nephrostomy drainage
• Persistent nephrocutaneous urine leakage
• Infundibular stenosis 2

Follow-up

• Regular imaging to assess stone-free status
• Metabolic evaluation and medical management to prevent recurrence
• Long-term monitoring for renal function preservation 6

Important Caveats

• Stone-free rates are substantially higher for partial staghorn stones compared to complete staghorn stones regardless of treatment modality 1
• Mortality risk is rare but present with all treatment modalities, particularly in patients with medical comorbidities or those who develop sepsis 1
• Transfusion rates are similar for PCNL and combination therapy (<20%) but higher for open surgery (20-25%) 1
• Despite advances in minimally invasive techniques, achieving stone-free status remains challenging with staghorn calculi, and multiple procedures may be required 2, 6