What is the treatment for Urinary Tract Infection (UTI) with staghorn calculus?

From the Guidelines

The treatment for a UTI with staghorn calculus typically involves a combination of antibiotics and surgical intervention, with percutaneous nephrolithotomy (PCNL) being the preferred surgical approach, as it offers superior outcomes and acceptably low morbidity, as evidenced by the American Urological Association (AUA) guidelines 1. The initial management of a UTI with staghorn calculus involves starting broad-spectrum antibiotics, such as fluoroquinolones (ciprofloxacin 500mg twice daily), trimethoprim-sulfamethoxazole (160/800mg twice daily), or third-generation cephalosporins, based on urine culture results and continuing them for 7-14 days to control the active infection. However, antibiotics alone are insufficient because the calculus serves as a reservoir for bacteria.

Key Considerations

• The definitive treatment requires surgical removal of the staghorn calculus, most commonly through PCNL, which involves making a small incision in the back to access the kidney and remove the stone.
• PCNL has emerged as the treatment of choice for the management of patients with staghorn calculi based on superior outcomes and acceptably low morbidity, with recent advances in instrumentation and technique improving stone-free rates, increasing treatment efficiency, and reducing morbidity 1.
• In some cases, extracorporeal shock wave lithotripsy (ESWL) or a combination of approaches may be necessary for complete stone clearance.
• Following stone removal, patients typically require long-term follow-up with periodic imaging and urine cultures to monitor for recurrence, as staghorn calculi have high recurrence rates.
• Preventive measures include increased fluid intake (2-3 liters daily), dietary modifications based on stone composition, and sometimes prophylactic antibiotics or urease inhibitors, particularly for struvite stones caused by urease-producing bacteria like Proteus mirabilis.

Surgical Approach

• PCNL is usually performed with the patient in a prone position and may be divided into two components, access and stone removal, with the urologist or radiologist placing a small coaxial needle into the kidney and then manipulating a flexible guidewire through the needle sheath under fluoroscopic or ultrasound guidance into the kidney and down the ureter 1.
• The trend toward PCNL monotherapy has been driven in part by the expanded role of flexible nephroscopy, better grasping devices and baskets, the holmium laser for intracorporeal lithotripsy, and also the use of multiple percutaneous access tracts.
• At the time of initial PCNL, flexible nephroscopy is used after debulking the stone with rigid nephroscopy to remove stones remote from the percutaneous access tract, and second-look flexible nephroscopy via the preexisting nephrostomy tract is used to retrieve residual stones if necessary 1.

From the Research

Treatment Options for Urinary Tract Infection (UTI) with Staghorn Calculus

• The treatment of staghorn calculi with UTI can be challenging and requires careful evaluation and management 2, 3, 4.
• Extracorporeal shock wave lithotripsy (ESWL) is a commonly used treatment for staghorn calculi, and it has been shown to be effective in disintegrating the stones 5.
• However, ESWL may not be sufficient for complete removal of the stones, and additional treatments such as percutaneous nephrolithotomy (PCNL) or flexible ureteroscopy may be necessary 3.
• PCNL is considered the gold standard surgical technique for treating staghorn renal stones, and it can be performed in supine or prone position 3.
• Retroperitoneal laparoscopic pyelolithotomy (RLP) with prolonged renal posterior lower segment incision is also an effective and safe procedure for patients with staghorn renal stones and concurrent UTI 4.
• The treatment goals for staghorn calculi with UTI include stone-free status, infection eradication, and recurrence prevention, and long-term or short-term antibiotic therapy is often recommended 3, 6.

Surgical Approaches

• PCNL is a commonly used surgical approach for treating staghorn renal stones, and it involves making a small incision in the back to access the kidney and remove the stone 3.
• RLP with prolonged renal posterior lower segment incision is a minimally invasive surgical approach that involves making a small incision in the back to access the kidney and remove the stone 4.
• Anatrophic nephrolithotomy is an alternative surgical approach that involves making an incision in the kidney to remove the stone, and it is typically used when percutaneous renal access is not possible 3.

Antibiotic Therapy

• Antibiotic therapy is an important aspect of treating UTI with staghorn calculi, and broad-spectrum antibiotics such as ceftazidime may be used as perioperative prophylaxis 6.
• Long-term or short-term antibiotic therapy may be recommended to prevent recurrence of UTI and to eradicate the infection 3, 6.