What is the best course of treatment for a patient presenting with gross hematuria and a staghorn calculus?

Management of Gross Hematuria with Staghorn Calculus

Percutaneous nephrolithotomy (PNL) should be the first-line definitive treatment for this patient, as it achieves stone-free rates over three times higher than alternatives while addressing both the calculus and the hematuria source. 1

Immediate Management Priorities

Address the Hematuria

• Gross hematuria in the setting of a staghorn calculus requires urgent assessment for infection, as pyonephrosis can develop and presents with systemic illness 2
• Obtain urine culture before initiating antibiotics if infection is suspected, as staghorn calculi harbor resistant organisms requiring targeted therapy 3
• Establish adequate drainage immediately if there is evidence of obstruction or infection—place either a ureteral stent or percutaneous nephrostomy tube to prevent severe obstruction and sepsis 1

Assess Renal Function

• Determine if the affected kidney has any meaningful function using nuclear medicine scan or contrast-enhanced imaging 4
• If the kidney is non-functioning and the contralateral kidney is normal, proceed directly to nephrectomy rather than stone removal 4, 1
• Nephrectomy is particularly indicated if there is chronic infection, recurrent pyelonephritis, or xanthogranulomatous pyelonephritis 4, 3

Definitive Treatment Algorithm

For Functioning Kidneys: PNL-Based Therapy

Primary approach:

• PNL monotherapy achieves stone-free rates of 74-83% and is the gold standard treatment 4, 1
• Modern technique uses upper pole access to reach most of the collecting system through a single tract 4
• Rigid nephroscopy with ultrasonic/pneumatic lithotripsy removes bulk stone, followed by flexible nephroscopy with holmium laser for residual fragments 4
• Always perform second-look flexible nephroscopy through the established tract if post-procedure imaging shows residual fragments—this is more sensitive than plain radiography and achieves 95% stone-free rates 1

If combination therapy is needed:

• Use PNL first to debulk the large stone volume 4
• Apply SWL only for fragments difficult to access percutaneously 4
• The final procedure must always be percutaneous nephroscopy, never SWL alone—ending with SWL yields only 23% stone-free rates 1

Treatment Modalities to Avoid

Do NOT use SWL monotherapy:

• SWL monotherapy achieves stone-free rates less than one-third of PNL-based approaches 1
• The only randomized trial (Meretyk) demonstrated PNL superiority with >3 times higher stone-free rates 1
• If SWL is attempted despite these limitations, pre-place drainage (stent or nephrostomy) to prevent fragment obstruction and sepsis 1

Avoid open surgery except in rare circumstances:

• Only 2% of patients required open surgery by 2000 due to PNL effectiveness 1
• Reserve anatrophic nephrolithotomy only for extremely large stones with unfavorable anatomy, extreme morbid obesity, or skeletal deformities preventing fluoroscopy 1
• Open surgery carries 20-25% transfusion rates and ~1% mortality 1

Expected Outcomes and Recovery

• Hospitalization ranges 1-5 days depending on complexity and need for secondary procedures 4
• Most patients resume normal activities 1-2 weeks after drainage tube removal 4
• Transfusion rates for PNL are 14-24%, significantly lower than open surgery 4
• Average 1.3 PNL procedures per patient, with 10-50% requiring additional procedures depending on stone complexity 4

Critical Pitfalls to Avoid

• Never withhold information about treatment options due to local unavailability or physician inexperience—patients must be informed of all alternatives including referral to centers with PNL capability 1
• Do not use chemolysis (Renacidin irrigations) routinely—insufficient evidence supports this approach and it prolongs hospitalization 4
• Recognize that fragmented staghorn calculi on plain radiograph may indicate pyonephrosis requiring urgent surgical attention 2
• Consider malignant transformation risk—chronic staghorn calculi can rarely cause squamous cell carcinoma of the renal pelvis, though this typically presents without hematuria as the primary finding 5