What is the recommended treatment for a patient with Staghorn calculi, flank pain, and hematuria with red blood cells (RBC) too numerous to count?

Treatment of Staghorn Calculi with Flank Pain and Hematuria

Percutaneous nephrolithotomy (PNL) should be your first-line definitive treatment for this patient with staghorn calculi, as it achieves stone-free rates more than three times greater than shock wave lithotripsy with similar complication rates. 1

Immediate Clinical Assessment

Diagnostic Workup

• Obtain non-contrast CT scan immediately to fully characterize stone burden, assess for complete versus partial staghorn configuration, and evaluate renal function 1, 2
• Send urine culture and susceptibility testing before initiating antibiotics, as staghorn calculi represent complicated UTI with broader microbial spectrum including E. coli, Proteus, Klebsiella, Pseudomonas, and Enterococcus 3
• Check serum calcium and intact PTH if hyperparathyroidism is suspected 2
• Assess renal function bilaterally - if the affected kidney is non-functioning and contralateral kidney is normal, nephrectomy should be considered instead of stone removal 4, 1

Rule Out Urgent Complications

The combination of flank pain and gross hematuria (RBCs too numerous to count) requires immediate assessment for:

• Sepsis or urosepsis - check vital signs, white blood cell count, and lactate 3, 5
• Severe obstruction - assess for hydronephrosis on imaging 3
• Significant bleeding - check hemoglobin/hematocrit 5

Initial Medical Management

Antibiotic Therapy

Start broad-spectrum parenteral antibiotics empirically while awaiting culture results 3:

• Fluoroquinolones: Ciprofloxacin 400 mg IV twice daily OR Levofloxacin 750 mg IV once daily 3
• Extended-spectrum cephalosporins: Ceftriaxone 1-2 g IV once daily OR Cefepime 1-2 g IV twice daily 3
• Aminoglycosides: Gentamicin 5 mg/kg IV once daily OR Amikacin 15 mg/kg IV once daily 3

Duration: 7-14 days total, with 7 days appropriate for prompt clinical response and 10-14 days for delayed response (not afebrile within 72 hours) 3

Drainage Considerations

• Place percutaneous nephrostomy if severe obstruction or sepsis is present before definitive stone management 4, 3
• This is a routine part of PNL and frequently used before shock wave lithotripsy 4

Definitive Surgical Treatment

Primary Recommendation: PNL-Based Therapy

PNL is the gold standard and should be your primary approach 1, 6:

• Achieves stone-free rates >3 times higher than SWL monotherapy in the only randomized prospective trial (Meretyk trial) 1
• Modern technique uses flexible nephroscopy after rigid nephroscopy debulking to remove stones remote from the access tract 1, 2
• Single-access PNL with flexible nephroscopy and holmium:YAG laser achieves 95% stone-free rates with mean 1.6 procedures per patient 1, 2
• Perform second-look flexible nephroscopy via the existing nephrostomy tract to retrieve residual stones identified on post-PNL imaging 1, 2

If Combination Therapy Is Used

The sequence must be: PNL debulking → SWL for residual fragments → final nephroscopy ("sandwich therapy") 1:

• Percutaneous nephroscopy must be the final procedure - never end with SWL alone, which yields only 23% stone-free rates 1
• Use SWL only for stones unreachable by flexible nephroscopy or unsafe for additional access tracts 1
• Nephroscopy is more sensitive than plain radiography for detecting residual fragments 1

Treatments to Avoid

Do NOT use SWL monotherapy for staghorn calculi 1:

• Meta-analysis shows significantly lower stone-free rates than PNL-based approaches 1
• Stone-free rates are highly dependent on stone burden and substantially lower for complete versus partial staghorn stones 1
• Never use SWL monotherapy for cystine staghorn stones - associated with poor stone-free rates for stones ≥25mm 1

Do NOT use open surgery except in rare circumstances 4, 1:

• Only 2% of Medicare patients underwent open stone procedures by 2000 1
• Reserved only for extremely large staghorn calculi with unfavorable collecting system anatomy 1
• Estimated transfusion rate 20-25% and mortality ~1% 1
• Anatrophic nephrolithotomy is the preferred open approach when necessary 4

Special Considerations for This Patient

If Kidney Function Is Poor

Consider nephrectomy if the involved kidney has negligible function and the contralateral kidney is normal 4, 1, 2:

• Indicated for poorly functioning, chronically infected kidneys with recurrent UTI, pyelonephritis, or sepsis 1
• Laparoscopic nephrectomy is an option, but open surgical nephrectomy may be safer if intense perirenal inflammation is present (as with xanthogranulomatous pyelonephritis) 4, 3

Expected Complications

Transfusion rates are <20% for PNL and combination therapy 1:

• Overall significant complications range 13-19% across all treatment modalities 1
• Death is rare but can occur with medical comorbidities or sepsis development 1
• Common intraoperative complications include bleeding, collecting system injury, visceral organ injury, and pulmonary complications 5
• Postoperative complications include infection/urosepsis, bleeding, persistent nephrocutaneous urine leakage, and infundibular stenosis 5

Post-Treatment Management

Stone-Free Assessment

• Non-contrast CT is the gold standard for determining stone-free status, though fragments adjacent to nephrostomy tubes may not be detected 1
• Stone-free rates are substantially higher for partial versus complete staghorn stones across all treatment modalities 1

Long-Term Prevention

• Perform stone analysis when material is available to guide preventive strategies 2
• Increase fluid intake to achieve urine volume ≥2.5 liters daily as the most critical preventive measure 2
• For recurrent infection stones, consider urease inhibitors (acetohydroxamic acid) as adjunctive therapy after stone removal 2, 3
• Metabolic evaluation with directed medical management is recommended for all staghorn stone formers, as the majority are metabolic in etiology and even infection stones are usually associated with metabolic abnormalities 7

Critical Pitfalls to Avoid

• Never withhold treatment options due to physician inexperience or local equipment unavailability - patients must be informed of all treatment alternatives and referred appropriately 1
• Do not delay definitive surgical management - conservative treatment carries 28% mortality rate over 10 years and 36% risk of developing significant renal impairment 6
• Do not assume absence of hydronephrosis rules out obstruction - dehydration can mask hydronephrosis 2
• Replace indwelling catheters if present for ≥2 weeks at the onset of infection to hasten symptom resolution 3