[Management of staghorn calculi]

Abstract

Objectives: More than 200 articles about treatment of staghorn calculi have been published over the last 15 years; we observe a progressive tendency to the elective indication of a combination of therapeutic methods. Recent development of flexible ureteroscopy and endoscopical holmium-YAG laser lithotripsy has prompted the application of a new method of combined treatment for staghorn calculi: retrograde ureteroscopy and external shock wave lithotripsy. The objective of this work is to analyze indications and results of various therapeutic methods in relation to staghorn calculi complexity.

Methods and results: We analyze the results of open surgery, extracorporeal shock wave lithotripsy, percutaneous nephrostomy and retrograde ureteroscopy in the treatment of staghorn calculi Group 1 (soft calculi < 700 mm2 of area and homogeneous pyelocalyceal distribution), Group 2 (calculi < 700 mm2 hard or with predominantly central pyelocalyceal distribution, wide infundibula and calyces with few branches), Group 3 (calculi > 700 mm2 with predominantly central or homogeneous distribution, absence of infundibular stenosis or excluded calyces) and Group 4 (great lithiasic mass predominantly homogeneous or peripheral, narrow infundibula or multiple infundibular stenosis and/or lithiasis within excluded calyces).

Conclusions: In Group 1 staghorn calculi ESWL (JJ catheter + ESWL) has good results in 62.5% - 72.5% of the patients after an average of 3.2-3.6 sessions. The combination of contact lithotripsy by retrograde ureteroscopy and ESWL may be a therapeutic alternative. In group 2, percutaneous renal surgery may be considered the technique of choice; persisting residual fragments are treated by ESWL. Group 3 calculi are indication for combined therapy, percutaneous renal surgery and ESWL. ESWL therapy only is not indicated; open surgery through a sinus approach combined with intraoperative pyelocalyceal nephroscopy may be considered an option. Open surgery is recommended for Group 4 calculi--sinus approach is preferred--with mechanical extraction of caliceal fragments and/or pyelocalyceal nephroscopy support.