Multiperc versus single perc with flexible instrumentation for staghorn calculi

Abstract

Several techniques have been described for percutaneous access and stone removal. The method of choice depends on the available instrumentation, stone burden in given caliceal anatomy, and the surgeon's preference, depending on his or her level of training. The argument for multiple strategic tracts vs single-tract percutaneous nephrolithotomy (PCNL) with or without flexible instrumentation for complete clearance of the stones is ongoing. The "multiperc" or multiple tract approach offers clearance of stones without the added cost of sophisticated instrumentation; further, a surgeon who can achieve a primary tract can easily create secondary tracts. This does not require a learning curve to be overcome. The argument against the multiperc approach is a potential for increased bleeding, which has not been substantiated in any published series. The single-tract approach without need for flexible instrumentation, currently published, is for small burden and partial staghorn stone where multiple tracts are not really necessary. Use of single-tract PCNL with flexible instrumentation, such as ureteroscopy and nephroscopy, ideally needs a supracostal approach with its attendant morbidity. The success of this procedure depends on the collecting system anatomy. Few studies published to date report suboptimal stone clearance rates with the advantages of shorter hospital stay and less blood loss. The currently available literature is not sufficient because of mostly retrospective studies, fewer patient accrual, and paucity of staghorn cases. Proper prospective studies with head-on comparisons are needed to prove or disprove the advantages and disadvantages of either approach.