MANAGEMENT OF STAGHORN CALCULI: CRITICAL ANALYSIS AFTER 250 CASES
JENS J. RASSWEILER, CHRISTIAN RENNER, FERDINAND EISENBERGER
Department of Urolraogy Klinikum Heilbronn, Teaching Hospital of University of Heidelberg and Department of Urology Katharinenhospital Stuttgart, Teaching Hospital of University of Tübingen, Germany
ABSTRACT
Objectives:
Based on long-term experience with over 250 patients and the review of
the literature we want to focus on the state of the art management of
complicated nephrolithiasis. This includes the application of extracorporeal
shock wave lithotripsy (ESWL) and endourology as well as the remaining
indications for open surgery.
Material and Methods: A total of 197 patients
were treated with the new technologies in a five year period and compared
to 83 patients who underwent open surgery for complicated nephrolithiasis
prior to the introduction of ESWL and endourology. Two-hundred and forty-seven
patients (186 respectively 61) could be followed over a period of up to
42 months to analyze the pattern of stone-clearance by passage of fragments,
recurrent stone formation and urinary tract infection.
Results: Stone distribution (borderline
vs. staghorn stones) was similar in both groups with a higher percentage
of complete staghorn stones in the open surgery-group. Blood transfusion
rate (37% vs. 10%) was significantly higher after open surgery, whereas
the rate of minor side effects did not differ in both groups. Also major
complications were observed at a similar rate (7 vs. 8%) as well as hospital
stay (17.2 vs. 15.4 days). Stone-free rate at discharge after open surgery
is significantly higher than after ESWL and endourology (80 vs. 31%).
In contrast to this, the stone-free rate after 42 respectively 36 months
does not differ significantly (72 vs. 60%). The majority of the remants
after the modern techniques were asymptomatic (CIRF), whereas the recurrence
rate after surgery is significantly higher (20% vs. 7%). Additionally,
the reduction of urinary tract infection (UTI) rate is better after the
modern approach (0.51 vs. 0.32 = UTI after/UTI before).
Conclusions: The introduction of minimally
invasive techniques has completely changed the management of complex stones.
Open surgery is only preferable in case of giant staghorns requiring numerous
percutaneous procedures along with ESWL, after failure of the modern techniques
or in cases necessitating additional surgical reconstruction. However,
the multimodal minimally invasive therapy of complex renal stones requires
an individual treatment plan for each patient depending on stone burden
and distribution, anatomy of the collecting system, and the composition
of the calculus.
Key words:
kidney, kidney calculi, lithotripsy, percutaneous nephrolithotomy, surgery
Braz J Urol, 26: 463-478, 2000
INTRODUCTION
More than 20 years after the clinical introduction of extracorporeal shock wave lithotripsy (ESWL) and endourological techniques, such as ureteroscopy (URS) and percutaneous nephrolithotripsy (PCNL) (1-3), the treatment of urolithiasis has changed completely. Whereas in the seventies and the beginning of the eighties of the last century, the majority of renal and ureteral stones have been removed by open surgery (4-7), in the new millenium the latter has become a very rare event at least in European, Japanese and Anglo-American centers. The widespread use of ESWL resulted in a significant decrease of patients suffering from renal stones and consecutively an increase of ureteral stones from 10-20% to 30-40% in our treated stone population (8,9). Additionally, we do not see as many complicated renal stones as we have been treated with the new multimodal minimally invasive techniques in the eighties and early nineties (Table-1). We have therefore observed an increase in ureteroscopy but a decrease in percutaneous stone surgery.
There
are several reasons to explain this situation: 1)- the minimal morbidity
associated with the new treatment modalities has significantly improved
the compliance of the patients to undergo early therapy of their stone
disease; 2)- the wide-spread use of diagnostic ultrasound has increased
the early detection rate of urinary calculi; 3)- the new generation antibiotics
(i.e. gyrase inhibitors) allow more effective treatment of urinary tract
infections, particularly with respect to urease-splitting bacteria (i.e.
proteus), and 4)- the possibility of multiple treatments in case of recurrent
stone formation (i.e. by ESWL) without a significantly enhanced risk of
deterioration of renal function or increasing technical difficulties,
like in the era of open surgery, has improved the prognosis of our stone
patients.
Nevertheless, even today we still see complex
renal stones requiring more than a simple extracorporeal shock wave lithotripsy
or an ureteroscopic stone removal. In the following, based on our own
experience and the review of the literature we want to focus on the state
of the art management of complicated nephrolithiasis, emphasizing all
existing minimally invasive techniques. However, in addition the remaining
indications for open surgery in the new millenium will be presented.
DEFINITION OF COMPLEX RENAL STONES
Complicated
nephrolithiasis consists of a variety of stone-bearing situations depending
on: 1)- the stone burden and distribution; 2)- the anatomy of the collecting
system; 3)- the stone composition; 4)- the renal function; 5)- associated
urinary tract infection.
The majority of complex renal stones are
staghorn calculi, but also multiple stones behind infundibular stenosis
or in a caliceal diverticulum may be complicated. Moreover, stones in
renal abnormalities, such as horseshoe-kidney, medullary sponge kidneys,
are most frequently difficult to manage (9). Finally, reduced renal function
and/or infection of the renal collecting system always represents a challenge
for the treating urologist. However, in the following we want to focus
on the management of staghorn stones.
STAGHORN CALCULI
Definition
Principally, staghorn calculi are defined
as branched stones in the renal collecting system. However, as mentioned
before, there are several different constellations, within this entity.
This has been taken into consideration by the more complex definition
of Rocco et al. (10) or the PICA-classification of Griffith et al. (11).
For the modern management of such stones three factors are of major importance
to decide the optimal treatment: 1)- the overall stone burden; 2)- the
localization of the stone burden (i.e. which and how many calyces are
involved); 3)- the anatomy of the collecting system (i.e. a dilated collecting
system).
Based on this, several authors have introduced
a relatively simple definition (Table-2) distinguishing between borderline
stones, partial and complete staghorn calculi (12). Of course, the stone
burden can be calculated more exactly using the area on the kidney-ureter-bladder
(KUB) x-ray plan film, as proposed by Lam et al. (13). This was extremely
useful in the evaluation of different therapeutic approaches, however
in the daily routine the above mention classification proved to be sufficient.
Treatment
Options
Whereas in former times, only the modification
of the open renal surgery, i.e. anatrophic versus radial nephrolithotomy
(4,7), was discussed and even conservative management was optioned (14),
nowadays a multimodal approach has been developed to minimize morbidity
of the treatment and aiming at optimal long-term results. This may include:
1)- extracorporeal shock wave lithotripsy with or without indwelling stent;
2)-percutaneous nephrolithotomy using different devices for stone disintegration;
3)- the combination of both techniques as a planned procedure; 4)- retrograde
ureteroscopic stone disintegration using a holmium laser; 5)- open surgery
(i.e. anatrophic or radial nephrolithotomy, sinusoidal pyelolithotomy).
Staghorn stones are unquestionably an indication
for interventional therapy, since all reports following conservative treatment
showed a substantially increased rate of nephrectomy (up to 50%) and an
increase in associated morbidity (i.e. dialysis); in many cases (up to
28%) the disease resulted in death (5,14). Of course, the choice among
the listed treatment modalities mainly depends on the specific finding
of the staghorn stone (i.e. stone classification) (15). On the other hand,
further factors such the age of the patient or the function of the stone-bearing
kidney may be important (Table-3). Finally, it has to be emphasized that
these criteria do not allow exact discrimination in every case.
Criteria
of Success
The goal of any of these procedures is to
carry the patient stone-free. However, with the introduction of ESWL particularly
in case of larger calculi or stones in the lower caliceal group, even
more than 40% of persisting fragments have been accepted (16,17), because
in the majority of cases (90%) these asymptomatic fragments proved to
be clinically insignificant (CIRF). This means, that these fragments did
not induce early stone recurrence, which was different to the presence
of residual stones in the era of open surgery, particularly in case of
infected calculi. This may be attributed to the improved generations of
antibiotics, but also to the fact, that the fragmented calculi are better
treatable resulting in some residual sterile fragments after ESWL (16,17).
Nevertheless, any patient with a treated staghorn stone requires a short
a consequent follow-up (18).
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| Figure 1 – Staghorn stones - Indications for the different procedures: A) ESWL-monotherapy: partial staghorn stone (calcium-oxalate-dihydrate) in the right kidney involving the pelvis and lower caliceal group together with filling of the middle and upper caliceal group; B) PCNL-monotherapy: borderline stone (calcium oxalate-monohydrate) filling one lower pole calyx with an dilated collecting system (right side), easy removable by one-stage PCNL via a single percutaneous tract; C) Combination: complete staghorn stone (struvite) on the right side with a dilated collecting system. Percutaneous debulking of the lower pole calyces and pelvis is followed by ESWL for fragmentation of the upper pole part; D) Open surgery: complete giant staghorn stone (calcium oxalate monohydrate) multiple stones in all calyces. Stone removal requires an extended pyelotomy plus multiple radial nephrolithotomies. Additionally there was an UPJ-stenosis requiring pyeloplasty. | |
Indications
for ESWL-Monotherapy
Extracorporeal shock wave lithotripsy should
be performed in case of minor stone burden, peripheral stone load (i.e.
multiple stone-filled calyces) and a narrow renal collecting system. Moreover,
patients with enhanced risk (i.e. cardiosclerosis, respirators problems)
or other difficulties related to percutaneous surgery (i.e. children,
urinary diversion) have to undergo ESWL alone (Figure-1A; Figure-2).
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Indicatios
for PCNL-Monotherapy
The percutaneous nephrolithotomy in single
session can be successfully applied for cases of major stone burden with
central (= pelvic) stone load in an enlarged (= dilated) collecting system
(i.e. borderline, and partial staghorn calculi) (Figure-1B). Furthermore,
slightly opaque or shock wave resistant calculi (i.e. cystine) are candidates
for PCNL alone (Figure-3).
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Indications
for the Combination
The combination of ESWL and PCNL, principally
started by the percutaneous approach, is applied for all cases of major
stone burden (i.e. partial and complete staghorn stones) (Figure-1C) with
central and peripheral stone load. The rationale for the combination therapy
is to reduce the morbidity of the PCNL, which is carried out in the majority
of cases via one lower pole tract, and the use of ESWL selectively for
disintegration of those calculi (parts of the staghorn stone) that cannot
be reached with the nephroscope (Figure-4).
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Indications
for Open Surgery
Surgery is a potential treatment option
for any staghorn for several reasons. The stone can be removed by a single
procedure with comparable stone-free rates. Therefore, some authors still
advocate open surgical removal in case of complete staghorn stones (19-22).
However, there is the problem of loss of renal function after such extensive
surgical interventions like anatrophic intersegmental pyelolithotomy,
which has been reported in the range of 30-50% (23). Overall, the residual
stone rate after open renal surgery is about 15%, with a 30% stone recurrence
rate over 6 years and a 40% risk of urinary tract infections (16,19-25).
We have therefore restricted the indications
for open surgery to those cases with giant stone burden that cannot be
reached endoscopically nor by a considerable number of ESWL-treatments
or if additional reconstructive surgery (i.e. calicoureterostomy, pyeloplasty)
is required, Figure-1D (25). Nephrectomy of non-functioning kidneys can
be performed laparoscopically (26-27).
Therapeutic
Approach
Independently to the following procedure,
every patient with a staghorn stone requires antibiotic prophylaxis (i.e.
gyrase inhibitors) at least 2 days prior to the intervention. In our series
38% of the patients presented with urinary tract infections prior to the
treatment (25), 51% of whom were Proteus mirabilis.
ESWL-Monotherapy
The techniques of extracorporeal shock wave
lithotripsy have been described in detail previously (28-31). In case
of a larger stone (> 2 cm) we recommend the insertion of a double J-stent
prior the procedure. This avoids obstruction of the ureter by formation
of a steinstrasse, but does not inhibit the passage of fragments along
the stent (13). Staghorn stones should be first treated at the pelvic
part to enable passage of fragments, thereafter the upper and middle calyces
are focussed leaving the lower pole untreated to avoid that fragments
fall into the lower calyces from where further passage may be prolonged
(Figure-3). Depending on the energy setting of the machine, the number
per session should not exceed 4000 impulses. The interval between each
treatment should be at least 2 days.
PCNL-Monotherapy
This is performed as a one-stage procedure
with the patient under general anesthesia using a retrograde balloon occlusion
catheter placed at the uretero-pelvic junction (12,25). Access is usually
through the lower pole posterior calyx with removal of the lower caliceal
and pelvic stone burden. In case of major stone burden, we always place
an Amplatz sheath down the percutaneous tract. This allows removal of
larger stone fragments and reduces the risk of pelviocaliceal influx.
Only in selective cases (i.e. stones less suitable for ESWL, i.e. cystine),
we recommend the puncture of an additional calyx to achieve complete stone
clearance in a single PCNL-session (Figure-3). Another option to access
stone burden in upper and middle calyces may be the use of a flexible
cystoscope together with a holmium or dye laser introduced via the Amplatz
sheath.
Combination
In the combined approach, we principally
recommend to start with a debulking PCNL via the lower pole posterior
calyx. The puncture of the kidney is performed under combined sonographic
and fluoroscopic control. On occasion, multiple tracts (maximum 3) can
be made, in case of massive stone burden (i.e. in the upper dilated calyx).
Open
Surgery
Whereas in our earlier experience the technique
of clamping and cooling was used (32,33), we have recently preferred the
technique of radial nephrotomies with intraoperative color-duplex-sonography
(7). Other options include extended pyelolithotomy, anatrophic nephrolithotomy
or posterior lower nephrolithotomy. Nowadays, we would not put the same
emphasis to achieve complete stone clearance, because minor residual stones
can be treated effectively with ESWL.
Own Experience
Patients
Some of our personal experience with the
multimodal minimally invasive management of staghorn calculi has been
published previously (12,25,33). In this paper, we want to focus on long-term
results in comparison to those obtained by open surgery. A total of 197
patients were treated with the new technologies in a 5-year period and
compared to 83 patients who underwent open surgery for complicated nephrolithiasis
prior to the introduction of ESWL and endourology. Two hundred and forty-seven
patients (186 respectively 61) could be followed over a period of 36 respectively
42 months to analyze the pattern of stone-clearance by passage of fragments,
recurrent stone formation and urinary tract infection.
Distribution
of Treatment
In correlation to the increasing stone burden
and complexity of the cases, the percentage of ESWL-monotherapy decreases
from 45% for borderline stones to 2% in case of a complete staghorn. PCNL
is most frequently performed (28%) for management of partial staghorn
calculi, whereas the combination is applied in 74% of all complete staghorns.
For borderline stones only 6% of the patients required more than 3 sessions
compared to 10% for partial and 21% for complete staghorn stones. Open
surgery was performed in 7% for partial and in 11% for complete staghorn
calculi. Overall, 53 patients were treated by ESWL-monotherapy, 56 by
PCNL-monotherapy, and 77 had a combination of both techniques (Table-4).
Treatment
Data
Thirty-seven percent of patients with “borderline”
and 35% of patients with partial staghorn calculi presented with urinary
tract infection prior to treatment, in contrast to 50% with complete staghorn
stones. A detailed analysis of all relevant data is listed on Tables-4,
5 and 6. Three or more sessions were necessary in 24% of all patients,
ranging from 0% (PCNL-monotherapy) to 54% (combination). This was because
maximally two PCNL-sessions were performed for stone removal. Any further
parts of the stone that could not be treated effectively received ESWL.
Blood transfusions were required in 10%
of the patients, in no case after ESWL-monotherapy, but in 17% after the
combination, mainly because of the increased technical difficulties of
percutaneous nephrolithotomy.
Auxiliary
measures have to be performed in 21% of all patients, ranging from 14%
after the combination to 36% after ESWL-monotherapy. Nowadays, this figure
could be even higher, since we recommend the prophylactic insertion of
a double-J stent prior to ESWL-monotherapy. However, only 8% needed curative
auxiliary measures (31), such as ureteroscopy or open surgery.
Forty-five percent of the patients experienced
minor side effects like colic or fever. Whereas colics have been more
frequently associated with ESWL-treatment, postoperative fever occurred
increasingly after PCNL. In contrast to this, major complication have
been observed only in 7% of all patients, including perirenal hematoma
after ESWL, bleeding after PCNL, colon perforation after PCNL, and pulmonary
embolism.
The mean hospital stay amounted to 15.4
days ranging from 11.6 to 19.8 days.
Follow-up
Data
The mean follow-up of our study was 36 months.
Thirty-one percent of all patients were stone-free at discharge ranging
from 63% after PCNL-monotherapy to 11% after ESWL-monotherapy. However,
after a 3 years period, 60% of the patients (48 to 71%) became stone-free,
depending mainly on the complexity of the treated stone (Figure-5). Twenty-five
percent (21 to 33%) of all patients had still clinically insignificant
residual fragments (CIRF), and only 8% (4 to 13%) had symptomatic fragments
mainly associated with UTI (Table-5). The overall recurrence rate amounted
to 7% independent on the treatment group. Only 11 % suffered still from
urinary tract infection compared to 35% at hospitalization (Table-5).
Comparison
with Open Surgery
Our series of open surgery was performed
prior to the introduction of ESWL and Endourology.
The stone distribution in terms of borderline
vs. staghorn stones was similar in both groups, but the percentage of
complete staghorn stones was higher in the open surgery group (Table-6).
The blood transfusion rate (37% vs. 10%) was significantly higher after
open surgery, whereas the rate of fever and other minor side effects did
not differ in both groups. Also major complications were observed in a
similar rate (7 vs. 8%) as well as hospital stay (17.2 vs. 15.4).
In the follow-up of both groups, there are
further significant differences (Table-7): the stone-free rate at discharge
after open surgery is significantly higher than after ESWL and endourology
(80 vs. 31%). In contrast to this, the stone-free rate after 42 respectively
36 months does not differ significantly (72 vs. 60%) but is in favor of
the open approach (Figure-6). It is to be noted, on the other hand, that
the majority of the remants after the modern techniques represent CIRF,
whereas the recurrence rate after surgery is significantly higher (20%
vs. 7%). Additionally, the reduction of urinary tract infection rate is
better after the modern approach (0.51 vs. 0.32 = UTI after/UTI before),
Table-7.
DISCUSSION
The surgical management of urinary stone disease has undergone dramatic changes and seen the implementation of technological innovations that are unsurpassed in the field of urological surgery over the past 20 years. Before these advancements, open surgery was the only surgical option for nephrolithiasis. In the current era, the first question in the management of any stone usually is whether the situation is amenable to ESWL. This should come as no surprise because of the ease of use and noninvasive nature of the procedure. The real issue is whether the excellent results obtainable with this technology in case of small stones translate into successful treatment when targets are complex stones such as staghorn calculi. The patient demand and the desire to avoid painful incisions and long recovery periods, and finally the pressure to provide cost-effective care with shorter hospitalizations after surgery have created a treatment philosophy that defines success as the ability to eradicate the stone with the least invasive modality.
Guidelines
for the Treatment of Staghorn Calculi
In this situation, particularly in case
of complex stones, urologists have to define the indications for selection
of the best procedure for treat the individual stone. The Nephrolithiasis
Clinical Guidelines Panel of the American Urological Association reviewed
110 articles concerned with staghorn calculi resulting to the following
guidelines (18). The committee believed that a newly diagnosed staghorn
was an indication for active treatment. Percutaneous stone removal, followed
by ESWL or repeat PCNL, should be used for most patients with struvite
staghorns. Neither ESWL-monotherapy nor open surgery should be used as
first-line treatment for staghorns in most patients.
As options PCNL and ESWL are equally effective
in treating small-volume staghorns when the renal anatomy is normal or
near normal. Also as an option, open surgery is appropriate therapy when
the staghorn cannot be managed by any reasonable number of PCNL and ESWL
sessions, i.e. in case of a giant staghorn. Nephrectomy is a reasonable
option for a poorly functioning stone-bearing kidney.
This summary is in accordance with our previously
stated indications (Table-3). It reflects, however, the limitations of
further clarifications mainly due to the lack of prospective randomized
studies as well as an accepted way to describe staghorns in the literature.
We therefore believe that it is important to focus further on the comparison
of the different treatment strategies for staghorn stone in the literature.
For this purpose, the changing treatment philosophy and consecutively
the criteria of therapeutic success have to be addressed.
Treatment
Philosophy
As stated before, the introduction of the
new technologies resulted to the philosophy to treat the stone most effectively
with minimal invasiveness and morbidity for the patient. This includes
the amount and severity of complications associated with the applied procedures,
length of hospitalization and disability, and initial stone-free rates.
However, the ultimate goals of therapy in this specific group of patients
should include the long-term stone-free rates, minimizing the rates of
recurrent stones and infection, and the preservation of renal function
(16,34).
Morbidity
of the Treatment
The morbidity of open surgery have been
reported extensively in the literature (4,6,21,22,35-40) including fever
(26-29%), blood transfusions (14-70%), pneumothorax (5%), recurrent bleeding
(4%), septicemia (1%), urinoma/fistula (1%), embolism (2%), flank abscess
(2%), flank pain (16%), flank bulge (5%), incisional hernia (2%) and wound
infections (4%) with a postoperative hospital stay ranging from 11 to
16 days.
Using the modern approach (3,12,13,15, 25,37-45),
the morbidity mainly is associated to percutaneous surgery with the need
of blood transfusions (5-53%), fever (12-64%), septicemia (2-4%), pneumothorax
(2%), A-V malformation requiring superselective embolization (1%), flank
abscess (1%), and colon perforation (1%). The hospital stay ranged between
9.5 and 18 days.
Our own experience with both methods (Tables-6
and 7) correlates with these data. There is no doubt, that due to the
complexity of the disease both approaches are associated with significant
side effects. On the other hand, there is sufficient evidence that the
overall peri- and postoperative morbidity of ESWL and endourology is significantly
less compared to the open approach. The fact that the modern techniques
require multiple treatment sessions (2.8 vs. 1 session) (18) does not
represent a disadvantage, because it has an impact neither on morbidity
nor on the hospital stay.
The differences between both approaches
are even more pronounced with respect to the long-term complications.
Whereas the time to normal activity ranged between 44 to 54 days after
open surgery, this was only 21 to 30 days after ESWL plus endourology
(38-40). Complete loss of renal function was seen in 2-8% after open surgery
associated with a nephrectomy rate of 7-14%. Based on these, earlier calculations
considered an overall dialysis rate of 5% of all patients with urolithiasis
(46,47). The nephrectomy rate in our series was only 2% using the modern
approach, and in a follow-up period of 3 years there was no further need
of renal ablation due to delayed loss of renal function (Tables-6 and
7). In our personal experience with almost 20 years of multimodal minimally
invasive stone management there have been only casuistic cases of stone-related
dialysis in the eighties, however, not a single remembered case in the
last ten years. This underlines the possibilities of ESWL and endourology
to treat and also retreat patients with complicated stone disease without
a significant risk of loss of renal function.
Residual
Fragments
When open surgery was the standard treatment
for the management of renal calculi, the presence of residual fragments
suggested a failed procedure, even those remaining fragments were small.
Because residual calculi may act as a nidus for recurrent stone formation,
complete stone removal was the principal goal of therapy. The introduction
of extracorporeal shock wave lithotripsy, however, shed a new perspective
on this century-old concept, minimizing the importance of postprocedural
residual fragments.
Nevertheless, in the last decade the main
goal of PCNL and ESWL treatment was to achieve a complete stone-free status
ignoring the fact that more and more patients benefit from successful
stone disintegration but with minor asymptomatic residual fragments, the
so called “clinically insignificant residual fragments” = CIRF
(Table-5). Of course, the acceptance of this change of therapeutic endpoints
would have a major impact on treatments strategies for all complex stones.
Some authors do not accept the CIRF-theory in case of complex stones because
the majority of calculi are associated with infection of the urinary tract
and consist of struvite with a high risk of persisting infection and stone
recurrence (19). This is true for open surgery: the stone free rates at
discharge are significantly higher (80-93%) than after the modern techniques
(19-37%). However, after 3 months these figures are rising up to 67-78%.
Our long-term experience after three years revealed an overall stone-free
rate of 60%, which was not statistically significant from the 72% stone-free
rate after open surgery. Subsequently, the recurrence rate was significantly
higher after open surgery (20% vs. 7%) (Table-7).
Infection
Moreover, about 3 quarters (46 of 61) of
the residual fragments were asymptomatic (= CIRF) in our series, which
has been found recently by other authors, too (42). In both series, more
than 50% of stones consisted of struvite, however, the rate of urinary
tract infection could be significantly reduced (i.e. from 35% to 11%).
The ratio UTI after/UTI before was significantly higher after open surgery
than when using ESWL and endourology (0.51 vs. 0.32) (Table-7). There
may be several reasons to explain these finding: 1)- residual fragments
are better reachable for antibiotic drugs than residual stones which still
may contain bacteria; 2)- the quality of antibiotics (i.e. gyrase inhibitors)
has improved; 3)- the operative trauma to the collecting system as well
as to the renal parenchyma is significantly less after PCNL plus ESWL
than after open surgery.
Anatomical criteria of the lower caliceal
system (i.e. length of the caliceal neck, pelvic-caliceal angle) may help
to predict the chance of complete stone clearance (48,49). Nevertheless,
one has to accept the fact, that even in case of complex stone the majority
of residual fragments after extracorporeal shock wave lithotripsy are
or may become clinically insignificant (= CIRF) and only about 10-15%
require further treatment (= SIRF). This has been in accordance to a recent
review of the literature concerning more than 14,000 patients (50).
In contrast to this, persisting infection
still remains one of the main problems after open surgery. Even in a recent
study Rocco et al. revealed a 21% UTI-rate in their follow-up (22).
Perspectives
In
summary, the introduction of minimally invasive techniques has also completely
changed the management of complex stones. Open surgery is only preferable
in case of giant staghorns requiring numerous percutaneous procedures
along with ESWL, after failure of the modern techniques or in cases necessitating
additional surgical reconstruction. Even stone-bearing non-functioning
kidneys can be removed laparoscopically in most situations. The majority
of long-term studies show almost similar stone-free rates, but lower percentages
of stone recurrence and urinary tract infections when using ESWL and endourology.
In addition, the number of dialysis cases because of progressing nephrolithisis
is trending towards zero. However, the multimodal minimally invasive therapy
of complex renal stones requires an individual treatment plan for each
patient depending on stone burden and distribution, anatomy of the collecting
system, and the composition of the calculus (Table-3).
Recently ureterorenoscopic techniques have
been introduced for the management of staghorn stones based on the holmium
laser technology (51). However, at present, we feel that such techniques
have only limited indications because of the problems with removal of
stone burden, intrarenal influx in case of infected stones, as well as
with respect to the prolonged operating time. On the other hand, there
may be reasonable indications for flexible ureterorenoscopy, i.e. in the
treatment of calculi behind caliceal neck stenosis (52).
Finally, as mentioned before, we have to
face the upcoming problem of adequate training and education in the surgical
management of complex renal stones. This affects both, the percutaneous
and open surgical techniques. The frequency of staghorn stones has declined
dramatically in our daily routine, which is in accordance with other centers
in Europe and United States. None of the existing centers - except those
in stone-belt areas - is currently able to reproduce the large series
of the eighties. On the other hand, increasing reports of extensive use
of the modern techniques are presented from countries, which previously
had only limited access to ESWL and endourology, i.e. in Eastern Europe,
India, (52). The main problem of training represents the difficulty and
complexity of these procedures, albeit percutaneous or open surgery. This
situation is similar to the training of laparoscopy and retroperitoneoscopy.
Therefore, we feel that such complex stone cases should be concentrated
to a few centers of expertise, which then could also provide adequate
training for urologists with special interests in this field.
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____________________
Received: July 19, 2000
Accepted: August 20, 2000
______________________
Correspondence address:
Dr. Jens Rassweiler
Department of Urology, Klinikum Heilbronn
Am Gesundbrunnen 20
D 74074 Heilbronn, Germany
Fax: ++ (49) 7131-492429
E-mail: jeans.rassweiler@t-online.de
EDITORIAL COMMENT
The
authors present their extensive experience in the contemporary management
of staghorn calculi. Having been leaders in the minimally invasive management
of staghorn calculi, including shock wave lithotripsy and percutaneous
techniques, this manuscript provides an excellent overview of endoscopic
and shock wave-related approaches to the management of complex renal stones.
Comparing almost 200 patients who had undergone
contemporary minimally invasive management of symptomatic staghorn calculi
to more than 80 patients who had undergone open nephrolithotomy, this
study finds that minimally invasive techniques offer reliable, safe and
efficacious options for the management of complex renal calculi. The results
and suggestions offered in the current manuscript are comparable to the
recommendations introduced in the American Urological Association’s
Nephrolithiasis Guidelines report on the management of staghorn calculi
(1). In essence, small-volume staghorn calculi in a non-dilated collecting
system can be managed in many cases with shock wave lithotripsy monotherapy.
However, for large volume staghorn calculi, a percutaneous approach either
as monotherapy or in conjunction with shock wave lithotripsy should provide
stone-free rates comparable to that of open surgery. Moreover, these minimally
invasive approaches offer the benefits of decreased blood loss, decreased
growth of residual fragments as well as a more rapid return to normal
activity.
The authors stress that the minimally invasive
techniques of shock wave lithotripsy and percutaneous nephrolithotomy
have replaced open stone surgery for the management of all but the most
complex of staghorn calculi. Finally, the authors note the importance
of adequate training in various endoscopic techniques, which will provide
the Urologist the ability to manage complex renal and ureteral stone disease.
Reference
1. Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman
JE, Macaluso JN Jr, McCullough DL: Nephrolithiasis Clinical Guidelines
Panel summary report on the management of staghorn calculi. The American
Urological Association Nephrolithiasis Clinical Guidelines Panel. J Urol
151:1648-1651, 1994.
Dr.
Glenn M. Preminger
Comprehensive Kidney Stone Center
Duke University Medical Center
Durham, North Carolina, USA