STONE DISEASE

Treatment of complete staghorn stones: a prospective randomized comparison of open surgery versus percutaneous nephrolithotomy
Al-Kohlany, K, Shokeir, AA, Mosbah, A, Mohsen, T, Shoma, AM, Eraky, I, El-Kenasy, M and El-Kappany, HA
J Urol. 2005; 173: 467-73

• Purpose: We studied the role of open surgery versus percutaneous nephrolithotomy (PCNL) in the treatment of complete staghorn stones in a prospective randomized manner.
• Materials and Methods: A total of 79 patients with 88 complete staghorn stones, defined as filling the entire collecting system or at least 80% of it, were prospectively randomized for PCNL (43) or open surgery (45). Intraoperative and postoperative morbidity, operative time, hospital stay, and stone clearance at discharge home and followup were compared for both methods. Patients with significant residuals in both groups were subjected to extracorporeal shock wave lithotripsy (Dornier Medical Systems, Inc., Marietta, Georgia) on an outpatient basis. Followup was completed for all cases with a mean duration +/- SD of 4.9 +/- 2.5 months (range 3 to 14). Renal function was evaluated by Tc-mercaptoacetyltriglycine renogram before and after treatment in both groups.
• Results: Intraoperative complications in terms of bleeding requiring blood transfusion, and pleural, vascular or ureteral injuries were recorded in 7 patients (16.3%) in the PCNL and 17 (37.8%) in the open surgery groups, a difference of significant value (p <0.05). Major postoperative complications including massive hematuria requiring blood transfusion, septicemia, urinary leakage and wound infection were observed in 8 patients (18.6%) in the PCNL group and in 14 (31.1%) in the open surgery group, a difference of no significant value. PCNL was associated with shorter operative time (127 +/- 30 vs 204 +/- 31 minutes, p <0.001), shorter hospital stay (6.4 +/- 4.2 vs 10 +/- 4.2 days, p <0.001) and earlier return to work (2.5 +/- 0.8 vs 4.1 +/- 1 weeks, p <0.001). On the other hand both treatment groups were comparable in regard to stone-free rates at discharge home (49% vs 66%) and at followup (74% vs 82%). At followup renal function improved or remained stable in 91% and 86.7% in the PCNL and open surgery groups, respectively.
• Conclusions: PCNL is a valuable treatment option for complete staghorn stones with a stone-free rate approaching that of open surgery. Moreover, it has the advantages of lower morbidity, shorter operative time, shorter hospital stay and earlier return to work.
  
  
• Editorial Comment
  In 1997, the AUA Nephrolithiasis Clinical Guidelines Panel performed an extensive literature review to determine the optimal treatment of staghorn calculi (1). At that time, not a single prospective, randomized, trial compared any of the treatment options: SWL, PCNL, combination therapy and open surgery. Based on their review, they recommended PCNL, with or without adjuvant SWL, as preferred treatment for staghorn calculi, because it combined high stone free rates with relatively low morbidity. A new Guidelines Panel recently completed an update of the review process, and changed their recommendation for treatment of most staghorn calculi to PCNL-based therapy because of poorer stone free rates in recent series of combination PCNL/SWL, likely due to heavy reliance on SWL and less on flexible nephroscopy for stone clearance (unpublished). In their review, a single prospective, randomized trial compared SWL with PCNL monotherapy and showed clear superiority of PCNL (2). Open surgery series in the updated review were few, and a decline in success rates is thought to be due to reservation of open surgery for patients with only the most complex staghorn calculi and those requiring extensive reconstruction of the collecting system, as well as to less experience in this technique in the era of minimally invasive surgery.
  The current authors performed a prospective, randomized trial comparing PCNL with open surgery for the treatment of complete staghorn calculi. They found that PCNL provided comparable stone free rates to open surgery but with reduced morbidity, shorter hospital length of stay and quicker recovery. These results validate the findings of the Guidelines Panel, and lend further credibility to the recommendation of PCNL-based therapy over open surgery by way of a non-biased comparison of the 2 modalities by a group of investigators with extensive experience in both approaches. Although open surgery has nearly vanished from practice in the U.S., the procedure is still performed in some countries with limited resources and equipment for newer minimally invasive techniques. With this trial, open surgery is relegated to an even more remote position in the armamentarium of surgical treatments for nephrolithiasis.

References
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. 1994; 151: 1648-51.
2. Meretyk S, Gofrit ON, Gafni O, Pode D, Shapiro A, Verstandig A, Sasson T, Katz G, Landau EH: Complete staghorn calculi: random prospective comparison between extracorporeal shock wave lithotripsy monotherapy and combined with percutaneous nephrostolithotomy. J Urol. 1997; 157: 780-6.

Dr. Margaret S. Pearle
Associate Professor of Urology
University of Texas Southwestern Med Ctr
Dallas, Texas, USA