STONE DISEASE

Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations
Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS Jr; (Members of the AUA Nephrolithiasis Guideline Panel
J Urol. 2005; 173: 1991-2000

NO ABSTRACT AVAILABLE

• Editorial Comment
  In 1994, the AUA Nephrolithiasis Clinical Guidelines Panel on Staghorn Calculi recommended that percutaneous nephrolithotomy (PNL) with or without adjuvant shock wave lithotripsy (SWL) (combination therapy) should constitute first line therapy for most patients with staghorn calculi. A new Guidelines panel was recently convened to review the literature from 1992 through 2003 to ascertain any recent changes in treatment outcomes for staghorn calculi. Based on their findings, the recommendation for first line treatment of staghorn calculi was PNL.
  This modification in treatment recommendation since the 1994 Guideline was based on superior stone-free rates for PNL compared with combination therapy (78% versus 66%, respectively), fewer mean total procedures/pt (1.9 vs. 3.3, respectively) and comparable morbidity. Further, the panel noted a decline in stone free rates for combination therapy since the 1994 recommendations, largely due to less rigid adherence to the regimen of PNL-SWL-PNL and greater reliance on SWL to clear fragments from the kidney. With the development of improved flexible nephroscopes and the Holmium: YAG laser, PNL monotherapy is used more readily and with greater success, resulting in less reliance on SWL for treatment of residual fragments.
  Once again, the Panel discouraged SWL monotherapy for treatment of staghorn calculi based on inferior stone free rates and higher mean total procedures per patient compared with the other treatment options. Although open surgery remains an option for the treatment of patients with complex staghorn calculi who might not be rendered free of stones after a reasonable number of percutaneous procedures, this option should be utilized exceptionally rarely.

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