Single upper-pole percutaneous access for treatment of > or = 5-cm complex branched staghorn calculi: is shockwave lithotripsy necessary?

Abstract

Percutaneous nephrolithotomy for staghorn calculi is reported to have a residual stone rate of 28%, while shockwave lithotripsy alone results in residual stones in approximately 50% of cases. Combination therapy, sandwich therapy, and multiple percutaneous accesses have also been advocated for staghorn stones. We believe these stones can often be removed with a staged procedure via a single upper-pole percutaneous access using flexible nephroscopy and the holmium:YAG laser. Our experience is reviewed. The hospital records of patients having a cumulative stone burden > or =5 cm who underwent percutaneous nephrolithotripsy (PCNL) for a single complex staghorn calculus were reviewed. There were 15 male and 34 female patients having 45 complete and 7 partial staghorn calculi constituting a mean stone burden of 6.7 cm (range 5.0-10.0 cm). A calix was punctured that would provide access to the majority of the involved calices. Thirty-five renal units were approached through a single upper-pole percutaneous access, and four and six renal units were accessed through single middle or lower-pole calices, respectively. The remaining seven renal units were treated with multiple percutaneous accesses. In the renal units having only a single access, a mean of 1.6 (range 1-3) procedures were required to achieve stone-free status. The mean operating room time was 2.9 hours (range 2.0-3.5 hours). For the second PCNL, the mean operating room time was 63 minutes (range 30-90 minutes). Two patients (two renal units) had residual stones <1 cm in diameter. One refused additional surgery, and the other is awaiting further treatment. The mean estimated blood loss was 238 mL (range 50-800 mL), with only one procedure (2.2%) necessitating a blood transfusion. One (2.8%) hydrothorax developed among the 35 upper-pole puncture cases. Six patients had transient oral temperature readings >101 degrees F with negative blood cultures. Other early complications included single cases of leg cellulitis, atrial fibrillation, and noncardiac chest pain. There were no delayed surgical complications. Patients were discharged from the hospital a mean 2 days (range 1-10 days) after the first PCNL. Use of flexible nephroscopy with holmium:YAG laser lithotripsy and Nitinol basket stone extraction has allowed us to render staghorn-containing renal units stone free in a mean of 1.6 procedures. Of the 45 renal units treated through a single percutaneous access, 43 (95%) were rendered stone free. The holmium:YAG laser appears to be a safe lithotrite for the kidney, as no complications occurred from its use.