Aggressive Approach To Staghorn Calculi-Safety And Efficacy Of Multiple Tracts Percutaneous Nephrolithotomy

Main Category: Urology / Nephrology
Article Date: 31 Jul 2008 - 2:00 PDT

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UroToday.com - Studying a group of 149 patients, twenty-five percent of whom presented with complete staghorn stones, twenty-five percent with borderline stone bulk, and fifty percent with partial staghorn stones, the authors placed an average of 2.6 nephrostomy tubes (2-6 per patient), with a supracostal puncture in nearly 60%.

Of note, 31% required transfusion while 5% developed sepsis and 2.7% developed a pseudoaneurysm; the average hospital stay was 6.8 days. The stone clearance rate after the first - and following a second look procedure -was 71% and 89%, respectively, on plain abdominal radiographs.

While the authors conclude, and I concur, that this is acceptable therapy, I believe that we can do better. It would appear that the authors used only a rigid endoscope and dismissed flexible nephroscopy: "For a larger stone bulk, flexible nephroscopy is usually tedious, time-consuming, and more prone to leaving stone residue."

I would disagree.

Based on the work of Leveillee, as well as Lingeman and others, the liberal use of the flexible nephroscope, and when needed, the holmium laser, results in stone free rates as high as 85-95%, and the use of multiple tracts is an uncommon practice. In my practice at UC Irvine, regardless of stone burden, the incidence of multiple tracts (never more than 2) is less than 10%, while the use of flexible nephroscopy, as well as prone flexible ureteroscopy, is commonplace. In addition, today, at the end of the procedure, most patients leave the operating room with no nephrostomy tube. This is achieved by sealing the tract with a hemostatic agent - providing the endoscopic and fluoroscopic evaluation of the kidney shows no stone remnants. These patients are often able to leave the hospital within 1-2 days.

Singla M, Srivastava A, Kapoor R, Gupta N, Ansari MS, Dubey D, Kumar A
Urology. 2008 Jun;71(6):1039-42
10.1016/j.urology.2007.11.072

Reported by UroToday.com Medical Editor Ralph V. Clayman, MD

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