Conservative Management of Staghorn Calculi: When Is It Safe?

BACKGROUND: To describe the clinical characteristics, infectious and kidney function patterns, and overall outcomes in a cohort of patients with staghorn calculi treated conservatively. METHODS: Staghorn calculi treated nonoperatively between January 2009 and January 2017 were identified. A retrospective analysis was completed. RESULTS: Twenty-nine patients were identified with a median age of 74 years (interquartile range [IQR] 61-81). Mean follow-up was 24 months. Fifty-nine percent (17/29) had complete staghorn calculi with 6/29 (21%) bilateral. Mean body mass index was 29.4 (IQR 24.8-31.7). Of the 29 patients, 14 were treated conservatively due to comorbidities, 12 refused treatments, and 3 were due to aberrant anatomy. The age-adjusted Charlson Comorbidity Index (CCI) score demonstrated 8 patients in our cohort with a CCI of <3, 11 patients with a CCI of 4 or 5, 7 patients with a CCI of 6 or 7, and 3 patients with a CCI of >8. Overall, kidney function remained stable for 19/29 patients (66%) and the glomerular filtration rate decreased by <10% for 4/29 (14%), by 10%-29% for 2/29 (7%), and >30% for 4/29 patients (14%) over the study period. None of the study patients required hemodialysis. No patients in the cohort developed an abscess, nor were any patients on daily prophylactic antibiotics. There was only one related admission for a complication during the study; this was for pyelonephritis. There were two deaths during the study period. One death was an unrelated cardiac death and the other was from urosepsis; this patient had been noncompliant with follow-up. CONCLUSIONS: Outcomes for patients treated conservatively were reasonable in this select group. There is a need for future prospective studies to show whether conservative treatment of these patients is safe.

[Initial experience with laparoscopic anatrophic nephrolithotomy].

Percutaneous nephrolithotomy is a recognized standard for minimally invasive treatment of large kidney stones. Percutaneous interventions for complete staghorn stones are associated with a higher risk of complications that precludes abandoning the traditional open operations, one of which is an anatrophic nephrolithotomy. This paper presents the first personal experience in laparoscopic transmesenteric anatrophic nephrolithotomy. The intervention was conducted in 3 patients (2 males and 1 female) aged 43 to 58 years, having a primary symptomatic complete left kidney staghorn stones sized from 7.2 to 9.1 cm along the longitudinal axis. Operation time ranged from 130 to 170 minutes, kidney warm ischemia time - from 21 to 24 minutes, blood loss - from 180 to 250 ml. The staghorn stone was completely extracted in 2 patients. In one patient, a 0.8 cm residual stone was left in the completely excluded calix, since it caused none clinical symptoms and did not impair urinary flow. At this stage, the number of laparoscopic procedures for complete staghorn nephrolithiasis is too small to carry out an adequate statistical analysis and draw any definite conclusions. Nevertheless, the first experience demonstrated not only plausibility but also the effectiveness of such operations.