Management of struvite or staghorn calculi
- Glenn M Preminger, MD
Glenn M Preminger, MD
- Section Editor — Renal Ureteral Stones
- Professor of Urologic Surgery
- Duke University Medical Center
- Director of Education
- Endourological Society
- Section Editors
- Stanley Goldfarb, MD
Stanley Goldfarb, MD
- Editor-in-Chief — Nephrology
- Section Editor — Mineral and Bone Metabolism; Renal Ureteral Stones
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Michael P O'Leary, MD, MPH
Michael P O'Leary, MD, MPH
- Section Editor — Urology
- Professor of Surgery, Harvard Medical School
- Senior Urologic Surgeon, Brigham and Women's Hospital
Staghorn calculi refer to branched stones that fill all or part of the renal pelvis and branch into several or all of the calyces. They are most often composed of struvite (magnesium ammonium phosphate) and/or calcium carbonate apatite. These stones are often referred to as 'infection stones' since they are strongly associated with urinary tract infections with urea splitting organisms. Cystine stones, although much less common, may also develop into staghorn calculi . (See "Cystine stones".)
Small struvite and/or calcium carbonate apatite stones can grow rapidly over a period of weeks to months into large staghorn calculi involving the calyces and entire renal pelvis. If left untreated, this can lead to deterioration of kidney function and end-stage renal disease . In addition, since the stones often remain infected, there is a risk of developing sepsis . Thus, most patients require definitive surgical treatment.
There are several alternative surgical treatments for staghorn calculi. The American Urological Association Nephrolithiasis Guidelines Panel reviewed the existing literature to determine the optimal application of these different treatment modalities [3,4]. The current discussion is largely based upon this Panel's recommendations for the management of staghorn calculi; the pathogenesis and clinical manifestations of struvite stones as well as the management of renal and ureteral calculi in general, are presented separately. (See "Pathogenesis and clinical manifestations of struvite stones" and "Options in the management of renal and ureteral stones in adults".)
Limitations of the data — There are limitations that must be considered when interpreting and adopting guidelines for the optimal treatment of staghorn calculi :
●Data from randomized controlled studies comparing treatment options are very limited
- Cranidis AI, Karayannis AA, Delakas DS, et al. Cystine stones: the efficacy of percutaneous and shock wave lithotripsy. Urol Int 1996; 56:180.
- Jungers P, Joly D, Barbey F, et al. ESRD caused by nephrolithiasis: prevalence, mechanisms, and prevention. Am J Kidney Dis 2004; 44:799.
- Preminger GM, Assimos DG, Lingeman JE, et al. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol 2005; 173:1991.
- Segura JW, Preminger GM, Assimos DG, et al. 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.
- Wong H, Riehl RL, Griffith DP. Medical management and prevention of struvite stones. In: Kidney stones: Medical and surgical management, Coe FL, Favis MJ, Pak CC, et al (Eds), Lippincott-Raven, Philadelphia 1996.
- Teichman JM, Long RD, Hulbert JC. Long-term renal fate and prognosis after staghorn calculus management. J Urol 1995; 153:1403.
- Gupta M, Bolton DM, Gupta PN, Stoller ML. Improved renal function following aggressive treatment of urolithiasis and concurrent mild to moderate renal insufficiency. J Urol 1994; 152:1086.
- Cohen TD, Preminger GM. Struvite calculi. Semin Nephrol 1996; 16:425.
- Honeck P, Wendt-Nordahl G, Krombach P, et al. Does open stone surgery still play a role in the treatment of urolithiasis? Data of a primary urolithiasis center. J Endourol 2009; 23:1209.
- Kaouk JH, Gill IS, Desai MM, et al. Laparoscopic anatrophic nephrolithotomy: feasibility study in a chronic porcine model. J Urol 2003; 169:691.
- Simforoosh N, Aminsharifi A, Tabibi A, et al. Laparoscopic anatrophic nephrolithotomy for managing large staghorn calculi. BJU Int 2008; 101:1293.
- Rodrigues Netto N Jr, Claro Jde A, Ferreira U. Is percutaneous monotherapy for staghorn calculus still indicated in the era of extracorporeal shockwave lithotripsy? J Endourol 1994; 8:195.
- Auge BK, Preminger GM. Update on shock wave lithotripsy technology. Curr Opin Urol 2002; 12:287.
- Zhu S, Dreyer T, Liebler M, et al. Reduction of tissue injury in shock-wave lithotripsy by using an acoustic diode. Ultrasound Med Biol 2004; 30:675.
- Zhou Y, Cocks FH, Preminger GM, Zhong P. Innovations in shock wave lithotripsy technology: updates in experimental studies. J Urol 2004; 172:1892.
- Lam HS, Lingeman JE, Mosbaugh PG, et al. Evolution of the technique of combination therapy for staghorn calculi: a decreasing role for extracorporeal shock wave lithotripsy. J Urol 1992; 148:1058.
- Streem SB, Geisinger MA. Combination therapy for staghorn calculi in solitary kidneys: functional results with long-term followup. J Urol 1993; 149:449.
- Assimos DG, Wrenn JJ, Harrison LH, et al. A comparison of anatrophic nephrolithotomy and percutaneous nephrolithotomy with and without extracorporeal shock wave lithotripsy for management of patients with staghorn calculi. J Urol 1991; 145:710.
- Gleeson M, Lerner SP, Griffith DP. Treatment of staghorn calculi with extracorporeal shock-wave lithotripsy and percutaneous nephrolithotomy. Urology 1991; 38:145.
- de la Rosette JJ, Tsakiris P, Ferrandino MN, et al. Beyond prone position in percutaneous nephrolithotomy: a comprehensive review. Eur Urol 2008; 54:1262.
- Scoffone CM, Cracco CM, Poggio M, Scarpa RM. Endoscopic combined intrarenal surgery for high burden renal stones. Arch Ital Urol Androl 2010; 82:41.
- Ferrandino MN, Monga M, Preminger GM. Adjuvant therapy after surgical stone management. Adv Chronic Kidney Dis 2009; 16:52.
- Kristensen C, Parks JH, Lindheimer M, Coe FL. Reduced glomerular filtration rate and hypercalciuria in primary struvite nephrolithiasis. Kidney Int 1987; 32:749.
- Cohen TD, Streem SB, Lammert G. Long-term incidence and risks for recurrent stones following contemporary management of upper tract calculi in patients with a urinary diversion. J Urol 1996; 155:62.
- Lam HS, Lingeman JE, Barron M, et al. Staghorn calculi: analysis of treatment results between initial percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy monotherapy with reference to surface area. J Urol 1992; 147:1219.
- Stanley KE, Winfield HN. Management of staghorn calculi: percutaneous nephrolithotripsy versus extracorporeal shock-wave lithotripsy. Semin Urol 1994; 12:15.
- Streem SB, Yost A, Dolmatch B. Combination "sandwich" therapy for extensive renal calculi in 100 consecutive patients: immediate, long-term and stratified results from a 10-year experience. J Urol 1997; 158:342.
- Meretyk S, Gofrit ON, Gafni O, et al. Complete staghorn calculi: random prospective comparison between extracorporeal shock wave lithotripsy monotherapy and combined with percutaneous nephrostolithotomy. J Urol 1997; 157:780.
- Desai M, Jain P, Ganpule A, et al. Developments in technique and technology: the effect on the results of percutaneous nephrolithotomy for staghorn calculi. BJU Int 2009; 104:542.
- Preminger GM. High burden and complex renal calculi: aggressive percutaneous nephrolithotomy versus multi-modal approaches. Arch Ital Urol Androl 2010; 82:37.
- Beck EM, Riehle RA Jr. The fate of residual fragments after extracorporeal shock wave lithotripsy monotherapy of infection stones. J Urol 1991; 145:6.
- Segura JW. Surgical management of urinary calculi. Semin Nephrol 1990; 10:53.
- Pode D, Lenkovsky Z, Shapiro A, Pfau A. Can extracorporeal shock wave lithotripsy eradicate persistent urinary infection associated with infected stones? J Urol 1988; 140:257.
- Cicerello E, Merlo F, Gambaro G, et al. Effect of alkaline citrate therapy on clearance of residual renal stone fragments after extracorporeal shock wave lithotripsy in sterile calcium and infection nephrolithiasis patients. J Urol 1994; 151:5.
- Cicerello E, Merlo F, Maccatrozzo L, et al. Urolithiasis 2000, Rodgers AL, Hibbert BE, Hess B, et al (Eds), University of Cape Town, Cape Town, South Africa 2000. p.592.
- Kang DE, Maloney MM, Haleblian GE, et al. Effect of medical management on recurrent stone formation following percutaneous nephrolithotomy. J Urol 2007; 177:1785.
- Srivastava A, Singh KJ, Suri A, et al. Vascular complications after percutaneous nephrolithotomy: are there any predictive factors? Urology 2005; 66:38.
- Limitations of the data
- TREATMENT OPTIONS
- Medical therapy alone
- Open surgery
- Percutaneous nephrolithotomy
- Shock-wave lithotripsy
- Combination of PNL and SWL
- Adjunctive procedures
- Post-procedure monitoring
- Stone-free rate
- - Residual stone fragments
- Repeat procedures
- Acute complications of surgical methods
- Long-term complications
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS