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
- Section Editor — Mineral and Bone Metabolism
- Section Editor — 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
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- 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.
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- 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
- SUMMARY AND RECOMMENDATIONS