Combined percutaneous ultrasonic lithotripsy and extracorporeal shock wave lithotripsy for struvite staghorn calculi

Summary A group of patients with struvite staghorn calculi were treated by combining percutaneous ultrasonic lithotripsy (PUL) and extracorporeal shock wave lithotripsy. Stone free rates at a mean follow-up of six months were only 23%. Far superior results have been achieved with PUL above. The primary treatment of struvite staghorn should be with PUL. Shock wave lithotripsy should be reserved for fragments difficult or dangerous to access.     

A comparison of anatrophic nephrolithotomy and percutaneous nephrolithotomy with and without extracorporeal shock wave lithotripsy for management of patients with staghorn calculi

A retrospective study was conducted comparing anatrophic nephrolithotomy (10 cases), percutaneous nephrolithotomy alone (4 cases) or percutaneous nephrolithotomy combined with extracorporeal shock wave lithotripsy (23 cases) for the treatment of large staghorn calculi. A comparison based on collecting system anatomy demonstrated that anatrophic nephrolithotomy resulted in a greater stone-free rate, shorter hospitalization and lower costs while complication rates were similar. Anatrophic nephrolithotomy should still be considered a viable treatment option, especially for patients with large branched calculi in complex collecting systems.     

Critical evaluation of treatment of staghorn calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy

The combined use of percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy in patients with staghorn calculi has become an established treatment regimen. We evaluated the results of 90 staghorn calculi-bearing kidneys treated with such combination therapy after a mean follow-up of approximately 2 years. A total of 69 kidneys (76.7 per cent) became free of stones at some point after treatment. However, due to stone recurrence this number decreased to 55 kidneys (61.1 per cent) at the end of follow-up. Patients who had undergone a previous open operation on the stone-bearing kidney showed less favorable results than the over-all group. When our results were compared to reported data on open surgery or percutaneous nephrolithotomy alone even better results may have been obtained by such treatment modalities. However, our data indicate that percutaneous stone debulking combined with further destruction of residual stone fragments by shock wave lithotripsy certainly is less invasive than an open operation and provides an alternative to percutaneous treatment alone, which can yield comparable results.     

Combined treatment of branched calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy

Eighty-seven patients with branched renal calculi were treated by a combination of percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. Stone debulking was achieved by percutaneous nephrolithotomy and residual stone fragments were destroyed by shock wave lithotripsy. Of the patients 70 (80 per cent) required 2 to 3 treatments, 12 (14 per cent) required 4 treatments and 5 (6 per cent) required 5 to 6 treatments. Results after 3 months indicated that 58 patients were free of stones, 3 had recurrent stones and 12 had disintegrated stone particles (less than 3 mm.) in the collecting system, while 13 were lost to followup. One patient had undergone nephrectomy. This treatment plan minimized the disadvantages of either technique when used alone and made open operative intervention unnecessary. Procedural and fluoroscopy times were reduced drastically compared to reported data on percutaneous nephrolithotomy only. We believe that more than 90 per cent of all branched calculi can be treated with this combined technique.     

Pneumatic lithotripsy through pyelotomy incision during open surgery for staghorn calculi: an alternative method to anatrophic nephrolithotomy

INTRODUCTION: Our purpose was to remove large-volume staghorn calculi with less morbidity and maximum ease without an anatrophic nephrolithotomy, with the use of a pneumatic lithotriptor during pyelolithotomy to disintegrate the branches of stones extending into the calyces and retained calyceal fragments. PATIENTS AND METHODS: Sixteen patients (17 renal units) with large-volume staghorn stones were evaluated with blood urea nitrogen (BUN), creatinine levels, urinalysis, and culture, excretory urography (IVP), and 99mtechnetium dimercaptosuccinic acid (DMSA) renal scintigraphy preoperatively. Patients were treated with a pneumatic lithotriptor at the time of open pyelolithotomy. Bilateral surgery was performed in 1 patient. The mean follow-up period was 12 (range 6-24) months. The patients were re-evaluated postoperatively at 6 months with BUN and serum creatinine measurements, urinalysis and culture, IVP, and renal scintigraphy with DMSA. Data were analyzed by one-way ANOVA test. p < 0.05 was considered statistically significant. RESULTS: After treatment, 15 of 17 renal units (88%) were rendered stone-free while residual fragments remained in two patients. Average operation time was 190 min (range 135-285) with a mean blood loss of 226 ml (range 140-425). No patient required blood transfusion. Average length of hospital stay was 4.2 days (range 3-7). Six months after surgery, mean BUN and creatinine levels were decreased from 31.2 to 28.2 mg/dl (p = 0.248) and from 1.3 to 1.1 mg/dl (p = 0.001), respectively. Renal scintigraphy with DMSA revealed an increase in ipsilateral average renal function from 39 to 43% (p = 0.043). IVP also revealed a decrease in pelvicalyceal dilatation in almost all patients with a well-functioning kidney and without any stone recurrence. No complications were encountered postoperatively except for an episode of high fever in 1 patient. CONCLUSION: Avoiding incision of the renal parenchyma and arterial clamping, without significant bleeding and the nephron loss seem to be the advantages of this technique. Kidney function can be preserved with this simple and easily applicable method, which may be an alternative procedure to anatrophic nephrolithotomy for the majority of patients with staghorn calculi requiring open surgery.     

Treatment of staghorn calculi with extracorporeal shock-wave lithotripsy and percutaneous nephrolithotomy

Between August 1983 and August 1987, 72 staghorn calculi were treated in 66 patients. Treatment was with percutaneous nephrolithotomy (PCNL) in 30, extracorporeal shock-wave lithotripsy (ESWL) in 18, combination PCNL-ESWL in 23, and nephrectomy in 1. Complications occurred in 59 percent of patients and were twice as common after PCNL as after ESWL. Radiologic follow-up on 69 kidneys (97%) showed 58 percent were stone-free, 15 percent had residual sand or matchheads less than 5 mm, 17 percent had residual fragments of 5-15 mm, and 10 percent had greater than 15 mm residual stone burden. With a mean follow-up of thirty months, 2 of 40 stone-free patients had persistent asymptomatic Proteus urinary tract infections, and 4 of 22 patients with residual calculi less than or equal to 15 mm required additional operative treatment.     

Primary extracorporeal shock wave lithotripsy of staghorn renal calculi.

186 patients with partial and 55 patients with complete renal staghorn calculi were treated with primary extracorporeal shock wave lithotripsy (ESWL) at the Department of Urology, University of Würzburg Medical School. Partial staghorn calculi required an average of 1.4, complete staghorn calculi an average of 2.2 treatment sessions using the Dornier HM 3 lithotriptor. 55% of all patients and 46% of the patients with complete staghorn calculi were rendered stone-free within 1 year after ESWL. Pretreatment urinary tract infections present in 50.6% of all patients could be reduced to 22.5% 1 year after ESWL. The most frequent complications after ESWL were ureteral obstruction caused by 'steinstrasse' (41.4%), fever (38.4%), and renal colics (29.4%). Severe complications needing open operative procedures or blood transfusions did not occur. 50% of all patients underwent auxiliary procedures (e.g. insertion of indwelling ureteral stents: 25.3%, percutaneous nephrostomy: 20.3%, percutaneous nephrolithotripsy: 2.9%). Pretreatment insertion of an indwelling ureteral stent was found to reduce posttreatment complications as well as the need for percutaneous nephrostomy only in patients with partial staghorn calculi. The data presented in this study demonstrate that primary ESWL therapy can be safely and successfully performed in the majority of patients with renal staghorn calculi. In patients requiring complete removal of all stone fragments, a percutaneous lithotripsy can be performed following ESWL.     

Combined extracorporeal shock wave lithotripsy and percutaneous alkalinization in uric acid calculi

The combination of percutaneous alkaline irrigation and lithotripsy was performed in 5 cases of uric acid calculi obstructing the ureter. Shock wave lithotripsy accelerates the dissolution of uric acid stones.     

Retroperitoneal laparoscopic anatrophic nephrolithotomy for large staghorn calculi

Objectives: Treatment of staghorn calculus is challenging. We evaluated the feasibility and efficacy of the retroperitoneal laparoscopic approach for the management of large staghorn renal calculi. Methods: Patients with staghorn renal calculi unsuitable for percutaneous nephrolithotomy were analyzed. They underwent retroperitoneal laparoscopic anatrophic nephrolithotomy, involving control of the renal artery, stone removal through a nephrotomy incision on the Brodel's line and closure with continuous sutures. Results: A total of 11 patients with renal stones were included in the present study. Mean patient age was 55 years (range 42–68) and stone size was 52 mm (range 43–61). Warm ischemia time and operative duration were 31 (range 23–38) and 139 min (range 105–160), respectively. No blood transfusion was needed during or after operation. An 8‐mm residual calculus remained in the lower calyces in one patient who was successfully treated by using shock wave lithotripsy. Intravenous pyelogram after surgery showed a functional corresponding renal unit, with an improvement in obstruction in all patients. Conclusions: Retroperitoneal laparoscopic technique can be applied for patients who are candidates for anatrophic nephrolithotomy. Larger studies with a longer follow up are needed to confirm these findings.     

Laparoscopic anatrophic nephrolithotomy for managing large staghorn calculi

OBJECTIVES

To evaluate the efficacy of a laparoscopic approach for managing large staghorn renal calculi.

PATIENTS AND METHODS

Laparoscopic transperitoneal anatrophic nephrolithotomy was used to duplicate open anatrophic nephrolithotomy in five patients (three men) with large staghorn renal stones unsuitable for percutaneous nephrolithotomy. Only the renal artery was clamped, using a bulldog clamp. The stone was removed through a nephrotomy incision on the Brodel line, which was closed using 3/0 polyglactin continuous sutures, and sutures were buttressed by haemostatic clips instead of knots. Intraoperative ultrasonography was used in the last two patients to evaluate residual stones.

RESULTS

The mean (range) stone size was 53 (45–65) mm, the patient age was 53 (45–58) years, and the warm ischaemia and operative duration were 32 (29–35) and 170 (120–225) min, respectively. No blood transfusion was needed during or after surgery. All of the procedures were uneventful and there was no urine leakage after surgery. Only an 8‐mm and a 6‐mm residual stone remained in the first and third patients, in the lower and middle calyces, respectively. Both of them were subsequently treated with shock wave lithotripsy. An intravenous pyelogram after surgery showed a functional corresponding renal unit, with a significant improvement in obstruction in all patients.

CONCLUSION

Laparoscopic anatrophic nephrolithotomy is a promising alternative for patients who are candidates for open surgery, with an acceptable stone‐free rate. While offering a minimally invasive approach, it can minimize the need for secondary invasive interventions. Further patients and a longer follow‐up are needed before this is suggested as the preferred method in selected patients in the future.     

输尿管软镜和体外冲击波治疗单通道经皮肾镜术后残石的比较

目的探讨输尿管软镜钬激光碎石（fURS）治疗单通道经皮肾镜碎石取石术（PCNL）治疗复杂性结石后残余结石的临床价值。 方法回顾性选择2014年1月至2016年12月来我院接受单通道PCNL治疗复杂性肾结石后出现残余结石<20 mm的患者105例。根据处理残石方法不同而分为试验组（fURS,n=60例）和对照组[体外冲击波碎石术（ESWL）,n=45例],并分析比较两组患者的一般资料、围手术期参数、并发症的情况。 结果试验组患者在平均手术时间、手术成功率、结石清除率、需要再次治疗率方面明显优于对照（t或χ²分别为6.255,7.415,9.358,10.423;P值分别为<0.001,0.006,0.002,0.001）,试验组患者术后疼痛、肾功能减退方面的并发症例数少于对照组,且总的并发症发生率显著低于对照组（χ²=6.369,P=0.012）。 结论针对单通道PCNL后残余结石的患者,相对于ESWL,fURS治疗后结石清除率更高,且术后并发症的更低,安全性高,值得在临床上推广。     

Extracorporeal shock wave lithotripsy of staghorn calculi

A total of 260 patients underwent treatment with extracorporeal shock wave lithotripsy (ESWL). Staghorn calculi were found in 32 cases. In carrying out ESWL for staghorn calculi, double pigtail stent was previously retained in principle. When the ureter was occluded by stone street in case a fever of more than 38° C lasted for 4–5 days after the first treatment with ESWL, percutaneous nephrostomy (PNS) was performed. In ESWL treatment alone a large number of shock waves were required, but double pigtail stent and PNS were used in combination individually, and larger stones were treated by the same waves. When combination therapy was used, hospital stay was short and the rate of remaining stones was low. Our therapeutic conclusions are discussed.     

Staghorn calculi: percutaneous versus anatrophic nephrolithotomy

In a retrospective analysis percutaneous ultrasonic lithotripsy and anatrophic nephrolithotomy for staghorn stones were compared to evaluate morbidity. In 46 patients treated percutaneously and 29 patients treated by open surgery, the procedure time, success rate, complication rate, length of hospitalization, disability period, and amount of analgesics needed in the postoperative period were analyzed. 5 patients treated during the learning period were not considered for this study, no matter whether they were treated by open or percutaneous surgery. Complete removal of all stone fragments was achieved in 73.8% of the patients treated percutaneously. Calculi were removed successfully in 82.1% of the patients submitted to anatrophic lithotomy. The group treated percutaneously showed shorter procedural time (mean 120 versus 210 min), shorter hospitalization period (5 versus 7 days), less need for analgesics (mean 1.6 versus 4.7 doses per patient), and an earlier return to normal physical activities (9 versus 43 days). Among the patients who underwent open surgery, 14 (50.0%) required additional interventions to treat complications. Although in the percutaneous group 28.5% required more than one percutaneous intervention, the overall complication rate per surgery of 20.0% was significantly lower, with no need for open surgery. Percutaneous nephrolithotomy proved to be of significantly lower morbidity than anatrophic lithotomy.     

经皮肾镜联合输尿管软镜碎石术治疗鹿角形肾结石体会

目的总结单一微通道经皮肾镜碎石术（MPCNL）联合输尿管软镜碎石术治疗鹿角形。肾结石的临床经验体会。方法57例鹿角形肾结石均采用MPCNL和输尿管软镜碎石术联合治疗。结石大小（2．7cm×3．3cm～3．8cm×5．2cm）,平均3．7cm×4．1cm。结果46例鹿角形结石一期碎石、取石成功,平均手术时间128min,平均出血量80mL（20～150mL）,结石清除率为80．7％;11例残余结石主要集中于肾下盏,少部分位于肾中盏,于术后1个月行二期输尿管软镜碎石术,平均手术时间为57min,结石总清除率为93％（53／57）。4例术后仍有少量结石残留,大小为0．4～0．8cm,予以体外冲击波碎石术（ESWL）治疗,随访3个月,结石清除2例。结论MPCNL联合输尿管软镜碎石术治疗鹿角形肾结石可有效提高结石清除率,减少创伤及并发症。     

Combined therapy of staghorn calculi with ureteroscopy and extracorporeal shock wave lithotripsy. Experience with 10 cases

We report our experience with 10 cases of staghorn calculi treated by combination therapy with ureteroscopy and extracorporeal shock wave lithotripsy (ESWL). The ultrasonic disintegration technique is described. The procedure, followed by ESWL, may in our opinion become an optimal method for the combination treatment of complex calculi.     

Staghorn calculi: percutaneous extraction versus anatrophic nephrolithotomy

We compared the procedure time, success rates, complications and recovery times for percutaneous ultrasonic lithotripsy (75 cases) and anatrophic nephrolithotomy (25) in patients with staghorn stones. Although the frequency of retained stone fragments was higher in the former group (13.3 versus 0 per cent), the shorter total procedure time (average 155.1 versus 266.5 minutes), lesser need for blood transfusions (average 2 units packed red cells in 53 per cent of the patients versus 3.5 units in 70 per cent) and narcotics (average 16 versus 33 doses), and far more rapid return to work (average 14.3 versus 54.5 days after the patients were discharged from the hospital) strongly favor percutaneous over open stone removal.     

Extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy

This article reviews the basic anesthetic considerations for ESWL and PCNL. General principles governing the operation of lithotripters, elements of treatment that impinge on safety, and effective intraoperative anesthesia and complications that may be encountered in the perioperative period are discussed. Factors influencing blood loss and concerns arising from positioning patients prone are addressed in the sections devoted to PCNL.