title: Staghorn calculi: analysis of treatment results between initial percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy monotherapy with reference to surface area.
abstract: Treatment recommendations and results reported for the management of staghorn calculi are highly variable. In an attempt to provide a more objective means to compare treatment results for staghorn renal calculi, stone burden as measured by stone surface area was used. Stone surface area was determined by computer analysis. A total of 380 cases of staghorn calculi treated at the same institution was evaluated. Treatment consisted of initial percutaneous nephrostolithotomy with or without extracorporeal shock wave lithotripsy (ESWL*) in 298 cases and ESWL monotherapy in 82. When considered as a group, the overall stone-free rate for initial percutaneous nephrostolithotomy (mean surface area 1,378.3 mm.2) was 84.2% compared to 51.2% (p less than 0.0001) for ESWL monotherapy (mean surface area 693.4 mm.2). For staghorn calculi smaller than 500 mm.2 a stone-free rate of 94.4% was achieved in the percutaneous nephrostolithotomy with or without ESWL group compared to 63.2% for ESWL monotherapy (p = 0.0214). For calculi of 501 to 1,000 mm.2 the stone-free rates were 86% and 45.7%, respectively (p less than 0.0001). When stone surface area exceeded 1,000 mm.2 the stone-free rate for percutaneous nephrostolithotomy with or without ESWL was 82.4% but it was only 22.2% for ESWL monotherapy (p = 0.0002). Overall, when adjusted for stone surface area the odds of being stone-free were more than 8 times higher for initial percutaneous nephrostolithotomy versus ESWL monotherapy (odds ratio = 8.36, p less than 0.0001). While percutaneous nephrostolithotomy with or without ESWL appears to be the procedure of choice for most staghorn stones, ESWL monotherapy may have a role for some stones smaller than 500 mm.2. In 12 such cases associated with a nondilated renal collecting system (mean surface area 380.5 mm.2) a stone-free rate of 91.7% was achieved. The number of procedures required to complete therapy was higher in the initial percutaneous nephrostolithotomy group (2.8 versus 2.1, p less than 0.0001). Although complications were more common in the ESWL monotherapy group (manifested as obstruction in 30.5%), bleeding requiring blood transfusion was more frequent in the initial percutaneous nephrostolithotomy group (9.4%).
authors.affiliation: Department of Medical Research, Methodist Hospital of Indiana, Indiana University School of Medicine, Indianapolis.
authors.forename: H S
authors.initials: HS
authors.lastname: Lam
authors.forename: J E
authors.initials: JE
authors.lastname: Lingeman
authors.forename: M
authors.initials: M
authors.lastname: Barron
authors.forename: D M
authors.initials: DM
authors.lastname: Newman
authors.forename: P G
authors.initials: PG
authors.lastname: Mosbaugh
authors.forename: R E
authors.initials: RE
authors.lastname: Steele
authors.forename: P M
authors.initials: PM
authors.lastname: Knapp
authors.forename: J W
authors.initials: JW
authors.lastname: Scott
authors.forename: A
authors.initials: A
authors.lastname: Nyhuis
authors.forename: J R
authors.initials: JR
authors.lastname: Woods
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D005260:Female; D006801:Humans; D007669:Kidney Calculi / Q000473:pathology / Q000628:therapy*; D008096:Lithotripsy; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous; D011379:Prognosis; D012074:Remission Induction