title: Multi-tract percutaneous nephrolithotomy for large complete staghorn calculi.
abstract: BACKGROUND
  The treatment of large complete staghorn calculi requires a sandwich combination of percutaneous nephrolithotomy (PCNL) and shockwave lithotripsy (SWL) or sometimes open surgery. Many urologists hesitate to place more than 2-3 tracts during PCNL because of the belief that this may increase complications. We present data to support multi-tract PCNL for large (surface area >3,000 mm(2)) complete staghorn calculi.
  
  
  METHODS
  From July 1998 to October 2003, 121 renal units (103 patients) with large complete staghorn renal calculi were treated with PCNL. All procedures were performed in the prone position after retrograde ureteral catheterization. Fluoroscopy-guided punctures were made by the urologist followed by track dilation to 34 french. When multiple tracts were anticipated all punctures were usually made at the outset and preplaced wires were put into the collecting system or down the ureter. Stones were fragmented and removed using a combination of pneumatic lithotripsy and suction. Postoperative stone clearance was documented on X-ray KUB.
  
  
  RESULTS
  121 renal units of 103 patients (15 women and 88 men, mean age 43 years) were treated. Six patients had associated bladder calculi that were treated simultaneously. The stone surface area was 3,089-6,012 (mean 4,800) mm(2). 10 patients (9.7%) had renal insufficiency with a mean (range) serum creatinine of 3.0 (1.5-5.5) mg/dl. The number of tracts required per patient were 2 tracts in 11, 3 tracts in 68, 4 tracts in 39, and 5 tracts in 3, giving a total of 397 tracts in 121 renal units, over a total of 140 procedures (including second-look procedures in 19 renal units). The points of entry of these tracts were 121 upper calyx (30.4%), 178 middle calyx (44.8%), and 98 lower calyx (24.6%). All 121 units had one upper polar access tract of which 92 (76%) were supracostal. Complications were blood transfusion (n = 18), pseudoaneurysm (n = 2), fever (n = 22), septic shock (n = 1) and hydrothorax (n = 3). PCNL monotherapy achieved an 84% complete clearance rate that improved to 94% with SWL in 8 renal units with small residual fragments. Stone compositions were calcium oxalate (91%), uric acid (2%) and mixed (7%).
  
  
  CONCLUSIONS
  Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi.
authors.affiliation: Department of Urology, All India Institute of Medical Sciences, New Delhi, India. monisharon@hotmail.com
authors.forename: Monish
authors.initials: M
authors.lastname: Aron
authors.forename: Rajiv
authors.initials: R
authors.lastname: Yadav
authors.forename: Rajiv
authors.initials: R
authors.lastname: Goel
authors.forename: Surendra B
authors.initials: SB
authors.lastname: Kolla
authors.forename: Gagan
authors.initials: G
authors.lastname: Gautam
authors.forename: Ashok K
authors.initials: AK
authors.lastname: Hemal
authors.forename: Narmada P
authors.initials: NP
authors.lastname: Gupta
mesh_terms: D000328:Adult; D005260:Female; D005471:Fluoroscopy; D005500:Follow-Up Studies; D006801:Humans; D007669:Kidney Calculi / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D009403:Nephrostomy, Percutaneous / Q000379:methods*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome