title: Tailored minimally invasive management of complex calculi in horseshoe kidney.
abstract: OBJECTIVE
  Complex calculi in horseshoe kidney (HK) present a significant management challenge. Here, we report the clinical efficacy of extracorporeal shock wave lithotripsy (ESWL), minimally invasive percutaneous nephrolithotomy (MPCNL) and flexible ureteroscopy (FURS), combined with holmium laser lithotripsy, in the treatment of calculi in HK.
  
  
  RESULTS
  From January 2005 to May 2014, 62 HK patients with renal calculi were reviewed in terms of medical history, treatment modality and therapeutic outcome in a single tertiary care hospital. Among the patients, 11 with a solitary stone ≤ 1.5 cm in diameter received ESWL, leading to overall stone-free rate of 72.7%; 18 with stone diameter ≤ 2-3 cm received retrograde flexible ureteroscopy, with a recorded mean digitized surface area (DSA) of 339.6 ± 103.9 mm2, mean operation time of 93.1 ± 11.5 minutes and overall stone-free rate of 88.9%; and 33 with staghorn or complex calculi (d ≥ 2 cm) had MPCNL or MPCNL-FURS, with a recorded mean DSA of 691.0 ± 329.9 vs. 802.9 ± 333.3 mm2, mean operation time of 106.4 ± 16.6 vs. 124.4 ± 15.1 min and overall stone-free rate of 89.5% vs. 92.9%. For complex calculi (d ≥ 2 cm), MPCNL combined with antegrade FURS was superior in terms of reducing number of tracts, controlling mean hemoglobin drop, but required longer operation time, comparing with MPCNL alone.
  
  
  CONCLUSIONS
  As minimally invasive treatments, a combination of MPCNL and antegrade FURS provides a safe and effective modality in the management of staghorn or complex calculi (d ≥ 2 cm) in HK with significantly reduced blood loss comparing to MPCNL alone, and retrograde FURS alone is favorable for stones with a diameter ≤ 2-3 cm. ESWL is effective for viable small solitary stones (d ≤ 1.5 cm). Treatment modality should be tailored based on individual condition.
authors.affiliation: Urology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Jie
authors.initials: J
authors.lastname: Ding
authors.affiliation: Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Yuanyuan
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: Urology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Qifeng
authors.initials: Q
authors.lastname: Cao
authors.affiliation: Urology Department, Anhui Provincial Hospital, Hefei, Anhui, China.
authors.forename: Tao
authors.initials: T
authors.lastname: Huang
authors.affiliation: Radiology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Wei
authors.initials: W
authors.lastname: Xu
authors.affiliation: Anesthesiology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Kai
authors.initials: K
authors.lastname: Huang
authors.affiliation: Ultrasonograhy Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Jing
authors.initials: J
authors.lastname: Fang
authors.affiliation: Urology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Qiang
authors.initials: Q
authors.lastname: Bai
authors.affiliation: Urology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Jun
authors.initials: J
authors.lastname: Qi
authors.affiliation: Urology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Yunteng
authors.initials: Y
authors.lastname: Huang
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D000069337:Fused Kidney / Q000601:surgery*; D006801:Humans; D007669:Kidney Calculi / Q000601:surgery*; D008096:Lithotripsy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D009403:Nephrostomy, Percutaneous / Q000379:methods*; D018666:Ureteroscopy / Q000379:methods*; D055815:Young Adult
keywords: Horseshoe kidney; extracorporeal shock wave lithotripsy; flexible ureteroscopy; lower pole calculi; minimally invasive percutaneous nephrolithotomy