Multi-Tract Percutaneous Nephrolithotomy for Large Complete Staghorn Calculi

Abstract

Introduction: 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 mm²) complete staghorn calculi. Patients and 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) mm². 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%). Conclusion: Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi.

Single lower calyceal percutaneous tract combined with flexible nephroscopy: A valuable treatment paradigm for staghorn stones

“…Although feasible, access to all the calices through a single percutaneous tract is difficult because of the peculiarities of the renal collecting system, therefore, multiple-access PCNL is the mainstay of the treatment conducted by many urologists, for the management of staghorn calculi. 8,9 Multi-tract approach preserve the advantage of offering straight and alternative accesses to the stone with use of large ultrasonic lithotripters for effective fragmentation and high SFRs . Accesses which are not prevented by the potential existence of anatomic anomalies such as malrotated kidney and infundibular stenosis, while the presence of which could make the access through a single percutaneous tract challenging.…”

Percutaneous-Based Management of Staghorn Calculi in Solitary Kidney: Combined Mini Percutaneous Nephrolithotomy versus Retrograde Intrarenal Surgery

“…The little tract was believed to reduce the risk of tract-related complications, while it was more time-consuming to remove stones with large burden [12]. The 32-Fr tract with a large nephroscope was always hampered by the narrow infundibulum and a greater torque would increase the risk of laceration to the renal parenchyma and severe bleeding, especially in solitary kidney [2,13]. To strike a balance, a 24-Fr tract was preferred in this series so that the majority of staghorn calculi could be extracted quickly by EMS Lithoclast with a modified nephroscope via the 24-Fr tract.…”

Standard-Tract Combined with Mini-Tract in Percutaneous Nephrolithotomy for Renal Staghorn Calculi

“…The debate continues over the use of single-tract versus multiple-tract PCNL in these cases. Some scholars believed that aggressive PCNL monotherapy using multiple tracts was safe and effective [3,4], and should be the first option for massive renal staghorn calculi. However, Manohar et al [5] found that greater blood loss occurred in patients requiring multiple tracts.…”