EVOLUTION OF THE TECHNIQUE OF COMBINATION THERAPY FOR STAGHORN CALCULI - A DECREASING ROLE FOR EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY

Percutaneous nephrostolithotomy with or without extracorporeal shock wave lithotripsy (ESWL) has been extensively used in the management of staghorn calculi, with stone-free rates varying from 23 to 86%. Explanations for the variability of such results include differences in stone burden, differences in percutaneous techniques and an overreliance on ESWL. The results and changing trends in the relative roles of percutaneous nephrostolithotomy and ESWL in the management of staghorn calculi at the Methodist Hospital of Indiana were examined. We reviewed 343 cases of staghorn calculi (partial and complete) with adequate followup data, which were managed with initial percutaneous nephrostolithotomy. Cases were divided into 2 groups: group 1 (252 cases) from 1984 to 1987 when access was performed by a radiologist and group 2 (91 cases) from 1988 to 1990 when access was performed by a urologist. Although stones in group 2 tended to be larger, a decreasing dependence on ESWL was noted (64.7% in group 1 compared to 35.2% in group 2, p <0.001). Despite the larger stone size in group 2, stone-free rates were similar (83.3% in group 1, 86.8% in group 2). In groups 1 and 2 percutaneous nephrostolithotomy alone achieved stone-free rates of 91% and 91.5%, respectively. The stone-free rate with the combination approach was 79.1% and 78.1% in groups 1 and 2, respectively. Technical refinements with percutaneous nephrostolithotomy in group 2 include accurate and carefully selected accesses (superior pole in 36.3%) for best approach to the stone, multiple accesses (13.3%) and improved skills in flexible nephroscopy. Blood transfusion has not been required in group 2 compared with 11.1% in group 1. Mean hospital stay was 12.4 days in group 1 and 10.3 days in group 2 (percutaneous nephrostolithotomy alone, 7.2 days). With careful attention to percutaneous nephrostolithotomy techniques, complex renal stones can be successfully managed endourologically, reducing the need for combination ESWL. Complications previously associated with percutaneous nephrostolithotomy have decreased.