Vol. 118, December Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
Original Articles RETROSPECTIVE STUDY OF 95 PATIENTS WITH STAGHORN CALCULUS DISEASE STEPHEN N. ROUS
WILLIAM R. TURNER
AND
From the Department of Urology, Medical University of South Carolina, Charleston, South Carolina
ABSTRACT
Medical records were reviewed for 95 consecutive patients hospitalized with a diagnosis of staghorn calculus disease. Of those patients in whom a conservative, non-operative approach was taken 30 per cent ultimately died of renal failure and/or sepsis. It is concluded that surgical intervention is the treatment of choice for patients with staghorn calculus disease. Optimal management of patients with staghorn calculi is still controversial. Although most urologic literature indicates a preference for an aggressive surgical approach the opinion is not unanimous, a segment of the urologic community preferring the non-operative approach particularly when symptoms are minimal or absent. To clarify further the issue and to promote better patient care medical records for all patients with this condition were reviewed. MATERIALS AND METHOD
Charts were reviewed for 95 patients hospitalized between 1957 and 1R76 with a diagnosis of staghorn calculus disease. This group represented all patients hospitalized with this condition at the Medical University Hospital and at the Veterans Administration Hospital. Staghorn calculi were defined as stones filling the renal pelvis and at least 2 major caliceal branches. A minimum of a 1-year followup was obtained. RESULTS
The average age of patients when first seen was just less than 50 years. There were 54 white and 41 black patients, a distribution approximating that found in our hospitals during the years of study. The sex distribution was 73 women and 22 men, with 5 men having quadriplegia or paraplegia and 1 having a neurogenic bladder secondary to a disk operation. Virtually all patients had minimal presenting symptomatology and almost a quarter (23 patients) had absolutely no signs or symptoms (table 1). A majority of patients with signs or symptoms (55) had an interval of 1 year between the onset of signs or symptoms and hospitalization. Significant bacteriuria was noted in 84 patients when they were first seen and the other 11 patients had a history of urinary tract infection, although their cultures were negative at presentation. The predominant organism found in the 84 patients was Proteus (64 patients), with Escherichia coli next in frequency (14 patients). Pseudomonas was present in 2 patients, Aerobacter in 2 and Klebsiella and Enterococcus in 1 each. Based upon the blood urea nitrogen and creatinine levels 35 patients had decreased renal function when they were first seen and 60 patients had normal function. Parathyroid adenomas were found during the diagnostic study prior to any Accepted for publication March 18, 1977. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 27-31, 1977.
renal operation in 9 of the 95 patients (10 per cent) but surgical removal of the adenoma resulted in cessation of stone formation in only 1 patient. All 9 patients had bacteriuria and the adenomas possibly were related to but clearly not causative of the staghorn calculus formation. At hospitalization 45 patients had a normal contralateral kidney on excretory urography and 25 had stone formation and/or roentgenographic evidence of pyelonephritis on the contralateral side (table 2). In 28 patients previous operations had been done for stone disease and 15 patients had had a previous operation on the kidney with the staghorn calculus. Of the 95 patients 36 were treated by Jlephrectomy, 30 were treated conservatively with no operation at all, 26 underwent pyelolithotomy, nephrolithotomy or both, 2 had heminephrectomy with stone removal and 1 had attempted stone removal, which was discontinued because of excessive bleeding (table 3). At the time ofnephrectomy in the 36 patients 26 contralateral kidneys were normal, 8 contralateral kidneys had stones or a history of stones or infection and 2 contralateral kidneys had a staghorn calculus. Of these 36 patients 21 have remained asymptomatic with no stones or infection in the solitary kidney and with normal renal function. In 1 patient _stones have formed in the solitary kidney and 2 patients with pre-existing infection and/or stone in the solitary kidney have had no further deterioration or stone formation and minimal or no decrease in renal function. Only 1 of 8 patients who have died since nephrectomy died of renal-related causes (table 4). Of 28 patients in whom removal of the staghorn calculi was attempted 19 were treated with pyeloinfundibulolithotomy (Gil Vernet technique), 4 with pyelonephrolithotomy, 3 with anatrophic nephrotomy1 and 2 with heminephrectomy. Of these 28 patients complete stone removal was accomplished in 21 and 14 of these had stable renal function postoperatively, 2 had improved renal function, 1 had new stone formation and 2 patients died ofrenal failure (table 5). Of the 7 patients who had incomplete stone removal (prior to the advent of good intraoperative radiologic techniques) persistent bacteriuria and/or pain and/or stone growth resulted in 3 patients and necessitated an additional operation to remove the residual stone or the kidney. Two patients had stable renal function without pain but with persistent bacteriuria and 1 patient had decreased renal function (table 6). Of 30 patients who were not operated upon 9 died of causes directly related to progressive renal failure and/or sepsis. Five patients remained asymptomatic but with persistent
902
95
RETROSPECTIVE STUDY OF
bacteri.uria, 4 continued to have pain, bacteriuria and de-creasing renal function, and 3 continued to have pain, bacte:riuria and stable renal function. Two patients subsequently had stone removal and/or nephrectomy because of symptoms, TABLE
1. Presenting symptoms or signs No. Pts.
No signs or symptoms; stone found serendipitously tract infection and investigation disclosed stone of stones so patient followed with J
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
Original Articles RETROSPECTIVE STUDY OF 95 PATIENTS WITH STAGHORN CALCULUS DISEASE STEPHEN N. ROUS
WILLIAM R. TURNER
AND
From the Department of Urology, Medical University of South Carolina, Charleston, South Carolina
ABSTRACT
Medical records were reviewed for 95 consecutive patients hospitalized with a diagnosis of staghorn calculus disease. Of those patients in whom a conservative, non-operative approach was taken 30 per cent ultimately died of renal failure and/or sepsis. It is concluded that surgical intervention is the treatment of choice for patients with staghorn calculus disease. Optimal management of patients with staghorn calculi is still controversial. Although most urologic literature indicates a preference for an aggressive surgical approach the opinion is not unanimous, a segment of the urologic community preferring the non-operative approach particularly when symptoms are minimal or absent. To clarify further the issue and to promote better patient care medical records for all patients with this condition were reviewed. MATERIALS AND METHOD
Charts were reviewed for 95 patients hospitalized between 1957 and 1R76 with a diagnosis of staghorn calculus disease. This group represented all patients hospitalized with this condition at the Medical University Hospital and at the Veterans Administration Hospital. Staghorn calculi were defined as stones filling the renal pelvis and at least 2 major caliceal branches. A minimum of a 1-year followup was obtained. RESULTS
The average age of patients when first seen was just less than 50 years. There were 54 white and 41 black patients, a distribution approximating that found in our hospitals during the years of study. The sex distribution was 73 women and 22 men, with 5 men having quadriplegia or paraplegia and 1 having a neurogenic bladder secondary to a disk operation. Virtually all patients had minimal presenting symptomatology and almost a quarter (23 patients) had absolutely no signs or symptoms (table 1). A majority of patients with signs or symptoms (55) had an interval of 1 year between the onset of signs or symptoms and hospitalization. Significant bacteriuria was noted in 84 patients when they were first seen and the other 11 patients had a history of urinary tract infection, although their cultures were negative at presentation. The predominant organism found in the 84 patients was Proteus (64 patients), with Escherichia coli next in frequency (14 patients). Pseudomonas was present in 2 patients, Aerobacter in 2 and Klebsiella and Enterococcus in 1 each. Based upon the blood urea nitrogen and creatinine levels 35 patients had decreased renal function when they were first seen and 60 patients had normal function. Parathyroid adenomas were found during the diagnostic study prior to any Accepted for publication March 18, 1977. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 27-31, 1977.
renal operation in 9 of the 95 patients (10 per cent) but surgical removal of the adenoma resulted in cessation of stone formation in only 1 patient. All 9 patients had bacteriuria and the adenomas possibly were related to but clearly not causative of the staghorn calculus formation. At hospitalization 45 patients had a normal contralateral kidney on excretory urography and 25 had stone formation and/or roentgenographic evidence of pyelonephritis on the contralateral side (table 2). In 28 patients previous operations had been done for stone disease and 15 patients had had a previous operation on the kidney with the staghorn calculus. Of the 95 patients 36 were treated by Jlephrectomy, 30 were treated conservatively with no operation at all, 26 underwent pyelolithotomy, nephrolithotomy or both, 2 had heminephrectomy with stone removal and 1 had attempted stone removal, which was discontinued because of excessive bleeding (table 3). At the time ofnephrectomy in the 36 patients 26 contralateral kidneys were normal, 8 contralateral kidneys had stones or a history of stones or infection and 2 contralateral kidneys had a staghorn calculus. Of these 36 patients 21 have remained asymptomatic with no stones or infection in the solitary kidney and with normal renal function. In 1 patient _stones have formed in the solitary kidney and 2 patients with pre-existing infection and/or stone in the solitary kidney have had no further deterioration or stone formation and minimal or no decrease in renal function. Only 1 of 8 patients who have died since nephrectomy died of renal-related causes (table 4). Of 28 patients in whom removal of the staghorn calculi was attempted 19 were treated with pyeloinfundibulolithotomy (Gil Vernet technique), 4 with pyelonephrolithotomy, 3 with anatrophic nephrotomy1 and 2 with heminephrectomy. Of these 28 patients complete stone removal was accomplished in 21 and 14 of these had stable renal function postoperatively, 2 had improved renal function, 1 had new stone formation and 2 patients died ofrenal failure (table 5). Of the 7 patients who had incomplete stone removal (prior to the advent of good intraoperative radiologic techniques) persistent bacteriuria and/or pain and/or stone growth resulted in 3 patients and necessitated an additional operation to remove the residual stone or the kidney. Two patients had stable renal function without pain but with persistent bacteriuria and 1 patient had decreased renal function (table 6). Of 30 patients who were not operated upon 9 died of causes directly related to progressive renal failure and/or sepsis. Five patients remained asymptomatic but with persistent
902
95
RETROSPECTIVE STUDY OF
bacteri.uria, 4 continued to have pain, bacteriuria and de-creasing renal function, and 3 continued to have pain, bacte:riuria and stable renal function. Two patients subsequently had stone removal and/or nephrectomy because of symptoms, TABLE
1. Presenting symptoms or signs No. Pts.
No signs or symptoms; stone found serendipitously tract infection and investigation disclosed stone of stones so patient followed with J
