British Journalof Urology (1991), 68,122-124 01991 British Journal of Urology
Staghorn Calculi-Long-term
Results of Management
S. KOGA, Y. ARAKAKI, M. MATSUOKA and C. OHYAMA Department of Urology, Okinawa Chubu Hospital, Gushikawa City, Okinawa, Japan
Summary-We have treated 167 patients with staghorn calculi. Conservative therapy was used in 61 patients who have been followed up for 1 to 18 years (average 7.8). Chronic renal failure occurred in 22 of these patients and 7 died from uraemia. The causes of chronic renal failure were bilateral staghorn calculi, staghorn calculi and contralateral urinary calculi, and chronic pyelonephritis of the contralateral kidney. The morbidity and mortality rates following conservative treatment were higher than those following surgical management. The pathological findings in 47 kidneys after nephrectomy showed severe hydronephrosis, renal abscess and xanthogranulomatous pyelonephritis. These results indicated that staghorn calculi destroyed the kidney and early complete removal of these stones is advisable.
The management of staghorn calculi has given rise to controversy. Libertino et al. (1971) analysed 17 cases of staghorn calculi in solitary kidneys and concluded that medical therapy was the treatment of choice for asymptomatic calculi. Others have stated that non-surgical management led to deterioration in the kidney, and suggested that surgical management was preferable (Blandy and Singh, 1976; Vargas et al., 1982). Recently, surgical management has achieved dominance as the development of surgical techniques progresses (Gil-Vernet, 1965; Smith and Boyce, 1968). However, complete removal of staghorn calculi is often difficult and the incidence of residual stone fragments is as high as 25% (Singh et aE., 1975; Rous and Turner, 1977). Surgical management may also cause vascular damage to the kidney and a decrease in renal function. We have reviewed patients with staghorn calculi and examined the pathological findings in excised kidneys, in order to investigate complications and to improve the management of staghorn calculi.
this hospital. The patients ranged in age from 17 to 84 years (average 5 1.O) and included 97 females and 70 males; female patients thus predominated 1.4: 1.O. A staghorn calculus was defined as one that fills the renal pelvis and extends into at least 2 major caliceal systems. The staghorn calculi were unilateral in 143 patients (right-sided in 70 and leftsided in 73) and bilateral in 24. Four patients had solitary kidneys. Chronic renal failure was diagnosed when the creatinine level exceeded 2.0 mg/dl. Management consisted of conservative therapy without surgery in 71 patients (87 kidneys), nephrectomy in 47 (47), extended pyelolithotomy in 33 (33), nephrolithotomy in 18 (18) and partial nephrectomy in 6 (6) (Table 1). Of 71 patients receiving conservative treatment, 61 have been followed up for 1 to 18 years (average 7.8). Four of 71 patients
Table 1 Management of Staghorn Calculi in 191 Kidneys (167 patients) No. of kidneys (%)
Patients and Methods
Between April 1965 and March 1984, 167 patients with staghorn calculi (191 kidneys) were seen at Accepted for publication 20 November 1990
Conservative therapy without surgical treatment Nephrectomy Extended pyelolithotomy Nephrolithotomy Partial nephrectomy
122
87 (45.6)
(24.6) 33 (17.3) 18 (9.4)
47 6
(3.1)
123
RESULTS OF MANAGEMENT
STAGHORN CALCULI-LONG-TERM
presented with chronic renal failure and 16 had bilateral staghorn calculi. Of the 47 patients treated by nephrectomy, 38 have been followed up for 2 to 18 years (average 10.8). Nephrectomy was performed in patients with severe renail damage and infection, and the pathological findings were assessed. Of 18 patients undergoing nephrolithotomy, 17 were followed up for 1 to 12 years (average 4.4). Of 33 patients undergoing extended pyelolithotomy, 27 have been followed up for 2 to 12 years (average 5.2). Six patients with partial nephrectomies were followed up for 2 to 11 years (average 5.6). In 8 patients with bilateral staighorn calculi, treatment varied for each kidney.
Results Of 167 patients, 13 (7.8%) were asymptomatic and 154 (92.2%) presented with symptoms (Table 2). The most common symptom was flank or abdominal pain. Urine cultures were performed in 78 patients (Table 3). Organisms grew in 85%, the most frequent organism being Proteus mirabilis. In 4 of 6 asymptomatic patients, urine culture showed urinary infection to be present. Septic shock occurred in 2 patients with urinary obstruction and pyelonephritis. Chronic renal failure occurred in 15 of 24 patients (63%) with bilateral staghorn calculi.
Table 4 Results of Conservative Therapy in 61 Patients No. ofpatients (%)
Normal renal function
39 (63.9)
Chronic renal failure Bilateral staghorn calculi Contralateral urinary calculi Chronic pyelonephritis of contralateral kidney
13 (21.3) 8 (13.1) 1 ( I .6)
Death due to uraemia (7) and other causes (3).
contralateral kidney and normal renal function. Chronic renal failure occurred in 22 patients (36%). In 19 of 22 patients chronic renal failure developed during follow-up. The causes were bilateral staghorn calculi (13), staghorn calculi and contralateral urinary calculi (8) and chronic pyelonephritis of the contralateral kidney (1). Seven of 61 patients (12%) died of uraemia due to bilateral staghorn calculi (4) and contralateral urinary calculi (3). Three patients died from other causes.
Nephrectomy Of 38 patients followed up, 30 (79%) had normal renal function. Chronic renal failure occurred during follow-up in 8 patients (21%). The causes were staghorn calculi or renal calculi in the remaining kidney (5) and chronic pyelonephritis Conservative therapy (3). Two patients (5%) died from uraemia due to The results of conservative therapy are summarised renal calculi with chronic pyelonephritis in the in Table 4. Of 61 patients followed up, 39 (64%) remaining kidney. Two patients died from other had unilateral staghorn calculi with a normal causes. The pathological findings in 47 kidneys after nephrectomy showed chronic pyelonephritis in 47 and severe hydronephrosis in 31 (Table 5). Table 2 Symptoms of Staghorn Calculi in 167 Patients Chronic pyelonephritis was seen in all excised kidneys and acute pyelonephritis or abscess was Symptoms No. ofpatients (%) often combined with chronic pyelonephritis. Pain Fever Gross haematuria Asymptomatic
115 (168.9)
43 (25.7) 30 (18.0) 13 (7.8)
Extended pyelolithotomy Of 27 patients followed up, 24 (89%) had normal renal function and 3 had chronic renal failure. One patient died from uraemia due to chronic pyelo-
Table 3 Urine Cultures in 78 Patients with Staghorn Calculi Organisms
No. (%)
Proteus species E. coli Klebsiella Staph. species Pseudomonas Others No growth
27 (34.6) 11 (14.1) 9 (11.5) 8 (10.3) 7 (9.0) 4
(5.1)
12 (15.4)
Table 5 Pathological Findings in 47 Kidneys after Nephrectomy (47 patients) Pathologicalfindings
No. ofkidneys (%)
Chronic pyelonephritis Hydronephrosis Acute pyelonephritis Abscess formation Xanthogranulomatous pyelonephritis
47 (100.0) 31 (66.0) 13 (27.7) 8 (17.0) 1
(2.1)
124
BRITISH JOURNAL OF UROLOGY
Partial nephrectomy Four of 6 patients had normal renal function. Two patients developed chronic renal failure after operation; 1 had a solitary kidney and the other had bilateral staghorn calculi which were treated with left partial nephrectomy and right extended pyelolithotomy.
infection and obstruction. Infection was seen in every case and obstruction exacerbated infection and deterioration. These results also suggest that infection and obstruction can become life-threatening and that the morbidity and mortality rates are much higher with conservative treatment. Complete surgical removal of staghorn calculi should be performed if the patient’s general condition and age allow. However, it is often difficult to remove the stones completely and residual and recurrent calculi present serious problems. Since urinary tract infection and metabolic abnormalities are important factors in the pathogenesis of staghorn calculi, we must evaluate underlying diseases. Long-term success in the management of staghorn calculi depends on complete removal of the calculi and a decrease in the recurrence rate.
Discussion
References
Singh et al. (1973) and Vargas et al. (1982) reported that asymptomatic staghorn calculi were rare and the concept of the silent staghorn calculus was incorrect. Our findings confirm that asymptomatic patients were few in number. Asymptomatic patients often have positive urine cultures and the silent staghorn calculi may give rise to symptoms sooner or later. Blandy and Singh (1976) studied 40 patients with staghorn calculi treated conservatively and the mortality rate was 28% compared with 7.2% in patients treated surgically. Rous and Turner (1977) claimed that the mortality rate following conservative therapy was 30%. Although our mortality rate is considerably lower (11.5%), it still exceeds that of extended pyelolithotomy or nephrolithotomy . It is difficult, however, to make a straightforward comparison as the conservative group contained patients in generally poor health. The morbidity and mortality rates were particularly high in patients with bilateral staghorn calculi and we have therefore concluded that surgical management is preferable. The pathological findings in kidneys following nephrectomy showed that the deterioration of kidneys with staghorn calculi was caused by
Blandy, J. P. and S i g h , M. (1976). The case for a more aggressive approach to staghorn stones. J . Urol., 115, 505506. Gi-Vernet, J. (1965). New surgical concepts in removing renal calculi. Urol. Znt., 20,255-288. Libertino, J. A.,Newman,H. R.,Lytton, B . e r d (1971).Staghorn calculi in solitary kidneys. J . Urol., 105,753-757. ROUS,S. N. and Turner, W. R. (1977). Retrospective study of 95 patients with staghorn calculus disease. J . Urol., 118, 902907. Sigh,M., Chapman, R., Tresidder, G. C. e t d (1973). The fate of the unoperated staghorncalculus. Br. J . Urol., 45,581-585. S i g h , M., Marshall, V. and Blandy, J. (1975). The residual renal stone. Br. J . Urol., 41, 125-129. Smith, M. J. V. and Boyce, W. H. (1968).Anatrophic nephrotomy and plastic calyrhaphy. J . Urol., 99, 521-527. Vargas, A. D., Bragin, S. D. and Mendez, R. (1982). Staghorn calculus : its clinical presentation, complication and management. J . Urol., 127,860-862.
nephritis caused by bilateral recurrent urolithiasis. Residual calculi were found in 6 patients (22%). Nephrolithotorny Of 17 patients followed up, 16 (94%) had normal renal function. One patient with bilateral staghorn calculi developed chronic renal failure after a right nephrolithotomy. It was not possible to remove calculi completely in 1 patient. No patient died from uraemia.
The Authors S. Koga, MD, Urologist, Nagasaki University. Y. Arakaki, MD, Urologist, Okinawa Chubu Hospital. M. Matsuoka, MD, Urologist, Okinawa Chubu Hospital. C. Ohyama, MD, Superintendent, Urologist, Nakagami Hospital. Requests for reprints to: S. Koga, Department of Urology, Nagasaki University School of Medicine, Nagasaki City, Nagasaki, Japan 852.
Staghorn Calculi-Long-term
Results of Management
S. KOGA, Y. ARAKAKI, M. MATSUOKA and C. OHYAMA Department of Urology, Okinawa Chubu Hospital, Gushikawa City, Okinawa, Japan
Summary-We have treated 167 patients with staghorn calculi. Conservative therapy was used in 61 patients who have been followed up for 1 to 18 years (average 7.8). Chronic renal failure occurred in 22 of these patients and 7 died from uraemia. The causes of chronic renal failure were bilateral staghorn calculi, staghorn calculi and contralateral urinary calculi, and chronic pyelonephritis of the contralateral kidney. The morbidity and mortality rates following conservative treatment were higher than those following surgical management. The pathological findings in 47 kidneys after nephrectomy showed severe hydronephrosis, renal abscess and xanthogranulomatous pyelonephritis. These results indicated that staghorn calculi destroyed the kidney and early complete removal of these stones is advisable.
The management of staghorn calculi has given rise to controversy. Libertino et al. (1971) analysed 17 cases of staghorn calculi in solitary kidneys and concluded that medical therapy was the treatment of choice for asymptomatic calculi. Others have stated that non-surgical management led to deterioration in the kidney, and suggested that surgical management was preferable (Blandy and Singh, 1976; Vargas et al., 1982). Recently, surgical management has achieved dominance as the development of surgical techniques progresses (Gil-Vernet, 1965; Smith and Boyce, 1968). However, complete removal of staghorn calculi is often difficult and the incidence of residual stone fragments is as high as 25% (Singh et aE., 1975; Rous and Turner, 1977). Surgical management may also cause vascular damage to the kidney and a decrease in renal function. We have reviewed patients with staghorn calculi and examined the pathological findings in excised kidneys, in order to investigate complications and to improve the management of staghorn calculi.
this hospital. The patients ranged in age from 17 to 84 years (average 5 1.O) and included 97 females and 70 males; female patients thus predominated 1.4: 1.O. A staghorn calculus was defined as one that fills the renal pelvis and extends into at least 2 major caliceal systems. The staghorn calculi were unilateral in 143 patients (right-sided in 70 and leftsided in 73) and bilateral in 24. Four patients had solitary kidneys. Chronic renal failure was diagnosed when the creatinine level exceeded 2.0 mg/dl. Management consisted of conservative therapy without surgery in 71 patients (87 kidneys), nephrectomy in 47 (47), extended pyelolithotomy in 33 (33), nephrolithotomy in 18 (18) and partial nephrectomy in 6 (6) (Table 1). Of 71 patients receiving conservative treatment, 61 have been followed up for 1 to 18 years (average 7.8). Four of 71 patients
Table 1 Management of Staghorn Calculi in 191 Kidneys (167 patients) No. of kidneys (%)
Patients and Methods
Between April 1965 and March 1984, 167 patients with staghorn calculi (191 kidneys) were seen at Accepted for publication 20 November 1990
Conservative therapy without surgical treatment Nephrectomy Extended pyelolithotomy Nephrolithotomy Partial nephrectomy
122
87 (45.6)
(24.6) 33 (17.3) 18 (9.4)
47 6
(3.1)
123
RESULTS OF MANAGEMENT
STAGHORN CALCULI-LONG-TERM
presented with chronic renal failure and 16 had bilateral staghorn calculi. Of the 47 patients treated by nephrectomy, 38 have been followed up for 2 to 18 years (average 10.8). Nephrectomy was performed in patients with severe renail damage and infection, and the pathological findings were assessed. Of 18 patients undergoing nephrolithotomy, 17 were followed up for 1 to 12 years (average 4.4). Of 33 patients undergoing extended pyelolithotomy, 27 have been followed up for 2 to 12 years (average 5.2). Six patients with partial nephrectomies were followed up for 2 to 11 years (average 5.6). In 8 patients with bilateral staighorn calculi, treatment varied for each kidney.
Results Of 167 patients, 13 (7.8%) were asymptomatic and 154 (92.2%) presented with symptoms (Table 2). The most common symptom was flank or abdominal pain. Urine cultures were performed in 78 patients (Table 3). Organisms grew in 85%, the most frequent organism being Proteus mirabilis. In 4 of 6 asymptomatic patients, urine culture showed urinary infection to be present. Septic shock occurred in 2 patients with urinary obstruction and pyelonephritis. Chronic renal failure occurred in 15 of 24 patients (63%) with bilateral staghorn calculi.
Table 4 Results of Conservative Therapy in 61 Patients No. ofpatients (%)
Normal renal function
39 (63.9)
Chronic renal failure Bilateral staghorn calculi Contralateral urinary calculi Chronic pyelonephritis of contralateral kidney
13 (21.3) 8 (13.1) 1 ( I .6)
Death due to uraemia (7) and other causes (3).
contralateral kidney and normal renal function. Chronic renal failure occurred in 22 patients (36%). In 19 of 22 patients chronic renal failure developed during follow-up. The causes were bilateral staghorn calculi (13), staghorn calculi and contralateral urinary calculi (8) and chronic pyelonephritis of the contralateral kidney (1). Seven of 61 patients (12%) died of uraemia due to bilateral staghorn calculi (4) and contralateral urinary calculi (3). Three patients died from other causes.
Nephrectomy Of 38 patients followed up, 30 (79%) had normal renal function. Chronic renal failure occurred during follow-up in 8 patients (21%). The causes were staghorn calculi or renal calculi in the remaining kidney (5) and chronic pyelonephritis Conservative therapy (3). Two patients (5%) died from uraemia due to The results of conservative therapy are summarised renal calculi with chronic pyelonephritis in the in Table 4. Of 61 patients followed up, 39 (64%) remaining kidney. Two patients died from other had unilateral staghorn calculi with a normal causes. The pathological findings in 47 kidneys after nephrectomy showed chronic pyelonephritis in 47 and severe hydronephrosis in 31 (Table 5). Table 2 Symptoms of Staghorn Calculi in 167 Patients Chronic pyelonephritis was seen in all excised kidneys and acute pyelonephritis or abscess was Symptoms No. ofpatients (%) often combined with chronic pyelonephritis. Pain Fever Gross haematuria Asymptomatic
115 (168.9)
43 (25.7) 30 (18.0) 13 (7.8)
Extended pyelolithotomy Of 27 patients followed up, 24 (89%) had normal renal function and 3 had chronic renal failure. One patient died from uraemia due to chronic pyelo-
Table 3 Urine Cultures in 78 Patients with Staghorn Calculi Organisms
No. (%)
Proteus species E. coli Klebsiella Staph. species Pseudomonas Others No growth
27 (34.6) 11 (14.1) 9 (11.5) 8 (10.3) 7 (9.0) 4
(5.1)
12 (15.4)
Table 5 Pathological Findings in 47 Kidneys after Nephrectomy (47 patients) Pathologicalfindings
No. ofkidneys (%)
Chronic pyelonephritis Hydronephrosis Acute pyelonephritis Abscess formation Xanthogranulomatous pyelonephritis
47 (100.0) 31 (66.0) 13 (27.7) 8 (17.0) 1
(2.1)
124
BRITISH JOURNAL OF UROLOGY
Partial nephrectomy Four of 6 patients had normal renal function. Two patients developed chronic renal failure after operation; 1 had a solitary kidney and the other had bilateral staghorn calculi which were treated with left partial nephrectomy and right extended pyelolithotomy.
infection and obstruction. Infection was seen in every case and obstruction exacerbated infection and deterioration. These results also suggest that infection and obstruction can become life-threatening and that the morbidity and mortality rates are much higher with conservative treatment. Complete surgical removal of staghorn calculi should be performed if the patient’s general condition and age allow. However, it is often difficult to remove the stones completely and residual and recurrent calculi present serious problems. Since urinary tract infection and metabolic abnormalities are important factors in the pathogenesis of staghorn calculi, we must evaluate underlying diseases. Long-term success in the management of staghorn calculi depends on complete removal of the calculi and a decrease in the recurrence rate.
Discussion
References
Singh et al. (1973) and Vargas et al. (1982) reported that asymptomatic staghorn calculi were rare and the concept of the silent staghorn calculus was incorrect. Our findings confirm that asymptomatic patients were few in number. Asymptomatic patients often have positive urine cultures and the silent staghorn calculi may give rise to symptoms sooner or later. Blandy and Singh (1976) studied 40 patients with staghorn calculi treated conservatively and the mortality rate was 28% compared with 7.2% in patients treated surgically. Rous and Turner (1977) claimed that the mortality rate following conservative therapy was 30%. Although our mortality rate is considerably lower (11.5%), it still exceeds that of extended pyelolithotomy or nephrolithotomy . It is difficult, however, to make a straightforward comparison as the conservative group contained patients in generally poor health. The morbidity and mortality rates were particularly high in patients with bilateral staghorn calculi and we have therefore concluded that surgical management is preferable. The pathological findings in kidneys following nephrectomy showed that the deterioration of kidneys with staghorn calculi was caused by
Blandy, J. P. and S i g h , M. (1976). The case for a more aggressive approach to staghorn stones. J . Urol., 115, 505506. Gi-Vernet, J. (1965). New surgical concepts in removing renal calculi. Urol. Znt., 20,255-288. Libertino, J. A.,Newman,H. R.,Lytton, B . e r d (1971).Staghorn calculi in solitary kidneys. J . Urol., 105,753-757. ROUS,S. N. and Turner, W. R. (1977). Retrospective study of 95 patients with staghorn calculus disease. J . Urol., 118, 902907. Sigh,M., Chapman, R., Tresidder, G. C. e t d (1973). The fate of the unoperated staghorncalculus. Br. J . Urol., 45,581-585. S i g h , M., Marshall, V. and Blandy, J. (1975). The residual renal stone. Br. J . Urol., 41, 125-129. Smith, M. J. V. and Boyce, W. H. (1968).Anatrophic nephrotomy and plastic calyrhaphy. J . Urol., 99, 521-527. Vargas, A. D., Bragin, S. D. and Mendez, R. (1982). Staghorn calculus : its clinical presentation, complication and management. J . Urol., 127,860-862.
nephritis caused by bilateral recurrent urolithiasis. Residual calculi were found in 6 patients (22%). Nephrolithotorny Of 17 patients followed up, 16 (94%) had normal renal function. One patient with bilateral staghorn calculi developed chronic renal failure after a right nephrolithotomy. It was not possible to remove calculi completely in 1 patient. No patient died from uraemia.
The Authors S. Koga, MD, Urologist, Nagasaki University. Y. Arakaki, MD, Urologist, Okinawa Chubu Hospital. M. Matsuoka, MD, Urologist, Okinawa Chubu Hospital. C. Ohyama, MD, Superintendent, Urologist, Nakagami Hospital. Requests for reprints to: S. Koga, Department of Urology, Nagasaki University School of Medicine, Nagasaki City, Nagasaki, Japan 852.
