S102 Percutaneous nephrolithotripsy and shockwave lithotripsy in the treatment of staghorn kidney lithiasis

To investigate the efficacy and safety of percutaneous nephrolithotripsy (PCNLT) as monotherapy and in combination with shockwave lithotripsy (SWL) in the treatment of staghorn kidney lithiasis.

For a 3 year period (July 2003 – July 2006), 513 patients underwent PCNLT, 225 of which were treated for staghorn stones. 142 (63.1%) were treated with PCNLT as monotherapy. In 57 (25.3%) of cases PCNLT was followed by SWL of residual stone fragments. 26 (11.5%) patients underwent so-called sandwich therapy – PCNLT+ESWL+PCNLT. In most cases a rigid 27 Ch nephroscope Olympus (Germany) was used for endoscopic lithotripsy. Flexible nephroscope Olympus (Germany) was used in 15 patients (6.6%) during the first stage of PCNLT and in 12 patients (5.3%) during the second stage. Lithostar Multiline (Siemens, Germany) was used for SWL. SWL was performed with 4000–6000 shock waves with power from 19 kV to 21 kV, after placement of double JJ ureteral stent. This method was used in 83 patients (36.8%), 11 of whom (13.2%) required two sessions of SWL. Of all patients, treated with SWL, 26 had a large number of stone fragments, as well as stones larger than 4 mm in diameter. This necessitated the use of PCNLT for debulking of those fragments through the existing nephrostomy tract and the patients were discharged from the hospital without nephrostomy tube. The patients with ureteral stent inserted prior to SWL were discharged from the hospital with the stent, which was removed after the elimination of most stone fragments. Patients follow-up at the first, third and sixth month included plain abdominal radiography and ultrasonography to demonstrate elimination of stone fragments. The final stone-free status was assessed by plain abdominal film, intravenous urography and ultrasonography.

The age, sex, stone size, presence of positive urine culture and grade of dilation of renal collecting system in the three groups of patients were statistically similar. 86% of patients in the first group, treated with PCNLT as monotherapy were stone free after the procedure. In the second group (PCNLT+SWL) the stone-free rate was 89% and in the third group (PCNLT+ESWL+PCNLT) – 90%. In general the overall success rate was 88.3% and the average postoperative hospital stay – 5.3 days. No complications such as disturbances of electrolyte balance or major bleeding, requiring surgical treatment, were observed. In 4 cases a 250 to 400 ml Er concentrate transfusion was necessary. 5 ureterorenoscopies (2.2%) were performed in patients with “steinstrasse” after ESWL. In these patients no ureteral stent was placed prior to the procedure.

PCNLT is the first line treatment option for staghorn lithiasis. It provides high stone-free rate with short postoperative hospital stay and low complications rate. SWL is successfully used as a secondary procedure for complete debulking of residual calculi.