|Year : 2002 | Volume
| Issue : 1 | Page : 42-49
Management of complete staghorn stone in a developing country
Anant Kumar, Sanjay Gogoi, Rakesh Kapoor, Aneesh Srivastava, Anil Mandhani
Department of Urology & Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
Department of Urology & Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Staghorn renal stones in a developing country, very often associated with insidious growth, late presentation, complications and recurrence, present an economic burden to the patient and a challenge to the treating surgeon. Despite proven effectiveness of modern endourological procedures, they are cost intensive and require multiple sittings. Current retrospective study was undertaken to evaluate the most effective therapy for these stones in a developing country.
Materials and Methods: 156 patients with extensively branched staghorn renal stones were treated at our center over a period of one decade. Of these patients 76 underwent PNL (group-I), 35 sandwich (group-11) and 45 open surgical procedures (group-III). Perioperative events including clearance rate, morbidity, complications, blood transfusions and ancillary procedures were compared between the three groups. Also compared was the length of inpatient treatment and the expenses incurred. In a subgroup analysis, treatment outcome and complications were separately analyzed in patients with renal failure (serum creatinine >2.0 mg%).
Results: The three groups were comparable in terms of age, sex, stone size, preoperative serum creatinine, hemoglobin and positive urine cultures. Overall stone free rate in group-I (85.52%) was higher than group-11 (74.28%) and group-III (79.41 %) although it did not reach statistical significance. Ancillary procedures were least required in group-III patients. ESWL was required in 23.7% of group-I and 8.8% of group-III patients (P<0.05). Ureteroscopy was required in 7.89%, 17.1 % and 4.4% of groups I, II and III respectively. While the incidence of urosepsis was comparable, major postoperative bleeding occurred in 10.52%, 8.6% and, 6.6% of groups I, II and III respectively. The mean hospital stay amongst the three groups was similar with a marginally longer stay in the sandwich group. The overall cost of the treatment including adjuvant therapy was significantlv less expensive in group-III compared to group-I and group-11.
Renal failure patients had higher clearance rates with open procedures compared to PNL (80% vs 62.5% respectively). Moreover these patients had higher incidence of major bleeding with PNL compared to open procedures (31.3% vs 10%).
Conclusions: Advantages of endourological procedures in the management of staghorn stones is offset by the need of ancillary treatments, which are expensive and which require frequent visits to the hospital. In view of high clearance rates, lesser treatment cost and lesser incidence of complications, open surgery still has a place in the management of staghorn renal stones in patients who have economic constraints and live in remote areas where medical facilities are not freely available. These advantages are also seen in the renal failure patients where complications with endourologic procedures were significantly more than that with open surgery. However postoperative morbidity and larger scar should be discussed with the patients.
Keywords: Staghorn Stones; Developing Country; Open Stone Surgery; Renal Failure
|How to cite this article:|
Kumar A, Gogoi S, Kapoor R, Srivastava A, Mandhani A. Management of complete staghorn stone in a developing country. Indian J Urol 2002;19:42-9
| Introduction|| |
Management of staghorn renal stones in a developing country is an economic burden to the patient as well as a challenge to the treating surgeon. Unlike in the West where the majority of the staghorn stones have an infective etiology (struvite), in India most of these stones are composed of calcium oxalate monohydrate. These stones are associated with insidious growth and late presentation, very often leading to renal failure. Further adding to the enormity of the problem is the high cost of the endourological procedures and shockwave lithotripsy.
Current guidelines by Panel for Nephrolithiasis  recommend percutaneous nephrolithotomy (PNL) followed by extracorporeal shockwave lithotripsy (ESWL) or repeat PNL. However the onus to attain complete clearance in one sitting still makes open surgical clearance a viable option specially so in poor patients who come from remote areas. We report our decade-long experience in managing these stones in a tertiary level referral hospital.
| Material and Methods|| |
All patients treated for extensively branched complete staghorn stones over the period of a decade (June 1989 and May 2000) were included in the study. Patients' records were retrospectively analyzed with regards to treatment outcome, complications and cost analysis.
Extensively branched staghorn stones classified as C5 according to Rocco's classification , were included in the study. Patients with urological developmental anomalies were excluded. Total stone surface area was calculated by tracing the image of the stone (as seen on a plain abdominal skiagram in AP projection) on a millimeter graph paper and estimating its surface area in mm.  For outcome analysis stone bulk was classified as low (<400 mm2 ) moderate (400-1000 mm2 ) and large (>1000 mm2 ).
Based on treatment protocol, patients were classified into three groups: PNL intensive (group-I). Sandwich therapy (group-II) and open surgical (group-III). In groupI, patients were treated with one or more sessions of PNL followed by ESWL if there were residual fragments. Sandwich therapy involved a PNL followed by ESWL and a subsequent PNL session for removal of residual debris. Patients managed with open surgical procedures were included in group-III.
Perioperative events including morbidity, complications, blood transfusions and ancillary procedures were compared between the three groups. Also compared was the length of in-patient treatment and the expenses incurred. In a subgroup analysis, treatment outcome and complications were separately analyzed in patients with renal failure (serum creatinine >2.0 mg%).
Patients were followed up initially at I month post-treatment with a plain abdominal skiagram, renal function assessment and bacteriology of voided urine sample. At 3 months a repeat intravenous urography was performed and final clearance was calculated.
PNL was performed by the standard technique in prone position and an intracorporeal pneumatic lithotriptor (Swiss lithoclast) was used. Posterior inferior or superior calyceal puncture was the commonest initial access tract; however separate punctures were also made as indicated by the stone geometry. ESWL was performed under sedation and an average of 3500 shockwaves was applied in one session. ESWL in the sandwich group was performed between the third and fifth day of first sitting of PNL. Lithotriptors used were Seimens Lithostar (1989-1995) and Technomed-Israel (1996-2000).
Open surgical procedures (extended pyelolithotorny and anatrophic nephrolithotomy) were carried out by the standard techniques. All efforts were made to completely debulk the stones, including the use of fluoroscopy. Since 1998 intra-operative flexible nephroscopy was also used to clear the residue.
Statistical analysis was performed using Fisher's T test for continuous variables and Fisher's exact test for proportions.
| Results|| |
A total of 156 patients (group-1=76, group-11=35 and group-III=45) qualified the inclusion criteria with the mean age of 42 years (range 7-86 years) and male to female ratio of 2.6:1. Of these, 143 had unilateral and 13 had bilateral stones. Although not statistically significant, the right kidney was more commonly involved than the left (1.5:1).
Mild abdominal pain was the commonest presenting symptom (53.2%). However, 35.8% of patients were asymptomatic and were incidentally detected. Recurrent dysuria or documented urinary tract infection was present in 27.56%. 16 patients (10.25%) presented with symptoms of frank urosepsis. Renal failure was present in 26 cases (16.66%) with serum creatinine of >2.0 mg%. 16 patients (11.26%) were recurrent stone formers. They had undergone prior stone removal elsewhere with complete clearance [Figure - 1].
The 3 groups were comparable in terms of age, sex, stone size, preoperative serum creatinine, preoperative hemoglobin and the incidence of positive urine culture. [Table - 1]
Overall stone free rate in group-I was higher (85.52%) than in group-11 (74.28%) and group-III (79.41 %) although it did not reach statistical significance. This was due to higher incidence of significant residue in the latter groups.
Of the 45 group-III patients. stone removal was attempted in 34 and the rest underwent nephrectomy (6 for nonfunctioning kidneys, and 5 for pyonephrosis). Clearance with surgery alone was achieved in 25 patients. Of 9 patients with residue, ESWL was performed in 4, of which 2 achieved complete clearance. Thus total clearance was achieved in 27 patients (79.4%).
Amongst the 3 groups the need for ancillary stone removal procedures was the minimum in group III. Ureteroscopy (URS) was required in 7.89%, 17.1 % and 4.4% of groups I, II and III respectively. Similarly adjuvant ESWL was required in 23.7% of group I and 8.8% of group III. This difference was found to be statistically significant (P<0.05 between groups I:III).
Major postoperative bleeding was the most severe complication following PNL. It was seen in 10.52% of groupI and 8.6% of group-II patients. 6 patients required angioembolization of which 5 belonged to group-I and one belonged to group-II. Of the group-Ill patients, 6.6% had major bleeding, however it was secondary hemorrhage and could be managed conservatively with bed rest, blood transfusions and antibiotics. Blood transfusion was required in 82.9% of group-I, 77% of group-II and 64.4% of group-III patients (P<0.05 between groups I & III). Mean perioperative blood transfusion was 2.8 units in group-I, 1.8 units in group-II and 1.4 units in group-III.
We also found a positive correlation between the number of punctures and the incidence of major bleeding. 82.89% of group-I, compared to 62.85% of group-II patients, had 2 or more punctures. This correlates with 10.5% and 8.6% incidence of major bleeding in group-I and group-II respectively.
The incidence of postoperative urosepsis was comparable in the 3 groups. It was 19.7%, 25.7% and 20% in groups I,II and III respectively. Management required treatment with aminoglycosides and third generation cephalosporins. Postoperative urinoma formation occurred in 9.2% of groupI and 8.6% of group-II patients with usual presentation of pain, lump and fever.
These cases were followed up with serial ultrasonography and prolonged percutaneous nephrostomy (PCN) drainage. 5 out of 7 group-I and all 3 group-III patients required ultrasound guided percutaneous tube drainage.
All cases with pleural complications had supracostal punctures for upper calyceal extensions. The incidences were comparable in group-I & group-II patients (5.26% versus 2.8%). Of the 4 group-I patients, 2 had pneumothorax, I had a nephropleural fistula and 1 had hydropneumothorax. All of these patients, including one of group-II with pneumothorax, could be managed with intracostal tube drainage. Minor complications like wound infection, PCN tract discharging sinus, prolonged drainage after removal of PCN and frank herniation were infrequent and have been shown in [Table - 2].
16 renal failure patients treated with PNL (group-la) and 10 renal failure patients treated with open surgical procedures (group-Illa), were subjected to a separate subgroup analysis (Total 26 patients).
Complete clearance in the group-la was achieved in 9 (56.25%) and 7 had residues. Of the 10 patients treated with open procedures, 7 attained complete clearance (70%) and 3 had residues.
Patients with residue, 3 of group-la and 2 of group-Illa underwent further treatment with ESWL. (Rest of the patients declined further treatment due to financial constraints.) Clearance was achieved in l patient each in both the groups, giving a total clearance with PNL of 62.5% and 80% with open surgery.
Overall stone free rate in this group of patients with renal failure was 69.23% [Figure - 2].
Renal failure patients had higher incidence of bleeding. Amongst group-la patients, 5 had major bleeding (31.3%). While 2 of these patients had spontaneous resolution, rest 3 required angioembolization. In contrast, major bleeding occurred in only I of group-111a patients (10%). It was a secondary hemorrhage and resolved with conservative treatment.
Hospitalization and Expenses
The mean duration of hospitalization was 11.2 days in group-I, 14 days in group-II and I I days in group-Ill. While group II patients received 1 session of ESWL during their hospital stay, group I and group III patients with significant residues underwent ESWL on an outpatient basis.
The mean hospital expenses incurred by group I, group II and group III was Rs. 16940 (±2136), Rs.26,102 (±1834) and Rs.9,872 (±2743) respectively. Patients with renal failure requiring preoperative dialysis had to bear additional charges (approximately Rs.1500 per dialysis session). Management of complications further added to the overall cost.
41.02% of our patients had a mean follow-up of more than 5 years. Stone recurrence was seen in 18 patients (28.13%). 14 of these had a recurrence after attaining complete stone free status at a mean duration of 47 months. Rest of the 4 patients had residual stones and they had a recurrence/re-growth of stone at a mean interval of 29.3 months.
Mean follow-up in the renal failure group of patients was 38 months. Overall renal function improvement was seen in 4 patients (15.38%), and deterioration in 3 patients (1 1.53%). Function remained static in 19 patients (73.07%). Amongst those patients in whom complete clearance was attained, renal function improved in 4, remained static in 13 and deteriorated in 1. Of the 8 patients with residual stones, function deteriorated in 2 and remained static in 6.
| Discussion|| |
Untreated staghorn stones are associated with significant morbidity, recurrent infection, stone growth and progressive loss of renal function. , The mortality rate in an untreated patient is reported to be in the range of 3-28%.  The tendency for them to recur and the complications they create have caused some to refer to them as stone cancer. 
In western countries the majority of these stones are composed of struvite (triple phosphate). Staghorns may also result from uninfected cystine or uric acid stones, but the amorphous quality of triple phosphate mineral mixture makes it particularly likely to mould to the shape of the pelvicalyceal system.  Struvite stones may from de novo but often form when pre-existing stones are colonized with Proteus or other urea-splitting bacteria. However in India most of these stones are composed of calcium oxalate monohydrate (70%) and struvite accounts for only 10-30%. 
Due to the infective etiology of majority of staghorn stones, various authors have emphasized the need for complete removal, as residual stones are associated with high rates of recurrent infection and stone growth. ,
Open surgical procedures were the cornerstone of treatment until the early 1980s. They were associated with improvement in renal function. 30% overall stone recurrence rate and 40% incidence of recurrent urinary tract infection. , However with the introduction of percutaneous nephrolithotomy (PNL) by Fernstrom and Johannson  in 1976, the indications for open surgery in these stones have become rare.
PNL monotherapy in staghorn stones is associated with a high clearance rate of about 87% (78%,  84.2%,  71 %  ). However there is a lack of unanimous classification of staghorn stones and a conservative estimate of clearance rate in a complete staghorn stones (Rocco's C-5) treated with PNL alone is approximately 60% (Bianchi  ). Post PNL stone free rate in patients with total clearance is high, however 62% with residual stones can develop stone recurrence within 3 years.
The use of "sandwich therapy" (combination therapy), which involves initial percutaneous stone debulking followed by ESWL of larger fragments and subsequent nephroscopy, offers reasonable outcome for most staghorn stones. In the series by Netto et al  the stone free rate increased from 78% (PNL alone) to 89% using sandwich therapy. Others have also reported similar findings. ,,
Open surgical procedures are only recommended in patients with complete staghorn stones associated with infundibular stenosis or distortion of intrarenal anatomy.  Recker  prospectively compared the result of anatrophic nephrolithotomy (AN) with sandwich therapy and ESWL monotherapy. Complete clearance was attained in 78% with AN, compared to 75% with sandwich therapy and 44% with ESWL. Similar findings have also been reported by others. 
ESWL monotherapy for staghorn stones has been reported to have a success rate ranging from 5 1 % to 74%. ,, However it is associated with high complication rates and need for ancillary procedures. Winfield et al reported 57% incidence of ureteral obstruction requiring nephrostomy catheter placement in 33%.  Lam correlated the success of ESWL monotherapy with the stone surface area and reported that for stones <500 mm 2 the clearance rate was 63.2% compared to 22.2% for stones >1000 mm 2 .
Although the mortality rates with PNL are reported to be less than 1%, complication rates are generally higher. Complications that are known include access tract injury to the pleura and adjacent organ, infection and major bleeding requiring transfusions. While the overall incidence of hydropneumothorax ranges from 1%-3%, some series report rates as high as 8.6%-13%  with supracostal puncture for the treatment of staghorn stories. Most of the small pneumothorax are amenable to conservative treatment provided the patient is asymptomatic, however pleural extravasations of infected urine or irrigation fluid necessitates placement of an intracostal tube.  We have been employing supracostal approach whenever it is indicated with an overall complication rate of 4.5%.
Significant blood loss can occur during PNL for large stones. Stroller et al  estimated the average blood loss from a one-stage single puncture PNL to be 2.8 gm/dl of hemoglobin. Multiple punctures and renal pelvic perforations doubled the blood loss. Patients with pre-existing nephrostomy tracts had half of the blood loss seen in PNL. Segura et al reported an average blood loss of 1.2 gm/dl of hemoglobin with a transfusion rate of 3%. The incidence of significant vascular injury requiring angioembolization is reported to be 0.9%.
Chandhoke et al  evaluated the cost-effectiveness of different treatment options for staghorn calculi. For stones <500 mm 2 in size, both sandwich and ESWL were equally effective. However when the stone burden is >500 mm 2 , sandwich therapy was the most cost-effective modality.
Our results should be viewed in context with the demographic parameters of majority of our patients, who due to ignorance, poverty, illiteracy and inadequate medical facilities present late for treatment. Moreover since health care is mostly self-financed, patients have high dropout rates before completion of therapy. This we believe affects the overall results.
Our stone clearance results are comparable to that reported in the literature. While PNL-intensive protocol (group-I) had the best stone clearance, it was associated with a higher incidence of complications and blood transfusion rates. Patients treated with open surgery (groupIII) fared better, both in terms of clearance as well as lesser transfusion rates compared to group-II patients (sandwich group).
Our patients had mean preoperative hemoglobin of 9.3 gm/dl and that explains the relatively high rate of blood transfusions despite comparable incidence of bleeding episodes. While only 10.5% of group-I patients had major bleeding, blood transfusion was required in 82.9%. In comparison 6.6% of group-III patients had major bleeding and blood transfusions was required in 64.4%. We also found a positive correlation between the number of punctures and the incidence of major bleeding. 82.89% of group-I compared to 62.85% of group-II patients had 2 or more punctures. This correlates with 10.5% and 8.6% incidence of major bleeding in group-I and group-II respectively.
The incidence of urosepsis was comparable in the 3 groups, despite the fact that 11.1% of group-Ill patients had pyonephrosis. Escherichia More Details coli (62%) was the commonest uro-pathogen, followed by Klebsiella pneumoniae (26%). Proteus was cultured in only 7% of patients.
The overall incidence of pleural complications amongst our patients undergoing PNL (groups I&II) was 5.15%, which is comparable to the world literature. The difference in group-I and group-II in regard to pleural complication was not significant.
Amongst the 3 treatment arms, sandwich group (groupII) was the most expensive secondary to the high cost of consumables, prolonged hospitalization, multiple treatment sessions and the high cost of ESWL. Open procedures (group-III) were the least expensive. The mean hospital stay amongst the three groups was similar with a marginally longer stay in the sandwich group. Minimally invasive endourological procedures permit shorter hospital stay. However this advantage was not seen in our patients as majority preferred to stay and recuperate in the hospital, rather than going back to their community where proper nursing care and health services are lacking.
As a group the overall stone clearance in the renal failure patients was only 70%. After monotherapy the rate of clearance with open surgical procedures (70%) was significantly better than that of the PNL-intensive group (56.25%). This lower stone clearance rate is in agreement with the report of the Nephrolithiasis Clinical Guideline Panel.  The reason for the lower clearance with PNL is explained by the conservative approach to the number of punctures (limited to 1-2) to reduce the chances of bleeding and shorter duration of intra-renal procedures to prevent fluid overload. The overall stone free rate even after adjuvant ESWL was much better in the open surgery group (80% vs 62.5% in group-III and group-I respectively). The incidence of major bleeding was significantly higher in the PNL group (38.5%) compared to open surgical group (14.3%). While wound infection was slightly more common in group-III patients with renal failure, it was not statistically significant.
Stone recurrence rate in our patients amongst those on regular follow up was 28.13%. In the literature regrowth rates of as much as 60% have been reported. The lower recurrence rate is partly explained by the non-infective etiology of majority of our patients.
The role of stone clearance in renal functional recovery is not yet defined. 28.5% of our patients with complete clearance had functional improvement. However despite clearance, renal function deteriorated in 7.1%. None of the patients with residual stones had functional improvement and deterioration was seen in 33.3%.
| Conclusions|| |
PNL alone or in combination with ESWL is a very effective modality in the management of staghorn stones even in a developing country. It provides good clearance rates with less morbidity and prompt recovery. However, quicker recovery to work by endourological procedures is offset by the need of ancillary treatments which are expensive and which require frequent visits to the hospital, mostly located at a distance and that adds to the financial burden. This aspect cannot be ignored in a developing country where resources are scarce.
In view of high clearance rates, lesser treatment cost and lesser incidence of complications, open surgery still has a place in the management of staghorn renal stones in patients who have economic constraints and live in remote areas where medical facilities are not freely available. The marginally longer duration of hospitalization does not significantly add to the expenses as hospitalized care is cheap and early discharge is not an issue. These advantages are also seen in the renal failure patients where complications with endourologic procedures were significantly more than that with open surgery. However postoperative morbidity and large scar should be discussed with the patients.
Stone clearance itself does not complete the treatment and these patients require long-term follow-up to manage recurrences and renal failure.
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[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]
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