大짧放射線홈學홈誌 第 25卷 第 5 號 pp. 680 - 688, 1989 Journal of Korean Radiological Society, 25(5) 680-688, 1989

Percutaneous Management of Staghorn Renal Calculi

〈국문초록〉

Won Jay Lee, M.D. Department of Radiology, Long lsland Jewish Medical Center

Albert Einstein College of Medicine, New Hyde Park, N. Y. U.S. A

麗角形賢結石의 經皮的 治癡

미 국 뉴욕 Albert Einstin 의 과대 학， Long Island J ewish 영 원

01 원 재

1987년 5월까지 4년간 154예의 녹각형신결석을 경피신결석 제거솔로 치료하였다. 이중 86 %는

잔류결석없이 퇴원하였A여 나머지 환자에서의 잔류결석의 크기는 5mm 이하였다. 24 %에서는

입원기간중 2회 이상의 시술이 필요하였고 73 % 이상에서 2개 이상의 경피경로를 시솔하였다 16 %에서 중증의 합영증이 발생하였고 1예의 사망이 있었다. 대부분의 합병증은세밀한 주의를 하

묘로써 강소시킬 수 있고 중재방사선학석 방법으로 해결될 수 있었마.

녹각형신결석을 처리함에 있어서 결석 제거에 성공하기 위해서는 신장의 해부학석 구조에 대한

이해， 석절한 경파신루 경로의 선택， 그러고 축련된 땅사선파-바뇨기과 전운의가 필요하마. 체

외 충격파 쇄석숭의 출현에도 불구하고 경피신결석제거술은 여전히 중요한 신결석의 치료 방엽이

여 특히 녹각형신결석의 치료에서는 더욱 중요한 시술법이라 하겠마.

- Abstract-

During a four year period , ending May 1987 , 154 cases of symptomatic staghorn calculi have

been treated by percutaneous nephrolithotomy. Of these patients, 86 % were discharged compl-

etely stone free with the remainder having fragments less than 5 mm in greatest diamete r. More

than one operative procedure during the same hospitalization was required in 24 % of patients

and multiple percutaneous tracts were established in excess of 73 % of them. Significant

complications occured in 16 % of patients and the re was one death. Most complications can be

generally be minimized by careful approach and manageable by interventional radiological

means

The management of patients with staghorn calculi requires a comprehensive understanding of

the renal anatomy , selection of appropriate pe rcutaneous nephrostomy tract sites, and radio-

logic-urologic expertise needed to remove the large stone masS. The advent of extracorporeal

shock wave lithotripsy will not abolish the need for nephrolithotomy, particulariy complex

stones such as staghorn calculi

이 논운은 1989년 7월 21 일 접수하여 1989년 8월 1일에 채택되었음 Recieved July 21 ‘ accepted August 1, 1989

- 680 -

Won Jay Lee:Percutaneous Management of Staghorn Rena l Calculi -

Introduction

Staghorn renal caIculi have plagued mankind

due to the extensive branching as well as their

frequent recurrence rate . In 1968, Smith and Boyce') reported on the anatrophic nephrolitho-

tomy as a new technique for the removal of stag-

horn caIculi . The idea to reduce renal parenc-

hymal damage and patient morbidity has stimula-

ted numerous therapeutic modalities to accomplish

this poin t.

To date , numerous advances have been made in the field of renal surgery2) , incIuding the removal of complex staghorn caIcuIi3). This techniques

compares favorably to the original open surgical

procedure with the main advantage being the shor-

ter postoperative convalescence.

With the proliferation of extracorporeal shock

wave Iithotripsy(ESWL) units throughout the wor-

Id , staghorn caIculi are being approached solely

with ESWL , in combination after a prior debul-king of stone burden percutaneously , or as the initial method of stone disintegration to be follo-

wed by percutaneous nephrolithotomy(PCNL).

When the first ESWL machine were being inst-

alled , it was frequently stated that they would make percutaneousstone removal obsolete . In-

deed , ESWL has been used to attack stones of some complexity partially replacing PCNL. Even

after the installation of ESWL at our institution ,

PCNL plays a major (primary) role in the manag-

ement of complex stone diseases. The indications

for the use of ESWL in the removal of staghorn

caIculi are currently under evaluation and will re-

quire further definition.

The purpose of this paper is to present our

experience with PCNL in staghorn caIculi and to

review the role of PCNL in the era of ESWL.

Materials and Methods

Patients

- 681

During a four year period from July 1983 to

May 1987 , 154 kidneys from 150 patients afficted with staghorn caIculi underwent percutaneous

ultrasonic Iithotripsy(PUL) at our institution. Four

patients had bilateral disease and two had stag-

horn calculin in ectopic pelvic kidneys . Of these

two pelvic kidneys , one was a horseshoe kidney while the other was an allograft renal transplant

draining into an ileal conduit urinary diversion .

Forty three patients (28 %) had previous open

stone procedures including pyelolithotomies and

anatrophic nephrolithotomies. There were 95 fem-

ale and 55 maIe patients ranging in age from 16 to

96 years , with a mean age of 65 years old. AII patients in whom a percutaneous nephrostomy was

attempted for removal of staghorn calculi are inc-

luded in this study.

Although our initial percutaneous experience

was Iimited to hgh risk patients , as was CIayman et a l. 3) , all subsequent patients presenting with staghorn caIculi at our institution underwent this

procedure regardless of operative risk4)

Preoperative Evaluation

Routine preoperative laboratory evaluation pri-

or to the establishment of the initial percutaneous

nephrostomy tract included a CBC, PT and PTT, serum creatinine , chest radiograph and EKG. Where indicated by history , a bleeding time was added to the standard slate of coagulation profiles

A c\ean-catch or catheterized urine specimen was

obtained for culture and sensitivity.

Routinely, intravenous antibiotic therapy was impremented on admission with a broad-spectrum

antibiotic, generally a cephalosporin. This was continued into the postoperative period until the

patient was aferbrile with appropriate changes by

results of the sensitivity tests .

The configuration and location of the dendritic

extentions of the staghorn calculi , as well as the collecting system anatomy were evaluated from a

recent intravenous urogram . A careful planning of

- 大韓放射線醫學會誌 : 第25卷 第 5 號 1989 -

the placement of the percutaneous nephrostomy

tract is then begun on the basis of excretory

urography and a plain abdominal radiograph

which was obtained just before the creation of the

percutaneous nephrostomy tract(s) . A coordinated

effort between the radiologist and urologist is

essential for the systematic removal of these exten-

slve processes.

Technique of Percutaneous Ultrasonic

Lithotripsy

Our methods for visua!ization of the collecting

system, techniques of percutaneous nephrostQmy access , tract dilatation , and stone removal , have been described previously4-8l. All patients were

admitted to the hospital two days prior to their

planned operative procedure. On the first hosp-

italization day , a cystoscopy and retrograde uret-eral catheter was inserted under local anesthesia

after preliminary testing and intravenous antibio-

tics were administered. This catheter was utilized

to opacify and hydrodilate the affected collecting

system in order to facilitate percutaneous nephr-

ostomy insertion. Other advantages of placing the

retrograde ureteral catheter preoperatively is the

prevention of antegrade migration of stone fragm-

ents down the ureter during ultrasonic lithotripsy

and facilitation of establishing a controlled guide

wire tract by grasping the end of the open ended

ureteral catheter with the two pronged grasping

forceps and then inserting a torque guidewire do-

wn the ureteropelvic junction and into the blad-

de r.

On the second hospitalization day , the patient is premedicated with parenteral analgesics and is

transferred to the radiology suite where percut-

aneous nephrostomy tract(s) are estab!ished under

local infiltration of 1 % lidocaine using intrav-

enous analgesics. On the following day , definitive ston removal is undertaken . Since November 1985, all patients have been admitted to the hospital one

day prior to surgery and retrograde ureteral

catheterization performed on the day of admis-

sion. All percutaneous nephrostomy tracts along

with stone removal were subsequently done in the

operating room at the same session.

On the day of procedure , the patients are brou-ght into the operating room and are induced under

general anesthesia via the endotracheal route. The

patient is then turned onto the operating room

table in the prone position and the portable C-arm

fluoroscopic unit is utilized. For those patients

having nephrostomy tracts established in the oper-

ating room with the C-arm fluoroscopy , retrograde pyelgram is performed to visualize the renal colle-

cting system in order to select nephrostomy tract

sltes.

It is essential , whenever possible , to select a posterior middle or lower p이e calyx for nephro-

stomy tract puncture to enter the collecting sys-

tem. For staghorn calculi branching into upper and

lower pole calices , initial puncture into the lower pole calyx may provide adequate exposure to the

entire stone. If the stone extends into the middle

and lower pole calices, then two nephrostomy tra-cts will often be needed into each system. Occa-

sionally , access to an upper caliceal stone can only be obtained by direct supracostal puncture. In th-

ese cases, diligent search for accompanying intr-usion into the pleural space must be sought.

Appropriate measures should be instituted in the

operation room to treat this problem.

In the case of ectopic pelvic kidneys , special techniques must be uti!ized to aid in the establ-

ishment of the nephrostomy tracël. For extensive

staghorn calculi, as many as three nephrostmy tra-cts may be created to gain access to the various

extenslOns.

After the intial guidewire is introduced down

the ureter, a second torque guidewire is inserted. This will become the “ working" wire and the ini-

tial one will be set aside as the “ safety" guidewire

In the case of a bulky staghorn calculus that fills

the entire collecting system , percutaneous punc-

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Won Jay Lee:Percutaneous Management of Staghorn Renal Calculi -

ture directly on the stone situated in the calyx is

done and the ultrasonic lithotrite burrows a path

through the stone to allow the guidewire to pass

into the collecting system.

The nephrostomy tract is then dilated with the

Amplatz renal dilators(Cook Urological , Spencer, IN) up to a 34F. outer sheath diameter. The

accompanyin 30F. dilator is removed and the to

rigid 26F. Storz nephroscope(Karl Storz, Culver City , CÞ.) is inserted. The outer sheath remains in place throughout the procedure as a conduit to the

collecting system to facilitate the passage of percu-

taneous instruments , to tamponade bleeders creat-ed during tract dilatation , and to maintain a low intrapelvic pressure during intrarenal irrigation.

Normal saline irrigant is our fluid of choice bec-

ause of the physiologic compatibility.

Nephroscopy localizes the stone and under dir-

ect vision and fluoroscopic backup , the stone is fragmented and aspirated with the ultrasonic li-

thotrite. This device , the safest and most versatile form , converts ultrasonic energy produced in the range of 20-27Khz into transverse and longitudinal

vibrations that are transmitted to the calculus via

contact with the hollow steel probe. This probe is

used like a drill with the fragments being sucked

into the central core connected to a vacuum pu-

mp, to keep in close contact with the probe for maximal transmission of energy and to permit

irrigation to clear the operative field and to cool

the probe. If large fragments could be removed , a two or three pronged grasping instrument was util-

ized to extract these stones through the Amplatz

sheath. At the termination of the procedure, a combination of nephroscopy and fluoroscopy con-

firmed a stone free collecting system. If the guide-

wire was placed down the ureter , a 24F. re-entry nephrostomy tube(Van-Tec, Spencer, IN) was inserted and additional tracts drained with a

14 Fr. Malecot nephrostomy(Cook Urological , Spencer, IN) tube . All tubes were secured to the skin with accompanying skin discs and suture ilgat-

ures of heavy silk suture material. The nephr-

ostomy tubes were connected to appropriate clos-

ed drainage system.

Follow-Up Studies

On the second postoperative day , non-contrast nephrotomography was performed to identify any

residual stone fragments . Nephrostogram was then

performed to determine any collecting system per-

forations , obstructions , or clot retention. If satisfa-ctory results are obtained , the nephrostomy tubes are clamped that day and removed the following

morning provided that the patient does not de-

velop fever , flank pain , or flank leakage around the nephrostomy tube site . The patient is disch-

arged home when the flank is dry

For those patients identified with residual stone

fragment , various options are offered to obtain a stone free kidney. Patients either have residual

fragments removed under local anesthesia, begin intrarenal chemolysis lO), or are rescheduled for a

second stage procedure under general anesthesia

The procedure is considered successful only if the

kidney is complètely stone free.

All patients have random diet 24 hour urine

collection brought back for their first postope-

rative visit. They are enrolled in our stone clinic

to determine the etiology of their stone disease by

comprehensive metabolic and nutritional evalu-

ation. Excretory urography was routinely perfo-

rmed at 3-6 months postoperatively and then ann-

ually there after.

Results

The results of 154 kidneys afflicted with stag-

horn calculi from 150 patients are as follows; Use

of two or more access route was necessary in 110

patients (73 % ). Seventy six kidneys (49 %) re-

quired creation of a second nephrostomy tract for

access to all parts of the stones and 34 kidneys (22

%) required a third tract. Thirty seven patients

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- 大韓放射線훨學會誌 第25卷 第 5 號 1989 -

A B C

Fig. 1. A. Plain abdominal radiograph shows a large branched stones occupying most of collecting system. A retrograde ureteral catheter is noted in place. B. Plain abdominal radiograph following first session percutaneous ultrasonic lithotripsy shows complete removal of calculus. Because of the extent of the stone, three nephrostomy tracts were required. C. Nephrostogram demonstrates collecting system patency. There is no evidence of extrav asation , obstruction or clot retention

(24 %) required multistaged nephr이ithotripsy for

complete stone removal. A total of 110 kidneys

(71 %) were rendered stone free after one oper-

ative procedure(Fig. 1). Seventeen more kidneys

were made stone free by chemolysis or panen-

doscopy. At the time of discharge , 132 of 154 kidneys (86 %) were completely stone free(Fig .

버eeding and then to embolize the segmental ves-

se l. Despite preoperative parenteral antibiotic cov-

erage , approximately 25 % of the patients devel-

oped positive urine cultures associated with fever

greater than 101 0 F. We believe that these infected

stones release bacteria during ultrasonic lithotripsy

l)(Table 1) . The procedure was considered succ- Table 1. Pesul ts of Percutaneous Ultrasonic Lithot. essful only if the kidney was stone free at disch- ripsy of Staghorn Calculi in 154 Kidneys

arge. Results among the first 75 kidneys and the

last 79 kidneys remain relatively unchanged , bec-ause more difficult cases were accepted during la-

ter period .

Of the 22 patients with procedure failure , resi-dual stone fragments were less than 5 mm in dia-

meter. Hospitalization stay averaged 13(range 8-

32) days . Yet, the most cost effective saving was that the postoperative convalescence at home only

averaged 16 days.

Major complications occurred in 25 (16 %) pa-

tients (Table 2). The most common complication

was bleeding requiring transfusion for hematocrit

less than 30 %. Only two patients required selec-

tive angiography to document the site of active

No. (% ) of procedures

(average/kiclney)

201 (l. 3)

Average procedure time (min) 165

No. (%) stone fre e after single session 117 (76)

No. having chemolysis (success/totaJ) 7/8 * No. having panendoscpic

fragment removal

No. (%) stone fr ee at discharge Average (range) hospital stay (days)

Average post-clischarge

convalescence(days)

23

132 (86)

13 (8-32)

16

• The patient in whom chemolysis fai led was seen early in the series:anatrophic nephrolithotomy was used to remove the stone remnants

.. For our purpose a staghorn calculus was defined as a branching calculus involving the maj ority of the re. nal pelvis and at least two major calices

- 684 -

- Won Jay Lee: Percutaneous Management of Staghorn Renal Calculi -

Table 2. Complications of Percutan.eous Ultrasonic Lithotripsy of Staghorn Calculi in 154 Kidneys in

150 Patients *

No. patients (% ) Comment

MAJOR:

Death

Pneumothorax/hemothorax

Renal pelvic lace ration

S epticemia/ shock

S tricture (UP J)

Oelayed bleeding

Pseudoaneurysm

A- V fi stula

MINOR:

Hemorrhage (transfusion)

Fever/infection

Pne밍umonia/ate허lec야tasis

U rinary extravasation

Paralytic lleus

Stone fragments in

retroperltoneum

Catheter dislodgement

TUR syndrome

* Forty-six patients had > 1 complication

1 (0. 7)

11 (7.1)

5(3.3)

3 (2.6)

2 (1. 3)

1 (0. 7)

1 (0.7)

24 (15. 6)

86 (56)

38(25)

15 (10)

19 (12)

20 (13)

4 (2.6)

9 (5. 8)

1 (0.7)

therapy causing such high infection rates. We are

now administering antibiotic coverage for proteus

infection , as it comprises the most common path-ogen cultured from the struvite stone population

Only four patients developed urosepsis

A ureteropelvic junction obstruction was obse-

rved in two patients on follow up IVU. However , it may have been caused by tissue reaction to the

stone rather than by the procedure itself.

One mortality has occurred in this group of first

150 patients . This 67 year old obese female with a

history of hypertension and diabetes mellitus suff-

ered a myocardial infarction in the recovery room

after a successful percutaneous procedure. Post-

Myocardial infarction

Resolved with chest tube drainage Nephrostomy drainage & stenting (3)

Open repair (2)

Responded to parenteral antibiotics Tissue reaction to stone?

Dilatation and stenting

Controlled by embolization

Average transfusion=2 units :

bleeding delayed 1 - 4 weeks in 3

Proteus infection. most common

Transient pleural effusion in 6

Stopped with nephrostomy

drainage. 1 urinoma drained.

No special measures

No special measures

Removal (8) . r eposition (1)

mortem examination revealed no evidence of renal

or perirenal hematoma. Because of the extent of

her obesity , this patient was not suitable candidate for ESWL

Discussion

Management of urologic patients is being grad-

ually but dramatically altered with new advances

in technical innovation and refinements of inter-

ventional uroradiology. At present , in most insti-tutions , PCNL has repaced the conventional op-erations , becoming the primary method of trea-tment in the absence of ESWL. Although ESWL

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大韓放射線흩§學會註 : 第25卷 第 5 號 1989 -

has become the treatment of choice for small, uninfected stones , there are numerous situations where its use is less than idealll). Since approxi-

mately 15 % of all renal stons are radiolucent , inability to synchronize the ESWL beams on the

stone reduces its use. As with the one mortality

illustrated , the size of the patient may preclude utilization. Finally, ESWL has been some what disappointing with regard to its use with staghorn

calculi. when used without percutaneous methods , only approximately 73 % of kidneys are stone free

after treatmentJ2) . Often , ureteroscopic procedures are required to reduce the ‘steinstrasse’ In compa-

rison , our study demonstrates an 86 % stone free kidney which is corraborated by similar results by

other groups 13,14).

The safety of PCNL was elegantly demonstrated

by Webb and Fitzpatrick피 They showed that neit-

her the percutaneous tract large enough to

accomodate a nephroscope nor the vibration of

the lithotripter had adverse effects on the dog

kidney. Specifically, there was no cortical scarring, no effect on large renal blood vessels, no pelvic or ureteric damage , and no changes in the creatinine clearance. It has also been found in a study by us

and Marberger et al that there is no permanent

loss of renal parenchymal function along the

nephrostomy tractI6,17).

Bleeding tends to be the most serious and freq-

uent of the complications of PCNL. Approx-

imately 56 % of our staghorn calculi required blo-

od transfusiops for hematocrit less than 30 % . This

is significantly higher than the ESWL group alone

When delayed bleeding occured, as in our series (2 patients) one must consider various vascular

consequences such as pseudoaneurysms or arterio-

venous fistula formation. The number of nephr-

ostomy tracts seems not to be coinside with the

formation of vascular complicationsI8). With the

exception of arteriovenous malformations, the bleeding that occurs after percutaneous nephr-

olithotomy can usually be controlled by nephro-

stomy tract tamponade with the Amplatz sheath

or a balloon catheter.

The second most frequent problem encountered

relates to the rate of urinary tract infection follow-

ing ultrasonic lithotripsy. Since the majority of the

staghorn calculi are associated with struv-

ite(magnesium ammonium phophate) composition

and urea-splitting bacteria such as Proteous, seed-ing of the urinary tract during lithotripsy is a pro-

blem. Exacerbation of the problem may be higher

after ESWL but the only data availabel is by

Kahnoski et al , who described 2 of 8 cases treated in conjunction with percutaneous ultrasonic lithot-ripsyI9).

Certain problems pertain only to percutaneous

techniques. In the case of upper pole caliceal sto-

nes , the insertion of nephrostomy tracts above the

12th rib is associated with hydrothorax , pneu-mothorax , ancVor hydrothorax. This requires a thoracotomy tube for a few days postoperatively .

This has not been the case with ESWL.

Electrolyte abnormalities from hyperabsorption

syndromes can be avoided with the impleme-

ntation of saline irrigation as compared to gly-20\ cme--'

Althogh PCNL may require several sessions and

be a frustrating experience for a less experienced

team of radiologists and urologists , it is a more efficient means of removing staghorn calculi than

is anatrophic nephrolithotomy21l. The procedure is

faster , required less blood transfusions , was better tolerated by patients, and had a faster postop-erative convalescence. Patients are usually able to

retrun to normal activities within 7 days after hos-

pital discharge. Since many patients will be stric-

ken with recurrent stone formation , the mini-mizing of the scar eases future percutaneous inter-

ventlOn.

The disadvantages of the higher retained stone

fragment rate following PCNL can be managed

effectively by meticulous ultrasonic lithotripsy , cal-yx by calyx , and proper tract planning. Adjunctive

- 686 -

- Won ]ay Lee:Percutaneous Management 01 Staghorn Renal Calculi -

procedures such as dilatation of infundibular sten-

osis or simultaneous endopyelotomy may be perf-

ormed by the percutaneous approach22 ,23).

Currently , itappears that the role of ESWL in the removal of staghorn calculi remains adjunctive

with percutaneous ultrasonic lithotripsy. As our

own data indicates , a percutaneous approach alone is associated with a significant rate of bleeding

necessitating transfusions , episodes of urosepsis , and residual stone fragments. Likewise , ESWL alone is unsatisfactory for patients with bulky sto-

ne disease because of the high mobidity from ob-

struction , especially in the face of infection . Many urologists are finding success with debulking stag-

horn calculi by percutaneous methods and cleaning

up residual pockets of stones with the ESWL

unit24) . Certainly , more investigation will be nee-

ded to evaluate this new modality and its applic-

ation to the removal of staghorn calculi. Our res-

ults prove the efficacy of the percutaneous appro-

ach to the ablation of staghorn calculi . Coordinated

effort between the radiologist and urologist is esse-

ntial for the systemic removal of this extεnsive 25) process

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