Single-access PCNL feasible for first-line treatment of staghorn calculi

Single-access percutaneous nephrolithotomy (PCNL) can clear the vast majority of staghorn stones with minimal morbidity, said Tim Large, MD, at the 2019 World Congress of Endourology and SWL in Abu Dhabi.

He reported findings from a multi-institutional retrospective review showing that over a 2-year period, 301 (89%) of 340 patients with full or partial staghorn calculi were treated with single-access PCNL. Postoperative computed tomography scans identified residual stone fragments in 169 patients (56%), of which only 54 (17.9%) had a fragment >4 mm. A secondary PCNL was performed in 117 (38.9%) of the 169 patients with a residual stone.

Follow-up imaging performed at 6 weeks showed that overall, 86% of patients were rendered stone-free. Complications were rare.

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“The results in our retrospective study reinforce the recommendation in both the AUA and EAU guidelines that PCNL be considered the first-line surgical intervention for patients with stones greater than 2 cm, including staghorn calculi,” said Dr. Large, assistant professor, Indiana University School of Medicine, Indianapolis.

“Alternative approaches may be chosen because of surgeon training or access to technology, but PCNL is a ubiquitous component of most training programs and very safe. Therefore, so that patients can avoid a major procedure, we would encourage referral to a colleague who specializes in PCNL in situations where a surgeon lacks comfort with or equipment for performing the technique.”

The retrospective study identified patients with staghorn calculi who were seen at Indiana University School of Medicine, Mayo Clinic, Rochester, MN, and British Columbia School of Medicine, Vancouver. The patients who underwent single access PCNL had a mean age of 57 years, 53% were women, and mean body mass index of 32.5 kg/m².

Approximately two-thirds of the stones had a Guy’s stone score of 4 and the remaining one-third were Guy’s stone score 3. The median stone burden was 163.4 mm².

Next:Mean OR time of 80 minutes for primary PCNL

Mean OR time was 80 minutes for the primary PCNL, and for patients who underwent a secondary PCNL, mean total OR time, including the first procedure, was <200 minutes.

“The secondary procedure rate for patients in our study was relatively high, which is normal, but the total OR time for patients who needed a second procedure was comparable if not less than that of alternate surgical approaches to treat staghorn calculi,” Dr. Large said.

Minimal complications

Mean hospital stay for the cohort was 2.3 days, eight patients (2.7%) required an ICU stay, and 15 patients (5.0%) required transfusion. Complications were minimal. Pleural effusion (5.0%) was the most common event followed by fever (2.7%) and sepsis (1.3%). There were no cases of solid organ injury.

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Dr. Large acknowledged that the AUA and EAU guidelines identify instances, such as concomitant uretopelvic junction obstruction, where robotic surgery to treat staghorn kidney stones is indicated. He said, however, that the retrospective study he presented supports prior publications recommending that PCNL should be the primary approach for the surgical management of partial and full staghorn stones.