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OBJECTIVE To discuss the feasibility, safety, and effectiveness of conventional laparoscopic partial nephrectomy combined with pyelolithotomy for patients with ipsilateral renal tumor and staghorn kidney stone. MATERIALS AND METHODS Retrospective multicentral comparative study. Group "Combo" was presented by patients with the mentioned combined pathology (n=15). Group "Standart" (n=69) formed from common patients who underwent standard lap partial nephrectomy for renal tumor in the absence of kidney stones. Perioperative factors and results were studied and compared. Video presentation of combined surgical technique is available at: https://youtu.be/fAfYJDvGzsU. RESULTS Of all patients, no positive margins, no conversions to open surgery or nephrectomy & any complications Clavien >III were detected. There were no any significant differences between the two groups except for OR time (150 [120; 210] vs 130 [100; 180] min; p=0,001). Differences between indexes of WIT (16,27+/-3,8 vs 15,9+/-4,5 min; p=0,107), EBL (200 [150; 300] vs 200 [150; 300] cc; p=0,981), length of stay (7 [6;9] vs 8[6;9] days; p=0,611), intraop complications (0,00 vs 4,3%; p=0,411) and values of postop Clavien III rate (0,00 vs 4,3%; p=0,411) for "Combo" & "Standart" respectively were comparable as well as oncological outcomes. Stone-free rate for combined procedures reached 93,3%. CONCLUSION conventional laparoscopic partial nephrectomy combined with pyelolithotomy for patients with ipsilateral renal tumor and staghorn kidney stone is safe and efficient alternative to 2-step treatment of this rare disease.

This study purpose to analyze the differences in the effectiveness of PCNL and open surgery in patients with staghorn stones. We searched the literatures from PubMed and ScienceDirect from year 2005 until 2020. The method used in this study was a systematic review with a quantitative statistical approach (meta-analysis) using primary research data. From 4 studies there were 148 cases of PCNL and 98 cases of open surgery. PCNL had lower postoperative stone-free rate than open surgery (OR 0.168). PCNL had a lower final stone-free rate than open surgery (OR 0.603). The number of patients who had complications with PCNL was lower than open surgery (OR 0.451). The number of patients receiving blood transfusions on PCNL was lower than for open surgery (OR 0.494). Patients who received PCNL procedure required a shorter hospital stay than open surgery (MD -3,234). The number of patients who received additional therapy modalities on PCNL was lower than open surgery (OR 1.917). The conclusions obtained in this study indicate that there are differences in the effectiveness of PCNL and open surgery for patients with staghorn stones. Keywords: percutaneous nephrolithotomy; open surgery; staghorn stone

This lecture is dedicated to increasing stone free rate (SFR) in patients with staghorn renal stones by using a multimodal approach. Percutaneous nephrolithotomy (PCNL) is the "gold standard" for the treatment of this group of patients. Depending on a stone size and complexity, SFR for PCNL varies from 55 to 98%. Due to low SFR, which is a main criterion for the effective procedure, various approaches currently are being suggested. In this lecture, we highlighted the following approaches: multi-access PCNL, a use of a ureteroscope in case of antegrade stone migration, a use of flexible instruments, ureterorenoscopy in combination with PCNL. Various lithotripsy techniques are briefly described. The advantage of ultrasound-guided puncture of the kidney is also discussed.

OBJECTIVE: The aim of the present study was to determine the effectiveness of the use of the three-dimensional (3D) printed segmented collapsible model of the pelvicalyceal system (PCS) to improve the learning curve of the residents. MATERIAL AND METHODS: 3D printed models based on computed tomography (CT) images of 10 patients with a staghorn stone were developed. Used images of patients were obtained from CT scans in Digital Imaging and Communications in Medicine format. The area of interest was extracted and saved in stereolithography format. Further, the bioengineer performed virtual segmentation corresponding to the level of each calyces group that was defined by an experienced urologist. The final stage was the printing of each separated detail. Special questionnaire for evaluating the effectiveness of 3D models during both the examination of PCS anatomy and planning percutaneous nephrolithotomy was invented. RESULTS: The determination of the anterior and posterior calyces of the upper group was improved by 61% and 69%, the difference in the determination of the calyces of the middle group was 60% and 51%, and the answers regarding the number of the anterior and posterior calyces of the lower group became better by 67% and 74%, respectively (p

Objective: Staghorn calculi present a particular and challenging entity of stone morphology. Treatment is associated with lower stone-free rates and higher complication rates compared to non-staghorn stones. In this review we looked for the most relevant data on preoperative imaging and access planning to help decision making for percutaneous surgery with this complex condition. Methods: We conducted a PubMed search of publications in the past 2 decades that include relevant information on the planning for management of staghorn stones. Non-contrast computerized tomography (NCCT) is indeed the standard imaging tool for percutaneous nephrolithotomy (PCNL); additional tools such as three-dimensional computed tomography (CT) reconstruction of the staghorn calculus may help plan access in complex cases. Ultrasound guided percutaneous access may be considered for staghorn stones when planning upper pole access in kidney malposition or complex intrarenal anatomy or with complex body habitus. Wideband doppler ultrasound and real-time virtual sonography can assist. New technologies to improve kidney access such as Uro Dyna-CT or electromagnetic sensor have been reported, but have not shown utilization in staghorn cases. Staghorn morphometry-based prediction algorithms may predict the number of tract(s) and stage(s) for PCNL monotherapy. Lower pole access can be equally effective as upper pole when planning for staghorn and complex stones, with significantly less complications rate; Stone-Tract length-Obstruction-Number of involved calyces-Essence of stone density (STONE) nephrolithometry seems to be the best system to predict outcomes of PCNL in staghorn cases. There is a growing trend of endoscopic combined intrarenal surgery (ECIRS) in concordance with PCNL to treat larger stones. Conservative management of staghorn calculi is an undesired option, but can be an alternative for a carefully selected group of high-risk patients. Conclusion: Staghorn stones may lead to deterioration of renal function and life-threatening urosepsis. This entity should be managed aggressively with planning ahead for surgery using the different tools available as the cornerstone for a successful outcome. Keywords: Staghorn stone, Preoperative planning, Imaging, Kidney access

Giant ureteral calculi are defined as stones greater than 5 cm in length or circumference. These giant calculi can cause blockage of the ureter, dilation of the kidney and also decreased kidney function if not treated in time. The patient in this report presented with complaints of bilateral episodic pain of the bilateral lumbar region. Kidney, ureter and bladder (KUB) X-ray test showed a large bilateral ureteral stone about 14 cm in length and 106 g weight in the left ureter and 3 cm longitudinal diameter in the right ureter and also a staghorn stone in the left upper collecting system. Thereafter, the ureteric calculi were managed successfully using the combination of open and endoscopic techniques.

This chapter covers PCNL strategy for a staghorn stone. Also included are guidelines, stone retrieval, case discussion, multiple puncture access and multiple puncture access.

Percutaneous nephrolithotomy (PCNL) is a common urologic surgery for large renal stone and staghorn stone. In this article, we summarized the tips and tricks of ultrasound-guided puncture PCNL from experienced endourologists covering the diagnostic or therapeutic use. We also discussed about the difference guided methods’ and dilation methods’ pros and cons.

Introduction Percutaneous nephrolithotomy (PNL) has replaced open surgery for the treatment of kidney stones due to its less invasive nature. Bleeding still occurs due to renal vascular injuries, dependent upon the access route of the procedure. Several other factors are also related to the increased risk of bleeding. This study aims to find the association between blood transfusion and other factors such as age, gender, body mass index (BMI), size of the stone, operative time, preoperative hemoglobin (Hb) level, stone surface area, hypertension, and diabetes mellitus. Materials and methods This was a descriptive cross-sectional study conducted over a period of six months between November 2019 and April 2020 at a tertiary care hospital in Karachi, Pakistan. The sample size of 131 patients was calculated using open-source epidemiological software (Open-Epi). Inclusion criteria included patients from both genders and ages between 26 and 70 years. Patients ≤25 years, having a liver disease or bleeding disorders, or refusing to participate in the study, were excluded. Laboratory data included preoperative routine complete blood count, serum creatinine (normal 0.5-1.5 mg/dL), platelet count, bleeding and coagulation profile, and urine culture. All patients also underwent renal ultrasound scans. Treatment was postponed until a negative urine culture was obtained from patients with a positive urine culture. Results The mean age of the patients was 42.4 ± 15.65 years. One third (29.8%) of the patients were females. The stone size was 850 ± 121.43 mm², the mean operative time of the procedure was 125.76 ± 53.4 minutes, and the mean number of cell packs transfused was 1.10 ± 0.31 units. Blood transfusion was done in 24 (18.3%) of the patients. Gender, diabetes mellitus, stone size, preoperative Hb level, and operative time were significantly related to blood transfusion. Conclusions Increased bleeding risk while performing PNL has been associated with many factors such as operating time, the gender of the patients, and stone size. Therefore, these factors should be controlled for the procedure to decrease the risk of bleeding and the need for blood transfusion. Furthermore, the kidney vasculature should not be compromised while performing the procedure.

Immediate removal of staghorn kidney stones is important to prevent life-threatening complications. With the advancement of endoscopic technology, retrograde intrarenal surgery (RIRS) is now an alternate treatment to the standard percutaneous nephrolithotomy (PCNL) for stones removal. However, when used to treat large stones (>3cm), RIRS can cause the formation steinstrasse (SS). Here, we present the case of a 68-year-old man with multiple stones in the collecting system of the right kidney after initial treatment with RIRS. After two years of multiple interventions, the SS was completely removed. To prevent this complication in patients, a detailed assessment of the stone (size, location) and renal anatomy should be completed before RIRS is performed.

Percutaneous nephrolithotomy (PCNL) has been extensively developed through the last two decades. Apart from the technique and procedural standardization, the optimal surgical setting and imaging equipment are fundamental in order to puncture the ideal calyx and achieve stone-free result with the lowest possible complications. The large variety of the instruments and disposables in order to puncture, dilate, perform lithotripsy, retrieve stone fragments and exit is of utmost importance to perform a safe and effective PCNL. In this chapter we describe the armamentariums used in the PCNL procedure, including nephroscopes, access and dilatation equipment, lithotripters, retrieval devices and nephrostomies.

Objetivo Reportar un caso de nefrolitotomía percutánea en paciente con deficiencia de proteína C y S. Introducción Los pacientes con déficit de proteína C y S tienen un riesgo alto de eventos tromboembólicos reportándose tasas de hasta el 6% y 8,4% respectivamente. Reporte de Caso Paciente femenina de 43 años con antecedente de deficiencia de proteína C y S, anticoagulación crónica con warfarina por trombosis venosa profunda (TVP), clínicamente con cuadro de cólico reno ureteral derecho y hematuria, la tomografía de vías urinarias mostró un cálculo coraliforme completo derecho. Fue llevada a nefrolitotomía percutánea derecha previa terapia puente con enoxaparina, el acceso percutáneo fue a través del cáliz inferior. Debido a que no fue posible acceder a los cálculos del cáliz medio y superior y que en la institución donde se realizó el procedimiento no se cuenta con nefroscopio flexible, se decidió realizar una segunda punción en cáliz superior, dejando a la paciente libre de cálculos. Se reinició la anticoagulación plena a las 12 horas del postoperatorio sin presentar sangrado asociado. Discusión Los pacientes con déficit de proteína C y S tienen un riesgo alto para eventos tromboembólicos. Kefer y col., realizaron un estudio en el que evaluaron la eficacia de la terapia puente en pacientes llevados a NLP, encontrando que la anticoagulación con warfarina puede suspenderse 5 días antes y reiniciarse 5 días después del procedimiento quirúrgico sin necesidad de terapia puente con enoxaparina. En la actualidad, las recomendaciones dadas por la Sociedad Americana de Urología, indican realizar la terapia puente mediante un grupo multidisciplinario. Resultados El déficit de proteína C y S corresponde a una entidad, con una prevalencia muy baja y condiciona el requerimiento de anticoagulantes orales de forma indefinida. Fue posible realizar una intervención quirúrgica sin complicaciones hemorrágicas ni tromboembólicas con el uso de terapia puente prequirúrgica.

Introduction Percutaneous nephrolithotomy procedure is generally used to treat stones resistant to other treatment modalities. Colonic perforation even though rare, is a serious complication that increases patient's morbidity. This case report describes the case of a patient with retrorenal colon who underwent percutaneous nephrolithotomy for management of pelvis/lower calyceal staghorn stone. Case presentation A 63-year-old female patient presented for the management of a staghorn pelvis-lower calyceal stone. The patient had a preoperative computed tomography scan of the abdomen and pelvis that showed an incidental finding of left retrorenal colon. Under computed tomography scan guidance, a nephrostomy tube was successfully placed by an interventional radiologist, and then she underwent percutaneous nephrolithotomy. Conclusion This case report aims to stress on the importance of doing a computed tomography scan whenever a prior abdominal surgery is performed. We strongly believe that gastrointestinal injuries could be avoided by using computed tomography guided access in high risk patients.

The Kidney Injury Test (KIT) Stone-Score provides an objective measure of stone burden. Unlike urinary supersaturation the KIT Stone-Scores assess underlying stone disease rather than urinary solute composition. We report a case of a 43-year-old woman with no history of nephrolithiasis who underwent an elective, voluntary KIT assay and was diagnosed with a large staghorn renal stone after an unanticipated markedly elevated score. This clinical scenario highlights the potential future use of the non-invasive urinary KIT assay as a reliable non‐invasive tool to detect and monitor urinary stone disease., Highlights • KIT assay consists of a panel of six urinary biomarkers measured on a random urine sample. • Healthy asymptomatic patient was diagnosed with an unanticipated staghorn kidney stone after an elevated elective KIT assay. • For healthy patients, the threshold for the KIT Stone-Score was determined to be less than or equal to 30. • Urinary KIT normalized 6-months post-operatively. • KIT assay predicts the future risk of recurrence and risk stratify kidney stone patients.

Percutaneous nephrolithotomy (PNL) is the primary treatment modality for management of staghorn stones. PNL in supine position has important advantages over prone positon. However, studies comparing prone and supine positions for PNL in staghorn stone patients have conflicting results, and the aim of the current study was to compare prone and supine positions for PNL in staghorn stone cases. Data of patients underwent PNL for staghorn stones in supine or prone position by a single urologist were collected prospectively. The supine and prone position groups were compared for stone free rate (SFR) and complication rates. All patients were evaluated with NCCT for evaluation of SFR. Chi-square test was used to compare categorical variables and Student t test was applied for continuous variables of the treatment groups. The groups were similar for demographic and stone-related characteristics. Multi-caliceal and intercostal access was more common in prone position. Operation duration was significantly shorter and hemoglobin drop was significantly less in supine group. SFR was 64.1 and 60.4% in the supine and prone groups, respectively (p = 0.72). Complication rates were similar in the two groups but Clavien III complications were observed in two patients in the prone group. PNL in supine position is an effective treatment for management of staghorn stones. The need for multi-caliceal and intercostal puncture is less when combined with retrograde intrarenal surgery. PNL in supine position should be considered as primary treatment option in staghorn stone cases.

Objective To identify factors associated with successful ultrasound guidance for each surgical step of ultrasound-guided percutaneous nephrolithotomy (PCNL). Patients and Methods Consecutive patients undergoing PCNL between March 2015 and June 2016 were prospectively enrolled. An attempt was made to use ultrasound guidance in renal access, tract dilation, and nephrostomy tube placement for each patient. For steps during which ultrasound guidance was unsuccessful, fluoroscopic screening was applied. Regression analysis identified patient characteristics associated with successful use of ultrasound guidance. Results A total of 96 patients composed this cohort, with a mean body mass index of 28.7 kg/m 2 . Mean stone size was 33.1 ± 18.9 mm, and no hydronephrosis was found in 63.5% of cases. Fluoroscopic screening was required for renal access in 27 cases (28.1%), tract dilation in 38 (39.6%), and nephrostomy tube placement in 80 (83.3%). Multivariate analysis demonstrated that successful ultrasound guidance was significantly associated with the presence of hydronephrosis for renal access and the absence of staghorn calculi for tract dilation. Ultrasound-guided nephrostomy tube placement appeared linked to surgeon experience. Conclusion To achieve completely x-ray–free ultrasound-guided PCNL, the ideal patient should have a hydronephrotic collecting system with no staghorn stone present. For practitioners looking to adopt ultrasound guidance into their PCNL practice, these represent the most appropriate patients to safely initiate a surgical experience.

Staghorn stones have always been a challenge for urologists, especially in some special situations, such as horseshoe kidney, ectopic kidney, paediatric kidney, and solitary kidney. The treatment of these staghorn stones must be aggressive because they can lead to renal function loss and serious complications. The gold-standard management for staghorn stones is surgical treatment with the aim of clearing the stones and preserving renal function. Treatment methods for staghorn stones have developed rapidly, such as extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, percutaneous nephrolithotomy and laparoscopy and open surgery. Whether the standard procedures for staghorn stones can also apply to these stones in special situations is still not agreed upon. The decision should be made individually according to the circumstances of the patient. In this review, we evaluates the previous studies and comments on the management of staghorn stones under special situations in the hope of guiding the optimal choice for urologists. Keywords: Staghorn stone, Horseshoe kidney, Ectopic kidney, Paediatric kidney, Solitary kidney, Management

Objective To identify the better of 2 treatment strategies, single stage vs 2 stages, and to create multiple tracts in mini-percutaneous nephrolithotomy (MPCNL) for the treatment of staghorn stone. Materials and Methods Records of patients who underwent MPCNL with multiple tracts for the treatment of staghorn stones from 2011 to 2013 were retrospectively reviewed. Two-stage (as group 1) and 1-stage strategies (as group 2) to establish the multiple tracts were performed. A total of 145 pairs were matched for the analysis according to age, preoperative hemoglobin, preoperative urine culture, stone surface area, and stone size. Results In group 2, 45.5% of success rate of patients were achieved after a single procedure with a mean of 2.63 ± 0.62 tracts. The remaining patients required a second procedure, necessitating the placement of multiple tracts or the reuse of the existing tracts. The final success rate was similar in both group 1 and group 2 (82.1% vs 84.2%; P = .638). There was a significant decrease in the mean number of total access tracts, infection complications, and blood transfusion rate in group 1 than in group 2. The infection and bleeding complications were similar for both groups during the subsequent treatment. Conclusion The 2-stage MPCNL treatment plan for staghorn stones was more advantageous for 2 reasons: (1) Almost half of the patients who were treated using a 1-stage treatment plan required subsequent procedure to achieve a satisfactory success rate; (2) An initial treatment plan using the 2-stage approach resulted in less complication and less tracts established.

Background: Percutaneous nephrolithotomy (PCNL) for large stone burden can be problematic in patients with significant risk of bleeding complications, specifically thrombocytopenia. This report demonstrates effective correction of two patients' thrombocytopenia, subsequently leading to removal of large stone burden through PCNL. Case Presentation: We present two Middle Eastern patients who presented with medical histories significant for thrombocytopenia, secondary to splenomegaly and hepatic vein thrombosis, and large volume nephrolithiasis. Patient 1 is a 65-year-old female with a right 5 cm stone and a platelet count of 34,000. Patient 2 is a 45-year-old female with a 3 cm left staghorn stone and a platelet count of 44,000. After consultation with hematology, both underwent therapy with prednisone and intravenous immunoglobulin without improvement in their platelet count. They then received 3 μg/kg/dose of romiplostim weekly that improved their platelet counts to 133,000 and 195,000 in 2 weeks, respectively. Patient 1's PCNL was completed in a single-stage procedure with stone-free status shown on CT postoperative day 1. Patient 2 underwent PCNL and a secondary ureteroscopy for residual stone fragments on postoperative day 2. Both patients experienced no complication during the procedure, hospital stay, or postoperative course. Both continued romiplostim for 20 days postoperatively with platelet levels returning to their baseline range after 1 month. Conclusion: In the appropriately selected patient, romiplostim can correct thrombocytopenia enough to safely and effectively perform PCNL in patients with underlying hematologic disorders. Close coordination between urology and hematology is imperative to ensure an effective outcome in this challenging patient population.

Objective: To describe the technique and outcomes of antegrade ureteroscopic assistance during the initial nephrostomy access for the management of renal staghorn stone. Materials and methods: From 2000 to 2009, a total of 153 patients with complete staghorn stones were treated with percutaneous nephrolithotomy (PCNL) at our hospital. Antegrade ureteroscopic assistance was applied, starting in the 50th patient, during the initial nephrostomy access so as to prevent the creation of a false tract and to create more intracalyceal space for subsequent tract dilation. We report the characteristics of the patients, stones, treatment outcomes, and complications in the groups with and without antegrade ureteroscopic assistance. Results: Intergroup differences in the groups with (n = 104) and without (n = 49) antegrade ureteroscopic assistance with regard to the patients' characteristics and stone surface areas were not significant (24.0 ± 18.1 cm2 versus 21.8 ± 11.8 cm2). Patients who underwent PCNL with antegrade ureteroscopic assistance required a significantly shorter operation time and hospital stay than those who underwent PCNL without antegrade ureteroscopic assistance (143 ± 78 minutes versus 105 ± 35 minutes, p

Background Retrograde intrarenal surgery (RIRS) is a known option for the treatment of upper tract calculi with an excellent success. However, the reports of RIRS in prepubertal children are limited. In this study, we evaluated the factors which affected the success rate and the complications of RIRS at renal stone treatment in childhood. Methods We retrospectively reviewed the records of children under 14 years old who underwent RIRS for renal stone disease between January 2009 and December 2012. Patients' age, gender, body mass index (BMI), stone size, stone location, stone number, intraoperative complications, stone free status, postoperative complications were recorded. Results There were 80 ureterorenoscopic procedures performed in 58 renal units of 47 children (23 males and 24 females). The patients' ages ranged from 8 months to 14 years (mean age 4.7±3.4years). There was a difference in the distribution of symptoms in age groups. UTI was higher in the 1–4years age group, abdominal pain was seen mostly in children aged 5–14years. Multiple stones (included staghorn stone) were noted in 60.4% of patients. In 27.6% of patients, ureteral stones were accompanied by renal stones in our series. In the infancy group, cystine and staghorn stones were more frequently seen, mostly bilateral. After a single ureteroscopic procedure for intrarenal stones in children, we achieved stone free status in 50.9% of the ureters (n=26). After the repeated sessions, the stone clearance rate reached to 85.1%. Conclusion Retrograde intrarenal surgery can be used as a first line therapy to treat renal stones in children. This is especially important if an associated ureteral stone is present that requires treatment; or in patients with cystinuria, which is not favorably treated with ESWL. Complications were seen more frequently in patients with cystine stones. Extravasation was noted more frequently in patients admitted with UTIs. There was a significant relationship between the conversion to open procedures and the age groups, with most procedures occurring in infancy. The parents should be informed about the probability of multiple procedures to achieve stone free status.

Urinary calculi are prevalent and result in significant morbidity,with a marked economic impact. Various therapeutic optionsexist, from medical to surgical management according to stonesize. Laparoscopic pyelolithotomy is a viable option for significantstaghorn renal stones. We report the case of a laparoscopicpyelolithotomy performed on a 48-year-old man with a left recurrent staghorn renal stone secondary to an ureteropelvic junction obstruction following a grade IV renal trauma several years ago.

Objectives To review reports focusing on the surgical treatment of staghorn stones in children, as despite all the improvements in the surgical treatment of paediatric urolithiasis the management of staghorn calculi still represents a challenging problem in urology practice. Methods To evaluate current knowledge about treating staghorn calculi in children, we searched PubMed for relevant articles published between 1991 and 2011, using a combination of related keywords, i.e. staghorn stone, child, kidney calculi, surgical treatment, electrohydraulic shockwave therapy (ESWL), percutaneous nephrolithotomy (PCNL), and open surgery. Reports relating to the treatment of paediatric stone disease in general (open surgery, PCNL, ESWL) were also searched with the same method. Additional references were obtained from the reference list of full-text reports. Results Although open surgery had been widely used in the past for treating such stones in children, currently it has only limited indications in highly selected patients. Current published data clearly indicate that, in experienced hands, both PCNL and ESWL are now effective methods for treating staghorn calculi in children. Conclusions Due to advanced techniques and instrumentation, it is now possible to successfully treat staghorn calculi in children, with very limited safety concerns. Currently, while PCNL is recommended as the first-line surgical treatment, ESWL, open surgery and/or combined methods are valuable but secondary options in the treatment of paediatric staghorn calculi.

Objective To determine factors affecting the stone-free rate and complications of percutaneous nephrolithotomy (PNL) for treatment of staghorn stones. Methods The computerized database of patients who underwent PNL for treatment of staghorn stones between January 2003 and January 2011 was reviewed. All perioperative complications were recorded and classified according to modified Clavien classification system. The stone-free rate was evaluated with low-dose noncontrast computed tomography (CT). Univariate and multivariate statistical analyses were performed to determine factors affecting stone-free and complication rates. Results The study included 241 patients (125 male and 116 female) with a mean age of 48.7 ±14.3 years. All patients underwent 251 PNL (10 patients had bilateral stones). The stone-free rate of PNL monotherapy was 56% (142 procedures). At 3 months, the stone-free rate increased to 73% (183 kidneys) after shock wave lithotripsy. Independent risk factors for residual stones were complete staghorn stone and presence of secondary calyceal stones (relative risks were 2.2 and 3.1, respectively). The complication rate was 27% (68 PNL). Independent risk factors for development of complications were performance of the procedure by urologists other than experienced endourologist and positive preoperative urine culture (relative risks were 2.2 and 2.1, respectively). Conclusion Factors affecting the incidence of residual stones after PNL are complete staghorn stones and the presence of secondary calyceal stones. Complications are significantly high if PNL is not performed by an experienced endourologist or if preoperative urine culture is positive.

Staghorn stone volume and its distribution within the collecting system, "staghorn morphometry," predicts the requirement of tract and stage for percutaneous nephrolithotomy (PCNL) monotherapy. The purpose of the study was to develop a CT urography staghorn morphometry-based prediction algorithm to predict tract(s) and stage(s) for PCNL monotherapy and classify staghorn accordingly.A retrospective case-control design of 94 units was used. CT software calculated the total stone volume (TSV) with absolute volume and percentile volume in the pelvis, planned entry calix, favorable and unfavorable calix. Entry calix was the optimum calix chosen, keeping the relations of the ribs and adjoining viscera that could clear maximum stone volume. Unfavorable calix was defined as having an acute angle from the entry calix and infundibular width of ≤ 8 mm. A prediction model with odds ratio (OR) (95% confidence interval) was constructed on univariate and multivariate regression factors.On univariate analysis, TSV (P=0.013), unfavorable calix stone volume (0.007), and percentile distribution of stone in pelvis (0.026), pelvis and entry calix (0.001), and unfavorable calix (0.001) predicted tracts while total stone (0.001), pelvic stone (0.0046), and unfavorable calix stone (0.001) volume and percentile volume in pelvis (0.04), pelvis and entry calix (0.005) and unfavorable calix (P0.001) predicted stage. Multivariate analysis showed that unfavorable calix stone percentile volume predicted tract (area under the curve [AUC] - 0.91) while TSV and unfavorable calix stone percentile volume (AUC - 0.846) predicted stage. The OR-based prediction model suggested a need for single tract and stage PCNL vs multiple tract and stage PCNL for TSV and unfavorable calix percentile stone volume of (5,000 mm(3) and 5%) and (20,000 mm(3) and 10%), respectively.The model predicts the tract and stage for PCNL monotherapy. Staghorn morphometry differentiates staghorn into type 1 (single tract and stage); type 2 (single tract-single/multiple stage, or multiple tract-single stage), and type 3 (multiple tract and stage).

Introduction and Objectives: Crossed fused ectopia is a rare congenital renal anomaly that can be associated with concomitant ureteropelvic junction obstruction, malrotation, and abnormal ...

Objective: The study was performed to know if the possibility of tumor growth around a stone can be diagnosed immediately following the procedure of endourological surgery.

Complex staghorn calculi have conventionally been treated with percutaneous nephrolithotomy, extracorporeal lithotripsy, or, occasionally, open surgery. Access to branched calculi is difficult through a single percutaneous track. We tested and make a case for a synchronous bidirectional technique combining the use of flexible instruments through percutaneous and retrograde approaches. We present a case of "pass the ball," which may have a place in tackling large, complex, or branched staghorn calculi without the need for multiple percutaneous punctures, removing larger fragments than is possible through the ureter and avoiding multiple passes through the ureter, saving time and decreasing the possibility of iatrogenic ureteral injury.

Introduction: Our purpose was to remove large-volume staghorn calculi with less morbidity and maximum ease without an anatrophic nephrolithotomy, with the use of a pneumatic lithotriptor during pyelolithotomy to disintegrate the branches of stones extending into the calyces and retained calyceal fragments. Patients and Methods: Sixteen patients (17 renal units) with large-volume staghorn stones were evaluated with blood urea nitrogen (BUN), creatinine levels, urinalysis, and culture, excretory urography (IVP), and 99mtechnetium dimercaptosuccinic acid (DMSA) renal scintigraphy preoperatively. Patients were treated with a pneumatic lithotriptor at the time of open pyelolithotomy. Bilateral surgery was performed in 1 patient. The mean follow-up period was 12 (range 6–24) months. The patients were re-evaluated postoperatively at 6 months with BUN and serum creatinine measurements, urinalysis and culture, IVP, and renal scintigraphy with DMSA. Data were analyzed by one-way ANOVA test. p < 0.05 was considered statistically significant. Results: After treatment, 15 of 17 renal units (88%) were rendered stone-free while residual fragments remained in two patients. Average operation time was 190 min (range 135–285) with a mean blood loss of 226 ml (range 140–425). No patient required blood transfusion. Average length of hospital stay was 4.2 days (range 3–7). Six months after surgery, mean BUN and creatinine levels were decreased from 31.2 to 28.2 mg/dl (p = 0.248) and from 1.3 to 1.1 mg/dl (p = 0.001), respectively. Renal scintigraphy with DMSA revealed an increase in ipsilateral average renal function from 39 to 43% (p = 0.043). IVP also revealed a decrease in pelvicalyceal dilatation in almost all patients with a well-functioning kidney and without any stone recurrence. No complications were encountered postoperatively except for an episode of high fever in 1 patient. Conclusion: Avoiding incision of the renal parenchyma and arterial clamping, without significant bleeding and the nephron loss seem to be the advantages of this technique. Kidney function can be preserved with this simple and easily applicable method, which may be an alternative procedure to anatrophic nephrolithotomy for the majority of patients with staghorn calculi requiring open surgery.

Once an adequate percutaneous tract is created, the next step is to clear the stone. The fragmentation and extraction strategies should be tailored according to stone (hardness, location, size, and burden) and instrument (chosen size of the Amplatz sheath, diameter of the working channel of the endoscope in use) factors. Such strategies are similar in both prone and supine position, in spite of the fact that the slightly downward inclination of the Amplatz sheath in the supine position favors fragments’ spontaneous evacuation. Various tips and tricks, like the variety of laser settings with their different effects or the vacuum-cleaner effect, are described.

Although the supracostal approach is thought to increase the difficulties and patient morbidity of PCNL, it facilitates the management of certain urinary infirmities, such as UPJ obstruction, staghorn stone, upper pole stone, proximal ureteral abnormalities, impacted UPJ stone and upper calix diverticulum. Hereby the authors briefly comment on the technical aspects of the supracostal approach, and also discuss the possible complications of this technique and how to avoid them.

International classification of staghorn calculi is always lacking. French classification is described. Physiopatholgy of staghorn calculi is based on urinary infection. Staghorn stones in emerging countries will be composed frequently of calcium oxalate. Recurrent urinary infection and urinary stasis favour staghorn stone formation and are clinically significant. Medical treatment is rather uneffective. Only antibiotics and elimination of all residual fragments could be recommended.

Congenital thoracic ectopic kidney is a very rare developmental anomaly and the rarest form of all ectopic kidneys. It is usually asymptomatic and discovered incidentally on routine chest radiography. Herein we reported the first case of staghorn stone in a thoracic kidney managed successfully by percutaneous nephrolithotomy.

Purpose: To investigate the safety and efficacy of high-power holmium laser (70 W) in percutaneous nephrolithotripsy (PCNL) for large staghorn calculi. Materials and Methods: From December...

Despite the advent of extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy still plays a prominent role in the management of large and staghorn renal calculi. Modalities available for intracorporeal lithotripsy include ultrasound, electrohydraulic, and laser. I report my experience with the Swiss Lithoclast in performing percutaneous nephrolithotripsy in 45 patients. The advantages of this device in percutaneous stone removal include its rapidity, safety, ease of use, and usefulness in clearing the initial calix during staghorn stone removal.

In the age of shock wave lithotripsy and endoscopic stone therapy (percutaneous nephrolithotomy and retrograde [flexible] ureterorenoscopy), open stone surgery is only rarely performed and the indications are limited to a very low number of selected cases. In centers offering all stone treatment modalities, open stone removing procedures constitute around 1–5% of all procedures. However, despite that most situations can be handled by minimally invasive treatment, open stone surgery is still mandatory in special cases. It is therefore absolutely necessary that the skills of open stone removing procedures do not completely fall into oblivion. This chapter reviews current indications for open stone surgery and gives an overview on the applied techniques.

The use of stone surface area measurements obtained from standard radiographs provides a more accurate and reproducible assessment of stone burden when reporting results and treatment recommendations for staghorn calculi. Techniques for determining stone surface area include use of graph paper, planimeter or computerized image analysis. The use of graph paper is inefficient while planimeters suffer from significant variation for areas less than 500 mm.2 (more than 5%). Computer image analysis is accurate, rapid and easiest to perform. Software programs compatible with microcomputers are readily available making assessment of stone surface area practical and inexpensive. Stone surface area showed close correlation to stone volume as measured by 3-dimensional computerized tomography (correlation coefficient 0.84, p = 0.005). Stone surface area determination enables more accurate reporting of treatment results and, thus, recommendations based upon stone burden. Comparison of data between institutions becomes more meaningful if stone surface area is used. Stone surface area also provides a useful basis to study and compare trends of treatment within a single institution.

A case of ESWL treatment, as monotherapy, of a ‘stoned’ ureteral stent in a 12-year-old boy was described. Two years previously, the patient had pyelolithotomy with staghorn stone removal, and double-J stent was left indwelling intraoperatively. The patient was lost for follow-up for 2 years, when he had multiple stone formation adherent to the whole length of the stent. Four ESWL sessions were required before the stent was freed for removal.

The results of 117 consecutive staghorn stones treated with extracorporeal shock wave lithotripsy (SWL) monotherapy between March 1985 and October 1988 were reviewed. At 8 months after the initial ...