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The content of this article is authorized by the publisher to use Yimaitong, please do not reprint without authorization
.
Staghorn stone is a branched stone that affects the entire renal calyx and renal pelvis.
It is named because it resembles male stag antlers (Figure 1).
With the advancement and popularization of percutaneous nephroscope technology, staghorn stones can pass through a single cavity.
Endoscopic surgery or combined with extracorporeal lithotripsy
.
This section mainly introduces the history and application of surgical treatment of staghorn stones
.
Figure 1 The clinical outcome of KUB in the right kidney Before the 1970s, it was generally believed that staghorn stones were mostly asymptomatic, or antibiotics could be used to control the symptoms, and they could "coexist peacefully" with people for a long time
.
If all the stones cannot be removed after open surgery, new staghorn-shaped stones will inevitably be formed.
Therefore, treatment with open surgery is only a short-term behavior and may not be reasonable
.
Until 1974, Boyce and others in the United States reported the treatment of 100 cases of calculus.
They confirmed that the non-atrophic renal parenchymal incision and removal of the calculus can remove the calculus and keep it from recurring after the operation.
Since then, the staghorn stone has been completely changed.
Therapeutic point of view
.
Shortly afterwards, Blandy et al.
reviewed 185 stone patients.
They found that the 10-year mortality rate of patients undergoing surgery and patients under clinical observation were 7.
2% and 28%, which was a difference of nearly 4 times
.
In 1991, Koga et al.
followed up 167 patients with staghorn stones for a long time, of which 1/3 had a follow-up period of nearly 8 years, further confirming that patients undergoing surgery progressed more slowly than patients undergoing conservative treatment, and the renal salvage rate was higher
.
Definition and classification Although staghorn stone is a well-known term, its clinical definition is not clear enough and difficult to quantify
.
It is relatively objective to calculate the size of staghorn calculi based on the area of the calculi.
The volume of calculi can also be calculated through three-dimensional images, but it is more cumbersome and difficult to promote clinically
.
In order to facilitate the comparison of the effects of various treatment methods, Young et al.
defined complete staghorn stones as branched stones with a length of more than 5 cm; Snyder and Smith adopted a more standard method to define it: stones are full of kidney calyces, and At least two renal calyces are involved
.
The clinical classification of staghorn stones are as follows
.
(1) According to the degree of involvement of the renal calyces and renal pelvis, staghorn kidney stones are divided into two types, complete and partial
.
The treatment of complete staghorn stones is the content discussed in this article; partial staghorn stones are sometimes called cast stones, and the treatment principle is similar to the aforementioned renal pelvis and calyx stones
.
(2) According to different stone shapes, staghorn stones can be divided into two types: "narrow and small" and "massive"
.
The shape of the former stone is similar to the shape of the internal cavity of the renal pelvis and renal calyx, and the volume is small, the renal pelvis and renal calyx are not expanded and deformed, and there is generally no renal damage (Figure 2); while the latter has a large stone shape and accompanied by expansion of the renal pelvis and renal calyx.
Water accumulation is obvious, often associated with urinary tract infection and renal impairment (Figure 2)
.
Figure 2 The left is a narrow staghorn stone, the right is a massive staghorn stone (3) According to the distribution of the stones, staghorn stones can also be divided into "central type" and "peripheral type"
.
The former generally grows in the ampulla type renal pelvis, which is characterized by the fact that most of the stones are located in the renal pelvis (Figure 3); while the latter mostly grows in the branched renal pelvis, which is characterized by the fact that the stones are branched, the renal pelvis is small, and the main body of the stones is mostly located.
Each kidney calyx (Figure 3)
.
Figure 3 The left is the central staghorn stone, and the right is the treatment guidelines for peripheral staghorn stones.
With the introduction of modern minimally invasive treatment techniques, the treatment concept of staghorn stones has been completely updated
.
At this stage, staghorn stones have 4 treatment methods: SWL treatment, PCNL treatment, PCNL combined with SWL treatment and open surgery
.
The treatment of staghorn stones is extremely challenging
.
For this reason, the American Urological Association (AUA) Kidney Stones Steering Group specifically listed it as the preferred research object
.
The expert group reviewed 1252 documents and conducted a meta-analysis on 110 of the data involving staghorn stones.
The analysis indicators and results include: ①The probability of all stones being eliminated, the stone-free rate is: SWL50%, PCNL73% , SWL and PCNL 80%, open surgery 82%
.
②The possibility of unplanned secondary treatment.
In terms of unplanned secondary treatment rate, SWL is P=0.
424, PCNL is P=0.
047, SWL and PCNL is P=0.
034, and open surgery is P=0.
002
.
③ the possibility of complications, major complications are: hydronephrosis, pneumonia, renal hematoma, vascular injury, urinary cyst, sepsis, renal failure, unplanned secondary treatment
.
After treatment of large staghorn-shaped stones with infection, the remaining stones may be re-infected or grow up to cause secondary symptoms or aggravation of the original symptoms
.
The incidence of complications of the four schemes is quite different, which are 30% for SWL, 7.
4% for PCNL, 24.
4% for SWL and PCNL, and 11.
9% for open surgery
.
However, the complications caused by SWL are less severe than those caused by other programs
.
Finally, the AUA Kidney Stone Steering Group formulated a set of treatment guidelines for staghorn stones based on the analysis results, and divided them into three levels
.
(1) Standard treatment means that once staghorn stones appear, patients should be required to receive active treatment, otherwise the stones will eventually cause renal damage or urinary sepsis
.
Before treatment, patients should be informed of the above four therapies from both positive and negative aspects
.
(2) Guidance treatment.
According to the recommendation of the steering group, PCNL is the first choice of treatment, and then use SWL together.
If necessary, PCNL can be used repeatedly; narrow staghorn-shaped stones with normal kidney anatomy, with an area of about 500mm2, which is equivalent For stones with a length of 2.
5 cm, the success rate of SWL alone can reach 92%, but this staghorn-shaped stone accounts for only 4%
.
(3) Selective treatment is only an option.
The expert group recommends that for some rare complex staghorn stones, including those who cannot be cured by PCNL or SWL a reasonable number of times, and those who need intranephroplasty, open Surgical treatment is also a reasonable choice, and non-atrophic renal parenchymal incision and lithotripsy are particularly recommended
.
Nephrectomy should be used for severely impaired renal function
.
In addition, for some small staghorn infection stones with normal anatomy, SWL or PCNL alone is equally effective, and either one can be used as a treatment
.
This article is an excerpt from "The Principle and Application of Shock Wave Lithotripsy" (China Science and Technology Press)
.
Yimaitong has been authorized by the publishing house
.
For more information, please read the original book
.
Scan the QR code below, or click to read the original text to purchase
.
.
Staghorn stone is a branched stone that affects the entire renal calyx and renal pelvis.
It is named because it resembles male stag antlers (Figure 1).
With the advancement and popularization of percutaneous nephroscope technology, staghorn stones can pass through a single cavity.
Endoscopic surgery or combined with extracorporeal lithotripsy
.
This section mainly introduces the history and application of surgical treatment of staghorn stones
.
Figure 1 The clinical outcome of KUB in the right kidney Before the 1970s, it was generally believed that staghorn stones were mostly asymptomatic, or antibiotics could be used to control the symptoms, and they could "coexist peacefully" with people for a long time
.
If all the stones cannot be removed after open surgery, new staghorn-shaped stones will inevitably be formed.
Therefore, treatment with open surgery is only a short-term behavior and may not be reasonable
.
Until 1974, Boyce and others in the United States reported the treatment of 100 cases of calculus.
They confirmed that the non-atrophic renal parenchymal incision and removal of the calculus can remove the calculus and keep it from recurring after the operation.
Since then, the staghorn stone has been completely changed.
Therapeutic point of view
.
Shortly afterwards, Blandy et al.
reviewed 185 stone patients.
They found that the 10-year mortality rate of patients undergoing surgery and patients under clinical observation were 7.
2% and 28%, which was a difference of nearly 4 times
.
In 1991, Koga et al.
followed up 167 patients with staghorn stones for a long time, of which 1/3 had a follow-up period of nearly 8 years, further confirming that patients undergoing surgery progressed more slowly than patients undergoing conservative treatment, and the renal salvage rate was higher
.
Definition and classification Although staghorn stone is a well-known term, its clinical definition is not clear enough and difficult to quantify
.
It is relatively objective to calculate the size of staghorn calculi based on the area of the calculi.
The volume of calculi can also be calculated through three-dimensional images, but it is more cumbersome and difficult to promote clinically
.
In order to facilitate the comparison of the effects of various treatment methods, Young et al.
defined complete staghorn stones as branched stones with a length of more than 5 cm; Snyder and Smith adopted a more standard method to define it: stones are full of kidney calyces, and At least two renal calyces are involved
.
The clinical classification of staghorn stones are as follows
.
(1) According to the degree of involvement of the renal calyces and renal pelvis, staghorn kidney stones are divided into two types, complete and partial
.
The treatment of complete staghorn stones is the content discussed in this article; partial staghorn stones are sometimes called cast stones, and the treatment principle is similar to the aforementioned renal pelvis and calyx stones
.
(2) According to different stone shapes, staghorn stones can be divided into two types: "narrow and small" and "massive"
.
The shape of the former stone is similar to the shape of the internal cavity of the renal pelvis and renal calyx, and the volume is small, the renal pelvis and renal calyx are not expanded and deformed, and there is generally no renal damage (Figure 2); while the latter has a large stone shape and accompanied by expansion of the renal pelvis and renal calyx.
Water accumulation is obvious, often associated with urinary tract infection and renal impairment (Figure 2)
.
Figure 2 The left is a narrow staghorn stone, the right is a massive staghorn stone (3) According to the distribution of the stones, staghorn stones can also be divided into "central type" and "peripheral type"
.
The former generally grows in the ampulla type renal pelvis, which is characterized by the fact that most of the stones are located in the renal pelvis (Figure 3); while the latter mostly grows in the branched renal pelvis, which is characterized by the fact that the stones are branched, the renal pelvis is small, and the main body of the stones is mostly located.
Each kidney calyx (Figure 3)
.
Figure 3 The left is the central staghorn stone, and the right is the treatment guidelines for peripheral staghorn stones.
With the introduction of modern minimally invasive treatment techniques, the treatment concept of staghorn stones has been completely updated
.
At this stage, staghorn stones have 4 treatment methods: SWL treatment, PCNL treatment, PCNL combined with SWL treatment and open surgery
.
The treatment of staghorn stones is extremely challenging
.
For this reason, the American Urological Association (AUA) Kidney Stones Steering Group specifically listed it as the preferred research object
.
The expert group reviewed 1252 documents and conducted a meta-analysis on 110 of the data involving staghorn stones.
The analysis indicators and results include: ①The probability of all stones being eliminated, the stone-free rate is: SWL50%, PCNL73% , SWL and PCNL 80%, open surgery 82%
.
②The possibility of unplanned secondary treatment.
In terms of unplanned secondary treatment rate, SWL is P=0.
424, PCNL is P=0.
047, SWL and PCNL is P=0.
034, and open surgery is P=0.
002
.
③ the possibility of complications, major complications are: hydronephrosis, pneumonia, renal hematoma, vascular injury, urinary cyst, sepsis, renal failure, unplanned secondary treatment
.
After treatment of large staghorn-shaped stones with infection, the remaining stones may be re-infected or grow up to cause secondary symptoms or aggravation of the original symptoms
.
The incidence of complications of the four schemes is quite different, which are 30% for SWL, 7.
4% for PCNL, 24.
4% for SWL and PCNL, and 11.
9% for open surgery
.
However, the complications caused by SWL are less severe than those caused by other programs
.
Finally, the AUA Kidney Stone Steering Group formulated a set of treatment guidelines for staghorn stones based on the analysis results, and divided them into three levels
.
(1) Standard treatment means that once staghorn stones appear, patients should be required to receive active treatment, otherwise the stones will eventually cause renal damage or urinary sepsis
.
Before treatment, patients should be informed of the above four therapies from both positive and negative aspects
.
(2) Guidance treatment.
According to the recommendation of the steering group, PCNL is the first choice of treatment, and then use SWL together.
If necessary, PCNL can be used repeatedly; narrow staghorn-shaped stones with normal kidney anatomy, with an area of about 500mm2, which is equivalent For stones with a length of 2.
5 cm, the success rate of SWL alone can reach 92%, but this staghorn-shaped stone accounts for only 4%
.
(3) Selective treatment is only an option.
The expert group recommends that for some rare complex staghorn stones, including those who cannot be cured by PCNL or SWL a reasonable number of times, and those who need intranephroplasty, open Surgical treatment is also a reasonable choice, and non-atrophic renal parenchymal incision and lithotripsy are particularly recommended
.
Nephrectomy should be used for severely impaired renal function
.
In addition, for some small staghorn infection stones with normal anatomy, SWL or PCNL alone is equally effective, and either one can be used as a treatment
.
This article is an excerpt from "The Principle and Application of Shock Wave Lithotripsy" (China Science and Technology Press)
.
Yimaitong has been authorized by the publishing house
.
For more information, please read the original book
.
Scan the QR code below, or click to read the original text to purchase
.
