Combined Treatment of Staghorn Calculi by Fiberoptic Transurethral Nephrolithotripsy and Extracorporeal Shock Wave Lithotripsy

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Abstract
Although various strategies have been proposed, the treatment of staghorn calculi is still controversial. We report on the treatment of 27 staghorn calculi using fiberoptic transurethral nephrolithotripsy (f-TUL) combined with extracorporeal shock wave lithotripsy (ESWL). Stones were initially disintegrated by f-TUL as an inpatient procedure. For stone fragmentation, we originally used an electrohydraulic lithotriptor (EHL) but changed to a pulsed-dye laser in 1993. After the stones were disintegrated as much as possible, a double-J ureteral stent was inserted and the patient was discharged. ESWL for the residual fragments was begun on an outpatient basis at 1 or 2 weeks after f-TUL and repeated until the residual fragments were smaller than 4 mm. Since 1989, 27 staghorn calculi in 26 patients have been treated. Among them, 21 were successfully fragmented using this combined treatment regimen. From 3 to 26 ESWL sessions (mean, 8.4 sessions) were required to disintegrate the staghorn calculi. Auxiliary percutaneous endourological procedures were necessary in 2 cases due to ureteral obstruction. The other 4 patients are still receiving ESWL for residual fragments. Urinary tract injury occurred in 2 patients early in this series when an EHL was used, but was managed without any surgical procedures. A fever greater than 38 degrees C developed in 9 patients. Combining f-TUL with ESWL provides an alternative treatment option for staghorn calculi. The use of a small caliber fiberscope (2.6 mm in diameter) and a laser for fragmentation decreased the risk of complications.