Management of complete staghorn stone in a developing country

Introduction: Staghorn renal stones in a developing country, very often associated with insidious growth, late presentation, complications and recurrence, present an economic burden to the patient and a challenge to the treat­ing surgeon. Despite proven effectiveness of modern endourological procedures, they are cost intensive and require multiple sittings. Current retrospective study was undertaken to evaluate the most effective therapy for these stones in a developing country. Materials and Methods: 156 patients with extensively branched staghorn renal stones were treated at our center over a period of one decade. Of these patients 76 under­went PNL (group-I), 35 sandwich (group-11) and 45 open surgical procedures (group-III). Perioperative events in­cluding clearance rate, morbidity, complications, blood transfusions and ancillary procedures were compared between the three groups. Also compared was the length of inpatient treatment and the expenses incurred. In a sub­group analysis, treatment outcome and complications were separately analyzed in patients with renal failure (serum creatinine >2.0 mg%). Results: The three groups were comparable in terms of age, sex, stone size, preoperative serum creatinine, hemoglobin and positive urine cultures. Overall stone free rate in group-I (85.52%) was higher than group-11 (74.28%) and group-III (79.41 %) although it did not reach statistical significance. Ancillary procedures were least required in group-III patients. ESWL was required in 23.7% of group-I and 8.8% of group-III patients (P<0.05). Ureteroscopy was required in 7.89%, 17.1 % and 4.4% of groups I, II and III respectively. While the incidence of urosepsis was comparable, major postoperative bleeding occurred in 10.52%, 8.6% and, 6.6% of groups I, II and III respectively. The mean hospital stay amongst the three groups was similar with a marginally longer stay in the sandwich group. The overall cost of the treatment includ­ing adjuvant therapy was significantlv less expensive in group-III compared to group-I and group-11. Renal failure patients had higher clearance rates with open procedures compared to PNL (80% vs 62.5% respec­tively). Moreover these patients had higher incidence of major bleeding with PNL compared to open procedures (31.3% vs 10%). Conclusions: Advantages of endourological procedures in the management of staghorn stones is offset by the need of ancillary treatments, which are expensive and which require frequent visits to the hospital. In view of high clear­ance rates, lesser treatment cost and lesser incidence of complications, open surgery still has a place in the man­agement of staghorn renal stones in patients who have economic constraints and live in remote areas where medi­cal facilities are not freely available. These advantages are also seen in the renal failure patients where complica­tions with endourologic procedures were significantly more than that with open surgery. However postoperative mor­bidity and larger scar should be discussed with the pa­tients.