Abstract
S
Surgical treatment has evolved for the past decades, from complicated open anatrophic nephrolithotomy to challenging percutaneous nephrolithotomy—sometimes through multiple access tracts. These are difficult and potentially morbid procedures for staghorn calculi—vastly different from treating a 2 to 3 cm renal pelvis stone. Kidneys that have been chronically infected/inflamed are hypervascular with a higher likelihood of infections and bleeding, particularly with a prolonged operative time.
Given these daunting challenges, the thoughtful endourologist sometimes wonders whether conservative (i.e., nonsurgical) treatment is the better option. In this study, Morgan et al. add to a limited set of data supporting nonsurgical treatment in selected cases. Their patient population is fairly complicated—older (median age 74 years), 59% complete staghorns, 21% bilateral, and with significant comorbidities (defined by the Charlson Comorbidity Index). In such patients, “stone-free” may be the wrong goal. Rather, we should seek preserved quantity and quality of life in an optimized balance. The question is whether surgery or no surgery will offer the better outcome.
Since predicting individual outcomes is inexact, consider the contemporary concept of value = outcome/cost. Although this is not a cost study, we can apply general principles and suppose that the “value” of surgery in these higher risk patients would be the (stone-free rate) − (complications)/(cost of one or more procedures) + (cost of complications). The numerator is reduced by a higher rate of complications and the denominator can quickly accumulate. By comparison, a nonsurgical approach results in a pretty good result (only a 14% rate of renal function decline) with a much lower initial cost in the absence of surgery. The latter value equation begins to look pretty good by comparison. In addition, not all staghorn stones are struvite/infection-related stones (although in this study stone composition was unknown). Nonstruvite stones would likely present an even better nonsurgical outcome.
Now, this does not argue for nonsurgical treatment in most patients. This study is a small sample of their overall experience, and the follow-up time is relatively short. Obviously the cost of renal failure and renal replacement therapy would run high for an individual patient. And there is contrasting data in the literature that argues strongly for surgical intervention. However, for some patients, conservative therapy is surely defensible. This study should, at the least, encourage us to stop and think before an automatic decision for surgery for all staghorn stones.