1. Top of page
  2. Introduction
  3. Definition of complex renal stones
  4. Staghorn calculi
  5. Discussion
  6. Perspectives
  7. References
  8. Authors

In the 20 years since the clinical introduction of ESWL [1] and endourological techniques such as ureteroscopy and percutaneous nephrolithotripsy [2,3], the treatment of urolithiasis has changed completely. Whereas in the 1970s and the early 1980s most renal and ureteric stones were removed by open surgery [4–7] this is now a rare event, at least in European, Japanese and Anglo-American centres. The widespread use of ESWL has resulted in significantly fewer patients with chronic renal stones and consequently an increase in the proportion of those with ureteric stones, from 10–20% to 30–40% in our population [8,9]. Additionally, there are fewer complicated renal stones after treatment with the new multimodal minimally invasive techniques than there were in the 1980s and early 1990s ( Table 1). Thus there has been an increase in the use of ureteroscopy but a decrease in percutaneous stone surgery.

Table 1.  Change in the indications for stone treatment; personal experience at three centres (Stuttgart, Mannheim, Heilbronn)
Incidence (%)
Calyceal stones354346
Pelvic stones422013
Staghorn stones 8 3 1
Ureteric stones153440
Treatment modality
PCNL20 5 2
Open surgery 9 10.1

There are several reasons to explain this situation: (i) the minimal morbidity associated with the new methods has significantly improved the compliance of the patients to undergo early therapy of their stone disease; (ii) the widespread use of diagnostic ultrasonography has increased the early detection rate of urinary calculi; (iii) the newer antibiotics (i.e. gyrase inhibitors) allow more effective treatment of UTIs, particularly urease-splitting bacteria (e.g. Proteus spp); and (iv) multiple treatments can be administered if there is recurrent stone formation (i.e. by ESWL) with no significantly enhanced risk of deterioration of renal function or increasing technical difficulties (as there was with open surgery); this has improved the prognosis for these patients.

Nevertheless, patients continue to present with complex renal stones requiring more than ESWL or ureteroscopic stone removal. In this review (based on our experience and published studies) we focus on the state-of-the-art management of complicated nephrolithiasis, emphasizing all the existing minimally invasive techniques. However, the remaining current indications for open surgery are also discussed.

Definition of complex renal stones

  1. Top of page
  2. Introduction
  3. Definition of complex renal stones
  4. Staghorn calculi
  5. Discussion
  6. Perspectives
  7. References
  8. Authors

Complicated nephrolithiasis consists of a variety of stone-bearing situations, depending on:

  • • 
    The stone burden and distribution;
  • • 
    Stone composition;
  • • 
    Renal function;
  • • 
    Associated UTI.

Most complex renal stones are staghorn calculi, but multiple stones behind an infundibular stenosis or in a calyceal diverticulum may be complicated. Moreover, stones in renal abnormalities, e.g. horse-shoe or medullary sponge kidneys, are often difficult to manage [9]. Finally, reduced renal function and/or infection of the renal collecting system always presents a challenge to the urologist.

Staghorn calculi

  1. Top of page
  2. Introduction
  3. Definition of complex renal stones
  4. Staghorn calculi
  5. Discussion
  6. Perspectives
  7. References
  8. Authors

Principally, staghorn calculi are defined as branched stones in the renal collecting system. However, as mentioned, there are several different arrangements within this entity. This was considered in the more complex definition by Rocco et al.[10] or the PICA classification of Griffith et al.[11]. In the modern management of such stones three factors are of major importance to decide the optimal treatment ( Fig. 1a):


Figure 1. Criteria determining the choice of treatment in the management of complex renal stones. a, top, stone size (geqslant R: gt-or-equal, slanted 3 cm); middle, location (branched); bottom, anatomy (calyceal neck stenosis) and radio-density. b, top, borderline (filling the pelvis and one calyx); middle, partial (filling geqslant R: gt-or-equal, slanted two calyces and the pelvis); bottom, complete (filling the entire renal calyceal system (or geqslant R: gt-or-equal, slanted 80%)).

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  • • 
    The overall stone burden;
  • • 
    The location of the stone burden (i.e. which and how many calyces are involved);
  • • 
    The anatomy of the collecting system (i.e. a dilated collecting system).

Based on this, several authors have introduced a relatively simple definition ( Fig. 1b), distinguishing between borderline stones, partial and complete staghorn calculi [12]. Obviously, the stone burden can be calculated more closely using the area on a plain film of the kidney, ureter and bladder (KUB), as proposed by Lam et al.[13]. This was very useful in evaluating different therapeutic approaches, but in daily routine the simple classification was sufficient.

Treatment options

Whereas previously only modifications of open renal surgery, i.e. anatrophic vs radial nephrolithotomy [4,7], were discussed (and even conservative management was an option [14]) currently a multimodal approach is used to minimize the morbidity of treatment and optimize the long-term results. This may include:

  • • 
    ESWL with or with no indwelling stent;
  • • 
    Percutaneous nephrolithotomy (PCNL) using different devices for stone disintegration;
  • • 
    A combination of both techniques as a planned procedure;
  • • 
    Retrograde ureteroscopic stone disintegration using a holmium laser;
  • • 
    Open surgery (i.e. anatrophic or radial nephrolithotomy, sinusoidal pyelolithotomy).

Staghorn stones are unquestionably an indication for interventional therapy, as all reports of conservative treatment show a substantially increased rate of nephrectomy (up to half) and an increase in associated morbidity (i.e. dialysis); in many cases (up to 28%) the disease resulted in death [5,14]. The choice of the listed treatments mainly depends on the specific finding of a staghorn stone (i.e. stone classification [15]). However, other factors, e.g. the age of the patient or the function of the stone-bearing kidney, may be important ( Table 2).

Table 2.  Criteria for choosing the treatment for staghorn calculi
Stone burdenminormajormajor
Distribution of stone load peripheralcentralcentral + peripheral
Renal collecting system narrowdilatednarrow/dilated
Chemical composition No cystine

Criteria of success

The goal of any of the procedures is to render the patient stone-free, but with the introduction of ESWL, particularly for larger calculi or those in the lower calyx, > 40% of persisting fragments have been accepted [16,17] as still being successful, because in most cases (90%) these are clinically insignificant residual fragments (CIRF), defined as:

  • • 
    Residual fragments of leqslant R: less-than-or-eq, slant 4 mm after ESWL;
  • • 
    Calcium oxalate/phosphate calculi;
  • • 
    Normal anatomy of the upper urinary tract;
  • • 
    No UTI;
  • • 
    No symptoms after ESWL;
  • • 
    No adjuvant therapy required.

These fragments are insignificant because they do not induce early stone recurrence, differing from the residual stones in the era of open surgery, particularly when infected. This may be attributable to improved antibiotics, but also possibly because the fragmented calculi are easier to treat, resulting in some residual sterile fragments after ESWL [16,17]. Nevertheless, any patient with a treated staghorn stone requires a close follow-up [18].

Indications for ESWL monotherapy

ESWL should be used in patients with a minor stone burden, peripheral stone load (i.e. multiple stone-filled calyces) and a narrow renal collecting system. Moreover, patients with enhanced risk (i.e. atherosclerosis, respiratory problems) or other difficulties related to percutaneous surgery (i.e. in children, or those with urinary diversion) must undergo ESWL alone ( Fig. 2a).


Figure 2. Staghorn stones; indications for the different procedures. a, ESWL monotherapy; a complete staghorn stone (struvite) in the right kidney after radical cystectomy and ileal conduit construction. Good fragmentation and stone passage can be expected because of the missing vesico-ureteric junction. b, PCNL monotherapy; borderline stone (calcium oxalate monohydrate) filling one lower pole calyx (left panel pyelogram, right panel KUB), easily removable by a one-stage PCNL via a single percutaneous tract. c, Combination: a complete staghorn stone within a dilated collecting system (left panel pyelogram, right panel KUB). Percutaneous debulking of the lower pole calyces and pelvis is followed by ESWL for fragmentation of the upper pole part. d, Open surgery: a complete staghorn stone in a complicated dendritic collecting system with a minimal pelvic stone burden and multiple stones behind infundibular stenoses (left panel pyelogram, right panel KUB). Stone removal requires multiple radial nephrolithotomies probably followed by a calycoplasty (i.e. upper pole).

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Indications for PCNL monotherapy

A single session of PCNL can be successful in patients with a major stone burden and a central (i.e. pelvic) stone load in an enlarged (i.e. dilated) collecting system (borderline and partial staghorn calculi, Fig. 2b). Furthermore, slightly opaque or shock-wave resistant calculi (i.e. cystine) are candidates for PCNL alone.

Indications combined ESWL and PCNL

The combination of ESWL and PCNL, principally initiated with a percutaneous approach, is applied in all patients with a major stone burden (i.e. partial and complete staghorn stones) with a central and peripheral stone load ( Fig. 2c). The rationale for the combined therapy is to reduce the morbidity of PCNL, which is carried out in most cases via one lower pole tract, and to use the ESWL selectively for disintegrating those calculi (parts of the staghorn stone) that cannot be reached with the nephroscope.

Indications for open surgery

Surgery is a potential treatment option for any staghorn stone, for several reasons. The stone can be removed by a single procedure and produce comparable stone-free rates. Therefore, some authors still advocate open surgical removal for complete staghorn stones [19–22]. However, there is the problem of the loss of renal function after such extensive surgical interventions like anatrophic intersegmental pyelolithotomy, which reportedly occurs in 30–50% of patients [23]. Overall, the residual stone rate after open renal surgery is ≈ 15%, with a 30% stone recurrence rate over 6 years and a 40% risk of UTI [16,19–25].

We have therefore restricted the indications for open surgery to those patients with a massive stone burden that cannot be reached endoscopically or by a considerable number of ESWL treatments, or if additional reconstructive surgery (i.e. calyco-ureterostomy, pyeloplasty) is required [25] ( Fig. 2d). Nonfunctioning kidneys can be removed laparoscopically [26,27].

Therapeutic approach

Independent of the procedure, every patient with a staghorn stone requires antibiotic prophylaxis (i.e. gyrase inhibitors) at least 2 days before the intervention. In our series, 38% of the patients presented with UTIs before treatment [25], 51% of which were from Proteus mirabilis ( Table 3).

Table 3.  Distribution of bacteria found in patients with staghorn stones (from [25])
SpeciesIncidence (%)
Proteus mirabilis51
Escherichia coli13
Providencia 9
Pseudomonas 4
Klebsiella 4
Staphylococcus 2
Citrobacter 2
Enterobacter 1
Serratia spp 1

ESWL monotherapy: The techniques of ESWL have been described in detail previously [28–31]. If the stone is large (> 2 cm) we recommend the insertion of a JJ stent before ESWL, to avoid obstruction of the ureter by steinstrasse; the stent does not inhibit the passage of fragments along the ureter [13]. Staghorn stones should be treated initially in the pelvic part to enable the passage of fragments; thereafter, the upper and middle calyces are treated, leaving the lower pole untreated to avoid fragments falling into the lower calyces, from where further passage may be prolonged ( Fig. 2a). Depending on the energy setting of the machine, the number of shocks per session should be < 4000; the interval between each treatment should be at least 2 days.

PCNL monotherapy: This is performed as a one-stage procedure, with the patient under general anaesthesia, using a retrograde balloon occlusion catheter placed at the PUJ [12,25]. Access is usually through the lower pole posterior calyx with removal of the lower calyceal and pelvic stone burden. If the stone burden is large, we always place an Amplatz sheath down the percutaneous tract. This allows the removal of larger stone fragments and reduces the risk of pelvicalyceal influx. Only in selected cases (e.g. stones less suitable for ESWL, like cystine) do we recommend the puncture of an additional calyx to achieve complete stone clearance in a single PCNL session. Another option to access stone burden in upper and middle calyces may be the use of a flexible cystoscope together with a holmium or dye laser introduced via the Amplatz sheath.

Combination: In the combined approach we recommend starting with a de-bulking PCNL via the lower pole posterior calyx. The kidney is punctured under combined ultrasonographic and fluoroscopic control; sometimes several tracts (maximum three) can be made ( Fig. 3) if there is a massive stone burden (i.e. in the upper dilated calyx).


Figure 3. Combination therapy for complete staghorn stone. a, retrograde pyelogram before PCNL. b, KUB. c, complete clearance of the lower calyx, pelvis and part of the upper calyces by PCNL via two tracts. d, KUB before two second ESWL sessions with fragmentation of the upper calyceal part. e, KUB after the second ESWL session, showing some larger fragments in the superior and inferior calyx. f, KUB after the third ESWL session shows complete disintegration of all residual fragments.

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Open surgery: Whereas in our earlier experience the technique of clamping and cooling was used [32,33], we have recently preferred the technique of radial nephrotomies with intraoperative colour duplex ultrasonography [7]. Other options include extended pyelolithotomy, anatrophic nephrolithotomy or posterior lower nephrolithotomy. Currently we do not place the same emphasis on achieving complete stone clearance, because minor residual stones can be treated effectively with ESWL.

Treatment results

Some of our experience with the multimodal minimally invasive management of staghorn calculi has been published [12,25,33]. Here, we focus on the long-term results compared with those obtained by open surgery. In all, 197 patients were treated with the new methods in a 5-year period and compared with 83 patients who underwent open surgery for complicated nephrolithiasis before the introduction of ESWL and endourology. In all, 247 patients (186 and 61, respectively) were followed over 36 and 42 months, respectively, to analyse the pattern of stone clearance by the passage of fragments, recurrent stone formation and UTI.

Correlating with the increasing stone burden and complexity, the proportion undergoing ESWL monotherapy decreased from 45% for borderline stones to 2% in those with a complete staghorn ( Table 4). PCNL was most frequently used to manage partial staghorn calculi, whereas the combination was applied in 74% of all complete staghorn stones. For borderline stones only 6% of the patients required more than three sessions, compared with 10% for partial and 21% for complete staghorn stones. Open surgery was performed in 7% for partial and in 11% for complete staghorn calculi. Overall, 53 patients were treated by ESWL monotherapy, 56 by PCNL monotherapy and 77 by the combined technique.

Table 4.  The distribution (%) of the use of different treatment modalities in the management of 197 complex renal (staghorn) stones
Type (total)ESWLPCNLCombinedOpen surgery
Borderline (70)452231 2
Partial (75)202852 5
Complete (52) 2137411

Of patients with borderline or partial staghorn calculi, 37% and 35%, respectively, presented with UTI before treatment, in contrast to half of those with complete staghorn stones; a detailed analysis of the relevant data is shown in Table 5. Three or more ESWL sessions were necessary in 24% of all patients, ranging from none (PCNL monotherapy) to 54% (combination). This was because at most two PCNL sessions were used for stone removal; any further fragments of the stone that could not be treated effectively underwent ESWL. Blood transfusions were required in 10% of the patients, in none after ESWL monotherapy but in 17% after combined treatment, mainly because of the increased technical difficulties of PCNL.

Table 5.  The clinical results from the modern management of complex renal stones, and the comparison with open surgery
CriteriaESWLPCNLPCNL+ESWLAllOpen surgery
  • *

    P < 0.05, other differences not significant;

  • †in nine patients caused by poor function, in three by septicaemia.

Total53   56   77    186   83
Borderline44 (83)25 (45)18  (23) 87 (47)40 (48)
Partial 7 (13)26 (46)30  (39) 63 (34)16 (19)
Complete 2  (4) 5  (9)29  (38) 35 (19)27 (33)
2nd session13 (25)15 (28)77 (100)105 (56)
3rd session 3  (6) –27  (35) 30 (16)
> 3 sessions 1  (2) –14  (18) 15 (8)
Blood transfusion – 5  (9)13  (17) 18 (10) *31 (37)
Auxiliary measures19 (36) 9 (17)11  (14) 39 (21)
Nephrectomy rate  – – –  3 (2)12 (14)
Ureterorenoscopy 3  (6) 1  (2) 7  (9) 11 (6)
Open surgery 2  (4) 2  (4) 1  (1)  4 (2)
Minor23 (44)22 (39)41 (52) 86 (45)28 (39)
colic12 (23) 4  (7)12 (15) 28 (15)
fever11 (21)18 (32)29 (37) 56 (30)27 (33)
wound problems – – – – 5  (6)
Major 5 (10) 4  (7) 4  (4) 13 (7) 6  (8)
septicaemia 3  (6) 1  (2) 1  (1)  5 (3) 3  (4)
bleeding 1  (2) 2  (4) 2  (2)  5 (3) –
others 1  (2) 1  (2) 1  (1)  3 (1) 3  (4)
Mean hospital stay (days)11.6 12.919.8 15.417.2
Follow-up (1984–87); open surgery (1981–83)
Stone-free at discharge6  (11)35 (63)17 (22) 58 (31) *49 (80)
in kidney32 (60)21 (37)57 (74)110 (59)12 (20)
in ureter15 (29) –3   (4) 18 (10) –
Stone-free after 36 months (42 months open surgery)35 (66)40 (71)37 (48)112 (60)44 (72)
CIRF11 (21)10 (18)25 (33) 46 (25) * 2  (3)
Symptomatic3  (6) 2  (4)10 (13) 15  (8) 3  (5)
Recurrence4  (8) 4  (7)5   (6) 13 (7) *12 (20)
at hospitalization14 (26)20 (36)31 (40) 65 (35)35 (57)
after 36 months6 (11) 4  (7)11 (14) 21 (11)18 (30)
UTI after/UTI before –  0.32 * 0.51

Auxiliary measures were used in 21% of all patients, ranging from 14% after combined to 36% after ESWL monotherapy. Currently this value could be even higher, as we recommend the prophylactic insertion of a JJ stent before ESWL monotherapy. However, only 8% needed curative auxiliary measures [31], e.g. ureteroscopy or open surgery.

Of all patients, 45% experienced minor side-effects like colic or fever. Whereas colic has been more frequently associated with ESWL treatment, postoperative fever occurred increasingly after PCNL. In contrast, major complications occurred in only 7% of all patients, including perirenal haematoma after ESWL, bleeding after PCNL, colon perforation after PCNL, and pulmonary embolism. The mean (range) hospital stay was 15.4 (11.6–19.8) days.

The mean follow-up of the study was 36 months ( Table 5); 31% of all patients were stone-free at discharge, ranging from 63% after PCNL monotherapy to 11% after ESWL monotherapy. However, after 3 years, 60 (48–71)% of the patients became stone-free, depending mainly on the complexity of the treated stone; 25 (21–33)% of all patients had still CIRF and only 8 (4–13)% had symptomatic fragments mainly associated with UTI. The overall recurrence rate was 7%, independent of the treatment group ( Table 5). Only 11% still had UTI, compared with 35% at hospitalization.

Comparison with open surgery: The series of open surgery was undertaken before the introduction of ESWL and endourological methods. The stone distribution (borderline vs staghorn stones) was similar in both groups, but the percentage of complete staghorn stones was higher in those undergoing open surgery ( Table 5). The blood transfusion rate (37% vs 10%) was significantly higher after open surgery, whereas the rate of fever and other minor side-effects did not differ between the groups. Major complications occurred at a similar rate (7% vs 8%) as did hospital stay (17.2 vs 15.4 days).

In the follow-up of both groups there were further significant differences ( Table 5); the stone-free rate at discharge after open surgery was significantly higher than after ESWL and endourology. In contrast, the stone-free rate after the respective follow-up periods did not differ significantly, but favoured the open approach ( Table 5). However, most remnants after using modern techniques represent CIRF, whereas the recurrence rate after surgery was significantly higher (20% vs 7%). The reduction in the incidence of UTI (after/before) was also better after using the modern approach (0.51 vs 0.32).


  1. Top of page
  2. Introduction
  3. Definition of complex renal stones
  4. Staghorn calculi
  5. Discussion
  6. Perspectives
  7. References
  8. Authors

Currently the first question in the management of any stone is whether the situation is amenable to ESWL; this is not surprising because of the ease of use and non-invasiveness of the procedure. The real issue is whether the excellent results obtainable with this technology in patients with small stones translate into successful treatment when the targets are complex stones, e.g. staghorn calculi. The patients' wish to avoid painful incisions and long recovery periods, and the pressure to provide cost-effective care with a shorter hospital stay after surgery, have created a treatment philosophy that defines success as the ability to eradicate the stone with the least invasive modality.

Guidelines for the treatment of staghorn calculi

In this situation, particularly for complex stones, urologists have to define the indications to select the best procedure for treating each stone. The Nephrolithiasis Clinical Guidelines Panel of the AUA reviewed 110 articles concerned with staghorn calculi, resulting in the following guidelines [16]. The committee considered that a newly diagnosed staghorn stone was an indication for active treatment. Percutaneous stone removal, followed by ESWL or repeat PCNL, should be used for most patients with struvite staghorn stones. Neither ESWL monotherapy nor open surgery should be used as a first-line treatment for staghorn stones in most patients. As options, PCNL and ESWL are equally effective in treating small-volume staghorn stones when the renal anatomy is normal or nearly normal. Also as an option, open surgery is appropriate therapy when the staghorn cannot be managed by any reasonable number of PCNL and ESWL sessions, i.e. if it is a giant staghorn.

This summary is in accordance with our previously stated indications but reflects the limitations of further clarification, mainly because there are no published prospective randomized studies or accepted ways of describing staghorn stones. We therefore consider that it is important to focus further on comparing the different published treatment strategies for staghorn stones. Thus we address the changing treatment philosophy and the criteria for therapeutic success.

Treatment philosophy

As stated before, the introduction of new technologies resulted in a philosophy of treating stones using the most effective, minimally invasive and least morbid method. This included the degree and severity of complications associated with the procedures used, the length of hospital stay and disability, and initial stone-free rates. However, the ultimate goals of therapy in this specific group of patients should include the long-term stone-free rates, minimizing the rates of recurrent stones and infection, and the preservation of renal function [18,34].


The morbidity of open surgery has been reported often [4,6,21,22,35–40] and includes fever (26–29%), blood transfusions (14–70%), pneumothorax (5%), recurrent bleeding (4%), septicaemia (1%), urinoma/fistula (1%), embolism (2%), flank abscess (2%), flank pain (16%), flank bulge (5%), incisional hernia (2%) and wound infections (4%), with a hospital stay after surgery of 11–16 days.

Using the modern approach [3,12,13,15,25,37–45], the morbidity is mainly associated with percutaneous surgery, with blood transfusion in 5–53%, fever in 12–64%, septicaemia in 2–4%, pneumothorax in 2%, arteriovenous malformation requiring superselective embolization in 1%, flank abscess in 1%, and colonic perforation in 1%. The hospital stay was 9.5–18 days.

Because of the complexity of the disease, both approaches are associated with significant side-effects, but there is sufficient evidence that the overall morbidity of ESWL and endourological intervention during and after treatment is significantly less than with the open approach. That the newer techniques require several treatment sessions (2.8 vs one session [18]) is not a disadvantage, because it has no effect on morbidity or hospital stay.

The differences between the approaches are more pronounced for long-term complications; whereas the time to return to normal activity was 44–54 days after open surgery, it was only 21–30 days after ESWL plus endourological procedures [38–40]. There was complete loss of renal function in 2–8% after open surgery, associated with a nephrectomy rate of 7–14%. From this, earlier calculations suggested an overall dialysis rate of 5% of all patients with urolithiasis [46,47]. The nephrectomy rate in our series was only 2% using the modern approach, and in a follow-up period of 3 years there was no further need for renal ablation caused by delayed loss of renal function ( Table 5). This underlines the potential of using ESWL and endourological procedures for treating and re-treating patients with complicated stone disease with no significant risk of loss of renal function.

Residual fragments and infection

When open surgery was the standard treatment for managing renal calculi, the presence of residual fragments suggested that the procedure had failed, even if those remaining fragments were small. Because residual calculi may act as a nidus for recurrent stone formation, complete stone removal was the principal goal of therapy. In the last decade the main goal of PCNL and ESWL was to completely clear stones, ignoring the fact that more patients benefit from successful stone disintegration but with minor asymptomatic residual fragments (CIRF). Some authors do not accept this for complex stones, because most calculi are associated with UTI and consist of struvite, with a high risk of persisting infection and stone recurrence [19]. This is true for open surgery; the stone-free rates at discharge are significantly higher (80–93%) than for modern techniques (19–37%), but after 3 months the latter increases to 67–78%. Our long-term experience after 3 years showed an overall stone-free rate of 60%, which was not significantly different from the 72% stone-free rate after open surgery. Subsequently, the recurrence rate was significantly higher after open surgery ( Table 5).

About 75% (46 of 61) of the patients with residual fragments were asymptomatic (i.e. CIRF) in our series, which was also reported recently by others [42]. In both series, more than half the stones consisted of struvite, but the rate of UTI was significantly less (i.e. 35% vs 11%) than after open surgery. The ratio of the incidence of UTI after/before was significantly higher after open surgery than when using ESWL and endourology ( Table 5). There may be several reasons to explain these findings: (i) residual fragments are more accessible by antibiotics than are residual stones, which may still contain bacteria; (ii) the quality of antibiotics (i.e. gyrase inhibitors) has improved; (iii) the operative trauma to the collecting system and to the renal parenchyma is significantly less after PCNL + ESWL than after open surgery.

Even in patients with complex stones it must be accepted that most residual fragments after ESWL are or may become clinically insignificant and only 10–15% require further treatment [48]. In contrast, persisting infection remains one of the main problems after open surgery. Even in a recent study, Rocco et al. reported a 21% rate of UTI during the follow-up [22].


  1. Top of page
  2. Introduction
  3. Definition of complex renal stones
  4. Staghorn calculi
  5. Discussion
  6. Perspectives
  7. References
  8. Authors

Recently, ureterorenoscopic techniques based on holmium laser technology have been introduced to manage staghorn stones [49]. However, at present such techniques have only limited indications because of the problems with removing the stone burden, intrarenal influx in infected stones, and with the prolonged operative duration. There may be reasonable indications for flexible ureterorenoscopy, e.g. in the treatment of calculi behind calyceal neck stenosis [50].

Finally, as noted, there is the problem of adequate training and education in the surgical management of complex renal stones. This affects both the percutaneous and open surgical techniques. The frequency of staghorn stones has declined dramatically in our daily practice, which is in accord with other centres in Europe and the USA. None of the existing centres (except those in ‘stone-belt’ areas) is currently able to reproduce the large series of the 1980s. However, there are increasing reports of the extensive use of modern techniques from countries which previously had only limited access to ESWL and endourology, i.e. in Eastern Europe and India [51]. The main problem in training is the difficulty and complexity of these procedures, whether percutaneous or open surgery. This situation is similar to the training in laparoscopy and retroperitoneoscopy. Therefore, patients with complex stones should be treated in a few centres of expertise, which then could also provide adequate training for urologists with a special interest in this field.


  1. Top of page
  2. Introduction
  3. Definition of complex renal stones
  4. Staghorn calculi
  5. Discussion
  6. Perspectives
  7. References
  8. Authors
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  1. Top of page
  2. Introduction
  3. Definition of complex renal stones
  4. Staghorn calculi
  5. Discussion
  6. Perspectives
  7. References
  8. Authors

J.J. Rassweiler, Head of Department, Klinikum Heilbronn, Professor of Urology University of Heidelberg.

C. Renner, Consultant Urologist.

F. Eisenberger, Head of Department, Katharinenhospital Stuttgart, Professor of Urology.