[Removal of staghorn calculi from the urinary tract with extracorporeal shock wave lithotripsy and endourologic treatment methods].

ESWL has been accepted as a method for treatment of urinary tract calculosis. In most cases with urinary tract calculi, the method has replaced the classic surgical procedure. Staghorn calculi are still too large to be simply managed with classic procedure; however, they may be successfully disintegrated (crushed) with the available lithotriptors, particularly with second generation lithotriptors such as LITHOSTAR. Technological innovations which appeared during the last two decades have induced sudden changes in the treatment of urinary tract calculosis. They were enabled by extracorporeal shock wave lithotripsy, which is a method associated with the lower morbidity rate. The method is readily accepted by most of the patients. It is effective in removal of calculi of different size and chemical composition. During the last decade, ESWL has been widely applied in a large proportion of patients with stag-horn calculi. Since the "STEINSTRASSE" phenomenon may develop following disintegration of the more massive stones, double J catheter (DJC) is always placed preventively before the staghorn calculi treatment. The clinicians well know how surgical treatment of staghorn calculosis is technically hard to perform, since there is a risk of renal blood vessels injuries and renal function impairment. Moreover, complete stage-horn urinary tract concrements are the most problematic stones with respect to kidney injuries, surgical treatment and rate of later complications. After the introduction into the clinical practice ESWL has become a treatment of choice for stag-horn calculi in approximately 85% of patients. It is performed in several steps. Over the last two years, 41 patients with partial or complete stag-horn calculi were treated in our institution. In 63% of cases, three treatments were performed per each patient, while 37% of our patients underwent more than three sessions. In a very small percentage, even seven treatments were performed. At the very beginning of the treatment, DJC was placed in 52% of patients, due to the expected "STEINSTRASSE" phenomenon, DJC enabled internal urine drainage and decreased the necessity of perdutaneous nephrostomy. Introduction of DJC reduced the number of cases with ureteral obstruction as well as the number of candidates for nephrostomy to below 29%. Percutaneous nephrostomy was performed in only a small number of patients, enabling satisfactory ureteral peristaltic with very good elimination of disintegrated stone detritus. Twenty-three of our patients developed urinary infections. In our series, the number of residual concrements was directly proportional to the degree of hydronephrosis before ESWL treatment (Table 1, 2, 3, 4). It may be concluded that in sity ESWL treatment of staghorn calculi with prophylactic placement of ureteral catheters is associated with lower complications rate when compared to patients who underwent the combined treatment using ESWL and percutaneous nephrolithotripsy. Single ESWL treatment should be carried out in all cases of uninfected stag-horn stones, clearly visualized upon X-ray examination, with mild hydronephrosis. In prominent hydronephrosis, with high probability of retaining of stone fragments in the lower renal calices, the therapeutical approach should include a combination of ESWL and nephrostolithotripsy. In draining stag-horn renal calculosis, disintegration should be initiated with the parts of the stone localized in the renal pelvis and upper renalc calices. Using such disintegration procedure, large stones in the urinary tract may be eliminated in several steps, which is always associated with the presence of sufficient fragments to be eliminated; however the intervals between the treatment are free of problems. In this way, stag-horn stones may be treated in out-patient wards with previous DJC catheter placement, which is a wise precaution.