British Journal of Urology (1973) 45, 581-585

The Fate of the Unoperated Staghorn Calculus

MANMEET SINGH, R. CHAPMAN, G. c. TRESIDDER and JOHN BLANDY

The Department of Urology. The London Hospital, London

One of the concepts in urology which dies most hard is that of the “silent staghorn calculus”. When in 1949 Priestley and Dunn reviewed 382 cases of staghorn calculi from the Mayo Clinic, they pointed out how rarely was a staghorn calculus not accompanied by severe urinary symptoms, and they went on to show that even in pre-antibiotic days it was better to remove the stone than to do a nephrectomy, and better to do a nephrectomy than to do nothing. Despite this renewed interest in nephrolithotomy, urological units continued to regard the operation with suspicion, not least because of the high rate of secondary haemorrhage. Good results from the renal bivalve operation were the exception (Maddern, 1967).

Some 15 years later Gil-Vernet (1964) demonstrated how it was possible to remove large staghorn calculi without cutting into the renal parenchyma. Even this was received with agood deal of criticism. Some of the critics argued that, because staghorn calculi were generally silent, one would do better to leave them alone, usually supporting their arguments with anecdotes rather than with statistics. Others pointed out the stupidity of removing the stone if it was bound in- evitably to recur. Nephrectomy seemed to them a far better way out.

We have always been enthusiasts for Gil-Vernet’s operation (Blandy and Tresidder, 1967 ; Singh, Tresidder and Blandy, 1971) and have now removed more than 103 large staghorn calculi from 86 patients, 16 of them with bilateral calculi.

Our follow-up now extends to nearly 9 years and further experience since we reported our results 2 years ago (Singh et al., 1971) has only tended to confirm our favourable impression; the results if anything have tended to improve as we have got better at it.

The questions however we have still not answered are:

1. Would not these patients have been just as well served if we had left them alone?

2. If we had just performed a nephrectomy?

Our critics have pointed out that they would not be likely to have done as badly as those in Priestley and Dunn’s pre-antibiotic series, now that there are better means of controlling infection.

It was plainly not possible to compare identical groups of patients, because in the last 9 years virtually every new case referred with a staghorn calculus has been operated on. Nevertheless, we have thought it worthwhile to find out what really did happen to patients with staghorn calculi in a period when antibiotics were available, but Gil-Vernet’s operation was not. We have called them “untreated”, meaning untreated by extended pyelolithotomy, although they received every other form of therapy available at that time.

or

Composition of Series

We were able to find records of 54 patients seen at the London Hospital in the years 1955 to 1972 with a diagnosis of staghorn calculus (Table I). Nine of these had bilateral calculi, so that in all 63 kidneys were studied. Of the unilateral cases, 8 had smaller calculi in the other kidney. There Read at the 29th Annual Meeting of the British Association of Urological Surgeons in London, June 1973.

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were 40 females and 14 males (Table 11). The mean age of untreated patients (56.4 years) however was somewhat higher than the treated ones (46-6 years).

Table I Staghorn Calculi not Treated by Gil-Vernet Extended Pyelolithotomy. The London Hospital, 1955-1972.

Patients Kidneys

Unilateral 45 45 Bilateral 9 18

Total 54 63

Table I1 Untreated Staghorn Calculi

Sex Incidence

Males 14 Females 40

Total 54

Not-so-silent Stones

None of the patients was symptomless on admission. Most of them had pain, haematuria or infection, and many had all three (Table 111). Unfortunately we had no way of knowing how

Table I11 Untrcated Staghorn Calculi-Symptoms

Patients :< Pain 44/54 81.5% Haematuria 26/54 48.0% Infection 43/54 79.4%

many other unsuspecting members of the public were walking around with silent calculi. But we could find out how many times unsuspected calculus would turn up at postmortem.

Over the same period, 8,996 postmortem examinations were performed at The London Hospi- tal, among which staghorn calculi were found in 9 cases (Table IV). Only 4 of these cases had no

Table IV Staghorn Calculi found Incidentally at Postmortem. The London Hospital, 1959-72

Total No. of postmortems 8,996 No. of urinary tract lithiasis 59 Staghorn calculi without symptoms 4 Staghorn calculi with symptoms 5

THE FATE OF THE UNOPERATED STAGHORN CALCULUS 583

severe or persistent symptoms during the patient’s lifetime and in these 4 the renal parenchyma was reduced to a thin scarred shell. This would suggest that if silent stones do occur, then they are very rare indeed (0.05 %).

Table V Unilateral Staghorn Calculi (45 Patients)

Subsequent Patients Death Survivals

Primary nephrectomy 20 (44.5 %) 4 16 Delayed nephrectomy 12 (26.7 %) 3 9 No surgical treatment 13 (28.8 %) 9 4

Total 45 (100%) 16 (35.6%) 29 (64.4%)

Subsequent Fate of 54 “Untreated” Patients

Unilateral Staghorn Calculi (45 Patients) (Table V) Nephrectomy was performed in the first instance in 20 of these patients, in 4 of them the other kidney continued to deteriorate and they died of renal failure. The remaining 16 are still being followed up. In 25 patients the stones were initially left alone: 12 of them subsequently had to have a nephrectomy, an event usually precipitated by pyonephrosis or intolerable symptoms and 3 of these patients subsequently died of uraemia.

Of the remaining 13, no less than 9 are known to have died, and so of the 16 patients known to have died, all but 4 died from renal failure.

This small series bears out Priestley and Dunn’s suggestion that unilateral cases do better when treated by nephrectomy than when the stone is left in situ.

Table VI Bilateral Staghorn Calculi (9 Patients)

No. Deaths Survival

Expectant treatment 5 (56%) 4* 1 Subsequent nephrectomy 4 (44 %)t 0 4

Total 9 (100%) 4 (44%) 5 (56%)

* All 4 died of renal failure at 17 years, 1 year, 2 years and 4 years respectively after initial diagnosis. t Nephrectomy at 10, 8, 1 and 13 years respectively after initiat diagnosis. None of the 5 survivors is without chronic symptoms.

Bilateral Staghorn Calculi (9 Patients) (Table VI) Four of these patients had to have a nephrectomy usually for pyonephrosis and all of them are still alive, but all have continuous and severe symptoms. Of the remaining 5 , 4 have died and the only survivor with truly giant calculi is far from being well.

Discussion

One may summarise these findings quite shortly. Nearly half of these patients have died of pro- gressive renal failure in the period of follow-up. Evidently staghorn calculi are neither silent nor

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safe. Those who had a nephrectomy fared better than those in whom the stone was left in situ: it seems that leaving a stone in situ poses a constant threat to the other kidney, and also an ever-present risk of pyonephrosis. Expectant treatment, based on the idea that stones are silent and safe, leads to enforced nephrectomy in half the cases and to death in the majority of the others.

In comparison with these figures, the results of removing staghorn calculi are encouraging

Table VII Fate of Staghorn Calculi Treated by Extended Pyelolithotomy. The London Hospital, 1964-73

Subsequent Subsequent Patients No. nephrectomy death

Unilateral 70 2 2 Bilateral 16 1 3

Total 86 3 5

Period of follow-up extends to 6+ years and 41 patients have been followed up for more than 2 years.

(Table VII), although we admit that these patients have been followed up for far less time than have the untreated cases.

Only 5 out of 86 patients have died and of these 3 had advanced renal failure when first referred to us after prolonged observation elsewhere. 3 of the 103 kidneys have come to nephrectomy, but 2 of these had no demonstrable renal function when the stone was first removed and they should probably have had a nephrectomy in the first place.

Table VIII Recurrence of Staghorn Calculi after Removal

Kidneys Recurrence % ~~

Complete removals 86 9/86 10.5 Incomplete removals 17 4/11 23.0

Total 103 131103 12.6

As we have shown before, new stone formation is not the rule and occurs in less than 1 kidneys. (Table VIII).

in 5

The most striking feature is that these patients continue to be without pain or haematuria, and the incidence of urinary infection has fallen from around 80 % to under 25 %.

Conclusion

The concept of the “silent staghorn calculus” is a false one. Conservative treatment of a staghorn calculus should be early and complete removal of the stone.

Summary

A retrospective study has been carried out to study the fate of unoperated staghorn calculi. 54 patients (63 kidneys) have been studied over a period of 17 years and the outcome has

been compared with a series of patients where staghorn calculi have been treated by extended pyelolithotomy.

THE FATE OF THE UNOPERATED STAGHORN CALCULUS 585

The patients with staghorn calculi are rarely symptom-free unless they are operated on. Expectant treatment of these cases has led to subsequent nephrectomy in half the cases and the

By comparison patients treated surgically have fared significantly better. The value of early and complete removal of staghorn calculi has been stressed.

majority of the rest have died of progressive renal failure.

References

BLANDY, J. P. and TRESIDDER, G. C. (1967). Extended pyelolithotomy for renal calculi. British Journal of Urology,

GIL-VERNET, J. M. Jr. (1964~) . New surgery in renal calculus. Film-13th Congress International Society of Uro- logy, London. - (1970). Resultados lejanos de la cirugia de 10s calculos coraliformes. La cirugia intrasinusal de 10s calculos

coraliformes. X V Congrhs de la Societe Internationale d'urologie, Tokyo, 12-18th July 1970. Tome 1, Rapports.

39, 121-130.

p. 11-56. MADDERN, J. P. (1967). Surgery of the staghorn calculus. British Journal of Urology, 39, 237-275. PRIESTLEY, J. T. and DUNN, J. H. (1949). Branched renal calculi. Journal of Urology, 61, 194-203. SINGH, M., TRESIDDER, G. C. and BLANDY, J. P. (1971). The long-term results of removal of staghorn calculi by

extended pyelolithotomy without cooling or renal artery occlusion. British Journal of Urology, 43, 658-664.

The Authors

Manmeet Singh, FRCS, Senior Lecturer in Urology. R. Chapman, FRCS, Surgical Registrar. G. C. Tresidder, FRCS, Consultant Urologist. John Blandy, DM, MCh, FRCS, Professor of Urology.