Although there have been no controlled, prospective studies comparing medical management with operative intervention, the role for early extirpation of staghorn calculi appears well established. During the last 25 years, many investigators have shown that an aggressive operative approach to affected patients is clearly advantageous. In those studies, the renal-related or sepsis-related mortality rates for patients treated primarily with medical management have been as high as 30%, compared with rates of only 5% for those managed with early operative intervention.<sup>2 Blandy J.P., Singh M. The case for a more aggressive approach to staghorn stones J Urol 1976 ;  115 : 505

Haga clic aquí para ir a la sección de Referencias, 17 Rous S.R., Turner W.R. Retrospective study of 95 patients with staghorn calculus disease J Urol 1977 ;  118 : 902

Haga clic aquí para ir a la sección de Referencias</sup> Even more recently, in the era of contemporary antibiotic therapy and routine availability of dialytic support, medical management has been associated with recurrence of symptomatic infection in 45% of patients, and continued loss of renal function and even renal-related mortality in up to 67% of patients.<sup>11 Koga S., Arakaki Y., Matsuoka M., Ohyama C. Staghorn calculi: Long-term results of management Br J Urol 1991 ;  68 : 122  [cross-ref]

Haga clic aquí para ir a la sección de Referencias, 31 Teichman J.M.H., Long R.D., Hulbert J.C. Long-term renal fate and prognosis after staghorn calculus management J Urol 1995 ;  153 : 1403  [cross-ref]

Haga clic aquí para ir a la sección de Referencias, 32 Vargas A.D., Bragin S.D., Mendez R. Staghorn calculus: Its clinical presentation, complications and management J Urol 1982 ;  127 : 860

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It seems clear that with rare exception the indications for intervention in a patient with a staghorn calculus, at least that presumed to be infection-related or composed of struvite, is simply the presence of that stone.<sup>21 Segura J.W., Preminger G.M., Assimos D.G. , y al. Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi J Urol 1994 ;  151 : 1648

Haga clic aquí para ir a la sección de Referencias</sup> Although the indications to intervene are clear, there is no definite consensus regarding the most appropriate form that the intervention should take. There is general agreement, however, that the intervention must be individualized, with specific consideration given to the size and configuration of the stone and the level of renal function overall and in the involved kidney. Additionally, the patient's body habitus and overall health or associated medical problems, especially as they relate to a risk of anesthesia, need to be factored into the development of an appropriate management plan.

With all the therapeutic modalities now available for managing affected patients, choosing the optimal technique requires consideration of many factors. These include the morbidity of the procedure, the length of hospitalization and disability, and the cost. Although these factors are important, primary consideration must be given to minimizing the rates of residual and recurrent stones and infection and to preserving renal function.

Landmark studies of carefully designed open operative procedures, such as anatrophic nephrolithotomy and extended pyelolithotomy, have documented the excellent immediate results that can be attained in regard to rates of morbidity and residual stones.<sup>8 Gil-Vernet J. New Surgical concepts in removing renal calculi Urol Int 1965 ;  20 : 255  [cross-ref]

Haga clic aquí para ir a la sección de Referencias, 24 Smith M.J.V., Boyce W.H. Anatrophic nephrotomy and plastic calyrhaphy J Urol 1968 ;  99 : 521

Haga clic aquí para ir a la sección de Referencias</sup> More important, however, is the documented long-term efficacy of these procedures. In reviewing the long-term follow-up of 100 patients undergoing anatrophic nephrolithotomy, Boyce and Elkins<sup>3 Boyce W.H., Elkins I.B. Reconstructive renal surgery following anatrophic nephrolithotomy: Follow up of 100 consecutive cases J Urol 1974 ;  111 : 307

Haga clic aquí para ir a la sección de Referencias</sup> reported an incidence of recurrent stone and infection of only 17% for either alone or 9% for both together. The same study showed overall renal function to remain stable or improve in 98% of patients. Perhaps more significant was a later report from the same center regarding 30 patients with a solitary kidney who had undergone anatrophic nephrolithotomy.<sup>30 Stubbs A.J., Resnick M.I., Boyce W.H. Anatrophic nephrolithotomy in the solitary kidney J Urol 1978 ;  119 : 457

Haga clic aquí para ir a la sección de Referencias</sup> After an average follow-up of 6 years, the group as a whole showed no significant difference in renal function preoperatively and postoperatively, although some patients did suffer deterioration.

Even more recently, several investigators have shown that with long-term follow-up, open operative intervention for staghorn calculi is associated with recurrent stone and infection in less than 30% of patients, respectively. These studies also suggest that better results are obtained if the renal unit initially is rendered stone-free.<sup>9 Griffith D.P. Struvite stones Kidney Int 1978 ;  13 : 372  [cross-ref]

Haga clic aquí para ir a la sección de Referencias, 12 Lerner S.P., Gleeson M.J., Griffith D.P. Infection stones J Urol 1989 ;  141 : 753

Haga clic aquí para ir a la sección de Referencias, 22 Silverman D.E., Stamey T.A. Management of infection stones: The Stanford experience Medicine 1983 ;  62 : 44

Haga clic aquí para ir a la sección de Referencias</sup> Although new, less invasive techniques are now available to manage patients with large or otherwise complex calculi, the immediate and long-term results should be compared with those now well-documented during the last quarter century for open operative intervention.