A silent presentation of massive staghorn calculi

Case Report

A 44-year-old woman with history of recurrent urinary tract infections (UTI) but no other comorbidities underwent a CT scan revealing bilateral renal staghorn calculi (Figure 1A) after being referred to our department due to CKD diagnosis.

Figure 1.
Removal of a massive staghorn calculi by left anatrophic nephrolithotomy and pyelolithotomy. A: Pre-operative CT scan showing bilateral staghorn calculi and dimensional asymmetry between the kidneys. The right kidney appeared with a lower volume and higher parenchymal rarefaction. B: Removed staghorn calculi. C: CT scan showing complete removal of the calculi from the left kidney.

Blood tests revealed a glomerular filtration rate (GFR) of 25 mL/min/1.73 m² with unremarkable additional metabolic assessment. Her urinary sediment showed pH of 7.5 with leukocyturia. A 24-hour urine collection ruled out increased excretion of calcium, uric acid, or oxalates but revealed proteinuria of 2g.

To preserve the remaining kidney function, the patient underwent left anatrophic nephrolithotomy and pyelolithotomy (Figure 1B), which resulted in complete removal of calculi (Figure 1C). Following the intervention, GFR remained stable at 20 mL/min/1.73 m². Stone analysis confirmed the presence of struvite calculi.

Staghorn calculi are associated with recurrent UTI caused by urease-producing organisms¹. Treatment is based on removal of kidney stones in conjunction with antibiotics².

Choosing anatrophic nephrolithotomy over alternative, non-invasive procedures has the advantage of addressing complex stone burdens and reducing the risk of residual fragments and the need for multiple interventions³,⁴.

Acknowledgment

The authors wish to thank all the physicians of the Internal Medicine, Radiology and Clinical Pathology Departments of the Centro Hospitalar e Universitário de São João, Porto, and the entire surgical team of the Urology Department of the Centro Hospitalar e Universitário de São João for their contribution to the care of the patient.

REFERENCES

• ¹
  Flannigan R, Choy WH, Chew B, Lange D. Renal struvite stones: pathogenesis, microbiology, and management strategies. Nat Rev Urol. 2014;11(6):333–41. doi: http://dx.doi.org/10.1038/nrurol.2014.99. PubMed PMID: 24818849.
  » https://doi.org/10.1038/nrurol.2014.99
• ²
  Sharbaugh A, Morgan Nikonow T, Kunkel G, Semins MJ. Contemporary best practice in the management of staghorn calculi. Ther Adv Urol. 2019;11:1756287219847099. doi: http://dx.doi.org/10.1177/1756287219847099. PubMed PMID: 35173810.
  » https://doi.org/10.1177/1756287219847099
• ³
  Keshavamurthy R, Karthikeyan VS, Mallya A, Sreenivas J, Nelivigi GG, Kamath AJ. Anatrophic nephrolithotomy in the management of large staghorn calculi: a single centre experience. J Clin Diagn Res. 2017;11(5):PC01–04. doi: http://dx.doi.org/10.7860/JCDR/2017/24723.9837. PubMed PMID: 28658843.
  » https://doi.org/10.7860/JCDR/2017/24723.9837
• ⁴
  Melissourgos ND, Davilas EN, Fragoulis A, Kiminas E, Farmakis A. Modified anatrophic nephrolithotomy for complete staghorn calculus disease: does it still have a place? Scand J Urol Nephrol. 2002;36(6):426–30. doi: http://dx.doi.org/10.1080/003655902762467576. PubMed PMID: 12623506.
  » https://doi.org/10.1080/003655902762467576

Publication Dates

• Publication in this collection
  03 Nov 2023
• Date of issue
  Oct-Dec 2023

History

• Received
  26 May 2023
• Accepted
  13 Sept 2023