Staghorn and large renal stones

General principles

Large and staghorn stones carry a risk of:

• infection;
• obstruction;
• progressive kidney injury.

The main treatment for large renal stones is percutaneous nephrolithotomy (PCNL); endoscopic treatment may be staged.

Assessment

• Stone size and configuration.
• Collecting system anatomy.
• Kidney function.
• Presence of infection.
• If an infected stone is suspected, obtain a urine culture and adjust antibiotic therapy.

Choice of approach

• PCNL allows removal of a substantial stone burden in one or more procedures.
• RIRS for complex anatomy and selected contraindications (sometimes in several stages).
• Combined approaches are selected individually.

Infection safety

• In infected obstruction, establish drainage first.
• Assess urine culture and sepsis risk factors before intervention.
• Choose antibiotic prophylaxis and treatment according to local resistance patterns.

Postoperative monitoring

• Monitor temperature, hemodynamics, urine output, hemoglobin, and creatinine.
• Assess for residual fragments.
• If fever develops after PCNL, actively rule out sepsis, bleeding, and obstruction.

Algorithm