Elawady HMH. et al., 2025: . Modalities of management of residual upper calyceal stones after percutaneous nephrolithotomy for staghorn stone: A randomized controlled trial.

Hossam Mohamed Hafez Elawady, Wael Ali Maged, Mostafa Mabrouk Bayoumi Aly Wahba, Ahmed Tawfick Hassan, Mahmoud Ahmed Mahmoud
Urologia. 2025 Nov;92(4):663-669. doi: 10.1177/03915603251351069

Abstract

Background: This study assessed the safety and efficacy of management strategies for residual upper calyceal stones (1-2 cm) following percutaneous nephrolithotomy for staghorn calculi, comparing conservative management to interventional approaches.

Methods: A randomized trial included 105 patients with residual stones, assigned to flexible ureterorenoscopic laser lithotripsy (Group A), extracorporeal shock wave lithotripsy (ESWL, Group B), or conservative management (Group C). Outcomes included the need for additional interventions, stone-free rates, complications, and cost-effectiveness. Patients were followed for 1 year to assess pain, hematuria, hospital readmission, and stone clearance.

Results: Conservative management led to a 20% intervention rate within a year, primarily due to pain, obstruction, or patient preference. A stone size ⩽ 1.4 cm predicted the likelihood of intervention. Flexible ureterorenoscopy had the highest stone-free rate (94.29%), followed by ESWL (71.43%, p = 0.023). ESWL was the most cost-effective option (10.17 × 10³ vs 39.47 × 10³ Egyptian pounds, p < 0.001) but was less effective for high-density stones.

Conclusions: While conservative management avoids immediate intervention, it carries a higher risk of future complications and delayed interventions. Early intervention with flexible ureterorenoscopy or ESWL offers better long-term outcomes, with ESWL being the most cost-effective option.

Comment Hans-Göran Tiselius

The author carried out a randomized study to get information on the results of RIRS, SWL and conservatively treated patients with upper calyceal residual stones after PCNL of staghorn stones.

Although no stone analysis was included it is obvious that the result was related to the HU-levels.

Patients treated with RIRS (A) had stone-free rates related to stone densities and those with insufficient stone clearance had a significantly higher HU-value: 1000-1057 compared with 704-1050. A similar difference was recorded for group B patients treated with SWL. As expected RIRS patients had a better stone-free rate than those treated with SWL.

Of particular interest is the information that RIRS was about four times as expensive as SWL.

It is of note that in the conservatively treated group there was significantly more need of medical attention compared with that in the intervention groups.

As expected, the outcome was superior in the RIRS-treated patients who had the stones removed under direct vision. The lower cost of SWL needs attention, but conservative treatment obviously is not an appealing alternative.

RIRS had a stone-free rate of 94.3% compared with 71.4% in the SWL-treated patients.

Hans-Göran Tiselius