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Staghorn calculi – causes and treatment. Brad Weaver 8/19/08. Struvite stones. Composed of magnesium ammonium phosphate “triple phosphate” crystals Precipitate at alkaline pH created by urease producing bacteria such as Proteus or Klebsiella Urease

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struvite stones
Struvite stones
  • Composed of magnesium ammonium phosphate “triple phosphate” crystals
  • Precipitate at alkaline pH created by urease producing bacteria such as Proteus or Klebsiella
  • Urease

Urea 2NH3 + CO2

NH3 + H20 NH4+ + OH-

struvite stones cont
Struvite stones cont.
  • Occur 3:1 ratio female:male
  • More common in those anatomically predisposed to infection such as with neurogenic bladder or urinary diversion
  • Staghorn calculi may also contain mixed calcium/struvite or all calcium stones
  • The presence of calcium warrants metabolic workup for cause of stones
struvite stone symptoms
Struvite stone symptoms
  • Often no symptoms directly related to stone
  • May present with UTI, flank pain, hematuria
  • Passage of struvite stone is rare
  • Can rapidly grow and lead to chronic pyelonephritis and parenchymal scarring
  • Struvite stones are radiopaque and can be seen on AXR and CT
cystine stones
Cystine stones
  • Cystine stones may also form staghorn calculi
  • Cystinuria is a rare autosomal recessive disease responsible to 1-2% of stone formers
  • Caused by mutations in genes, SLC3A1 and SLC7A9, that are involved in amino acid transport
  • Median age of onset of kidney stones is 12
  • Hexagonal crystals in urine sediment
  • Treatment with fluids, alkali, cystine binding drugs – penicillamine, tiopronin, and captopril
medical management of staghorn calculi
Medical management of staghorn calculi
  • Dietary phosphorus reduction
  • Antibiotics rarely successful at eradicating bacteria in struvite stone
  • Acetohydoxamic acid (AHA, Lithostat) is a urease inhibitor that has been shown to stop stone growth in 80% vs. 40% on placebo. Use is limited by frequent side effects including palpitations, nausea, and hemolytic anemia
surgical management
Surgical management
  • Open surgery
  • Percutaneous nephrolithotomy (PNL)
  • Shock wave lithotripsy (SWL)
retrospective study
Retrospective study
  • 112 patients with staghorn calculus with mean follow up 7.7 years
  • Renal deterioration occurred in 28%
  • Worse outcome associated with solitary kidney, recurrent stones, hypertension, urinary diversion, and neurogenic bladder

J Urol 1995 May;153(5):1403-7