PCNL tract on the left showed a well-healed scar. There was no costovertebral tenderness bilaterally. Abdomen was soft with a well-healed midline abdominal incision. Her blood pressure was 167/67 with normal remaining vital signs. As such, her surgery was delayed for 9 months.Įxamination revealed an elderly Caucasian female who was 5.0 feet tall with body mass index of 32.5 kg/m 2. She was scheduled to undergo right PCNL 6 weeks later, but postponed her surgery due to her husband's poor health and ultimate passing. She was discharged from the hospital on postoperative day 3. Stone analysis demonstrated 90% struvite and 10% calcium phosphate, with stone culture positive for Enterococcus faecalis and Proteus mirabilis. A low dose CT scan of the abdomen and pelvis without contrast the following morning revealed resolution of the left collecting system staghorn with persistence of a 4 mm and 8 mm upper and lower pole renal parenchymal calcification, respectively the right staghorn calculus was unchanged. After a 7-day course of levofloxacin, she underwent an upper pole left percutaneous nephrolithotomy (PCNL) with bridging anticoagulation therapy. She underwent an MAG-3 renal Lasix scan, which showed split function of 49.3% on the left and 50.7% on the right, with decreased drainage on the left side (T½ of 22.17 minutes on the left vs 5.33 minutes on the right) with associated left hydronephrosis. Her family history revealed kidney stones in her daughter. Her medications included prophylactic dose cephalexin, lisinopril, furosemide, valsartan, calcium carbonate, acetaminophen with codeine, colace, amiodarone, warfarin, lovastatin, and iron. Her prior surgeries included bilateral hip and knee prostheses and oophorectomy. Her medical history included hypertension, chronic kidney disease, arthritis, atrial fibrillation, hepatitis B, hyperlipidemia, and anemia. Significant in her medical history was a parathyroidectomy 7 years ago for hyperparathyroidism, discovered following metabolic workup for nephrolithiasis serum parathyroid hormone and calcium levels returned to normal. Hounsfield units on the left stone were 694 and on the right stone were 664. Laboratory studies by her physician revealed worsening renal function subsequently, a CT scan showed bilateral >3-cm renal staghorn calculi involving three renal calyces bilaterally with moderate left hydronephrosis. If left untreated, staghorn calculi result in chronic infection and eventually may progress to xanthogranulomatous pyelonephritis 5.A 77- year-old female was referred due to a history of intermittent left flank pain and recurrent urinary-tract infections. Staghorn calculi need to be treated surgically, usually PCNL (percutaneous nephrolithotomy) +/- ESWL (extracorporeal shockwave lithotripsy) and the entire stone removed, including small fragments, as otherwise, these residual fragments act as a reservoir for infection and recurrent stone formation. When viewed on bone windows they have a laminated appearance, due to alternating bands of magnesium ammonium phosphate and calcium phosphate 5. Staghorn calculi are radiopaque and conform to the renal pelvis and calyces, which are often to some degree dilated. The collecting system is filled with a densely calcified mass, producing marked posterior acoustic shadowing. The vast majority of staghorn calculi are radiopaque and appear as branching calcific densities overlying the renal outline and may mimic an excretory phase intravenous pyelogram. Uric acid and cystine are the underlying components of a minority of these calculi 5. Struvite accounts for approximately 70% of the composition of these calculi and is usually mixed with calcium phosphate thus rendering them radiopaque on both plain films and CT. Urease hydrolyses urea to ammonium with an increase in the urinary pH 3-5. Proteus, Klebsiella, Pseudomonas and Enterobacter). Staghorn calculi are composed of struvite (chemically this is magnesium ammonium phosphate or MAP) and are usually seen in the setting of recurrent urinary tract infection with urease-producing bacteria (e.g. The majority of staghorn calculi are symptomatic, presenting with fever, haematuria, flank pain and potentially septicaemia and abscess formation. Staghorn calculi are the result of recurrent infection and are thus more commonly encountered in women 6, those with renal tract anomalies, reflux, spinal cord injuries, neurogenic bladder or ileal ureteral diversion.
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