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
Urea 2NH3 + CO2
NH3 + H20 NH4+ + OH-
Magnesium ammonium phosphate crystals
– orthorhombic shape
 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
• 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
Abdominal plain film showing b/l
radiopaque staghorn calculi
CT w/o contrast showing R staghorn
calculus
 Cystine stones
• Cystine stones may also • Hexagonal crystals in urine
form staghorn calculi sediment
• Cystinuria is a rare • Treatment with fluids, alkali,
autosomal recessive disease cystine binding drugs –
responsible to 1-2% of penicillamine, tiopronin,
stone formers and captopril
• Caused by mutations in
genes, SLC3A1 and SLC7A9,
that are involved in amino
acid transport
• Median age of onset of
kidney stones is 12
 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
• Open surgery
• Percutaneous nephrolithotomy (PNL)
• Shock wave lithotripsy (SWL)
 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