Successful Management of Large Staghorn Calculus with PCNL: Renal calculi, particularly large staghorn stones, pose a significant clinical challenge due to their association with obstruction, infection, and long-term renal damage. Percutaneous Nephrolithotomy has emerged as the gold standard for managing large renal stones. We present the case of a young male patient with a large left renal pelvic and lower calyceal calculus with associated hydronephrosis, successfully managed with PCNL and DJ stenting, resulting in complete stone clearance and favorable postoperative recovery.
Introduction
Urolithiasis is a common urological condition with varying clinical presentations depending on the size, location, and number of calculi. Large renal pelvic and staghorn calculi can lead to obstruction and progressive renal impairment if not treated promptly. Minimally invasive procedures such as PCNL have significantly improved outcomes in such complex cases.
Case Presentation
A 36-year-old male presented with complaints of intermittent left flank pain for a few days. There were no associated symptoms such as fever, hematuria, or lower urinary tract symptoms. The patient had no significant past medical or surgical history and no known drug allergies.
On clinical evaluation, the patient was stable. Laboratory investigations revealed a serum creatinine level of 1.27 mg/dL, indicating preserved renal function.
Investigations
Ultrasonography (USG) of the abdomen revealed:
- Large staghorn calculus occupying the left renal pelvis
- Additional small calculus in the lower calyx
- Mild to moderate hydronephrosis of the left kidney
- Small calculi in the right kidney without evidence of obstruction
Intravenous pyelography (IVP) demonstrated:
- Normally functioning right kidney
- Large left renal pelvic and lower calyceal calculi
Other preoperative investigations including chest X-ray, ECG, and 2D echocardiography were within normal limits.
Diagnosis
- Large left renal pelvic and lower calyceal calculi (staghorn calculus)
- Mild to moderate left hydronephrosis
- Small right renal calculi
Treatment Plan
After detailed counselling regarding treatment options, risks, and expected outcomes, the patient was planned for surgical management using a minimally invasive approach.
Surgical Procedure
The patient underwent:
- Cystoscopy
- Left retrograde pyelography (RGP)
- PCNL with Double J (DJ) stenting
under general anesthesia.
Intraoperative findings included:
- Large renal pelvic and lower calyceal stones on the left side
Procedure details:
- Initial cystoscopy was performed, and a ureteric catheter was placed
- The patient was positioned prone
- RGP confirmed the stone burden and pelvicalyceal anatomy
- Percutaneous access was obtained
- Stone fragmentation was performed using lithotripsy (Lithoclast)
- Complete stone clearance was achieved
- DJ stent placement ensured adequate drainage
- A nephrostomy tube was placed at the end of the procedure
The patient tolerated the procedure well without intraoperative complications.
Postoperative Course
The postoperative period was uneventful.
Follow-up imaging (USG/X-ray) showed:
- No residual large calculi in the left kidney
- No hydronephrosis
- DJ stent and nephrostomy tube in situ
- No perinephric collection
The nephrostomy tube was removed on postoperative day 1. The patient showed good recovery with significant symptomatic relief and was discharged in stable condition.
Discussion
Staghorn calculi are complex renal stones that occupy a large portion of the collecting system and are often associated with infection and obstruction. If left untreated, they can lead to progressive renal damage.
Percutaneous Nephrolithotomy is considered the treatment of choice for such large stones due to:
- High stone clearance rates
- Minimally invasive nature
- Reduced morbidity compared to open surgery
In this case, early intervention prevented further deterioration of renal function and achieved complete clearance in a single session. The use of DJ stenting ensured proper urinary drainage and facilitated healing.
The presence of small contralateral renal calculi highlights the importance of metabolic evaluation and long-term follow-up in such patients to prevent recurrence.
Conclusion
This case demonstrates that PCNL is a safe and highly effective treatment for large renal pelvic and staghorn calculi. Timely diagnosis and intervention can lead to excellent outcomes, prevent complications, and preserve renal function.
Clinical Message
- Large renal stones should be treated promptly to avoid long-term complications
- PCNL remains the gold standard for managing staghorn calculi
- Comprehensive evaluation and expert surgical care are essential for optimal outcomes
About the Institute
The procedure was successfully performed at the Institute of Urology, Jaipur, a center equipped with advanced endourological facilities. Under the expert guidance of Dr. M. Roychowdhury and Dr. Rajan Bansal, complex urological cases are managed with precision, ensuring high success rates and patient safety. The institute provides comprehensive care, including consultation, diagnostics, minimally invasive surgery, and postoperative follow-up under one roof.
