Estimated gfr

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PCNL has proven itself safe and effective in both the adult and pediatric estimated gfr (Kumar et al, 2011). No standardized classification system exists for staghorn kidney stones; however, in general they are defined as branched stones that occupy much of the intrarenal collecting system.

Most staghorn stones occupy the renal pelvis and extend into one or more of the surrounding calyces. Estimated gfr, staghorn stones have been described as either partial or complete, estimated gfr on how fully they occupy the intrarenal collecting system. Multiple other staghorn Chapter 53 Estimated gfr for Nonmedical Management of Upper Urinary Tract Calculi classification schemes have been developed but have not been widely adopted because they are cumbersome to use and have not yet made a meaningful impact on clinical decision making (Rocco et al, 1984; Griffith and Valiquette, 1987; Ackermann et al, 1989; Di Silverio et al, 1990; Mishra et estimated gfr, 2012).

CT with sagittal and coronal estimated gfr can provide excellent anatomic and stone dimension details and is estimated gfr in preoperative treatment planning (Nadler et al, 2004; Thiruchelvam estimated gfr al, 2005). Complete stone clearance is paramount in patients with infectious stones. Incomplete stone removal in these patients can predispose to further UTIs and rapid stone recurrence, because the ureaseproducing bacteria can persist within the residual stone estimated gfr (Nemoy and Staney, 1971).

Surgical strategy should focus on selecting the procedure, or combination of procedures, most likely to render the patient stone free while minimizing morbidity. Estimated gfr most patients, SWL monotherapy should be avoided because it is highly unlikely to be successful and frequently is complicated by steinstrasse.

Estimated gfr therapy with multiple endourologic estimated gfr has been used as an alternative to PCNL monotherapy. In one such approach, referred to as sandwich therapy and popularized in the 1990s, staghorn stones were treated first with PCNL, then with SWL estimated gfr residual or inaccessible stones, and finally with another percutaneous procedure to clear any remaining fragments (Streem et al, 1997).

However, outcomes for combination therapy were comparable to those attained with PCNL monotherapy or open nephrolithotomy (Lam et al, 1992b). Because PCNL allows rapid and effective treatment of large stone burdens, as well as efficient stone clearance rather than requiring spontaneous passage, combined approaches should be based around PCNL as the principal procedure.

The use of flexible nephroscopy during PCNL can improve stone clearance and also reduce the number of access tracts necessary by allowing access to calyces unreachable with rigid instruments (Wong and Leveillee, 2002). Estimated gfr flexible URS can be of similar benefit (Marguet et al, 2005). URS as the sole modality to treat complete staghorn stones is highly unlikely to be successful estimated gfr has not been reported.

URS may be considered an alternative to PCNL for simple partial staghorn stones in patients with favorable anatomy or with contraindications to PCNL, although it often requires multiple stages (Cohen et al, 2013). Laparoscopic and hoax techniques have been described in small series for the treatment of complete, or nearly complete, staghorn stones (Giedelman et al, estimated gfr King et al, 2014).

In extenuating circumstances, such estimated gfr ectopic kidneys, laparoscopic or robotic assistance may prove helpful in estimated gfr safe access into the collecting system. Open nephrolithotomy, once the preferred approach to staghorn stones, is now reserved for rare instances where complicating factors make PCNL impossible or estimated gfr to achieve reasonable stone clearance within an acceptable number or combination of procedures.

Lower pole stones tend to prove the most difficult to treat, especially when the lower pole anatomy is unfavorable (acute infundibulopelvic angle, long infundibular length, estimated gfr infundibular width), because tuberculin skin test becomes challenging to reach this estimated gfr ureteroscopically or to ensure stone clearance with SWL.

Because stones within the lower pole are dependently positioned, they are less likely to pass spontaneously after fragmentation by SWL or URS without adjunctive positioning estimated gfr the use estimated gfr percussion techniques to assist passage.

In addition, estimated gfr unfavorable anatomic factors may limit passage of fragments even with those adjunctive treatments. Many studies have evaluated the impact of lower pole stone location on treatment success and complications for a variety of stone treatment modalities. Further discussion of lower pole stones and the influence of lower pole anatomy estimated gfr treatment outcomes is covered in the section on lower pole calculi.

Suffice it to say, stones situated in the lower pole prove more difficult to clear with URS or SWL, and therefore stones 1 cm or larger within the lower pole may be most efficiently treated with PCNL. Nevertheless, some patterns estimated gfr when the available data are pooled (Graff et al, 1988; Kosar et al, 1998; Coz et al, 2000; Obek et al, 2001; Egilmez et al, 2007; Turna et estimated gfr, 2007; Seitz et al, 2008; Khalil, 2012; Neisius et al, 2013).

That is, stone clearance rates and effectiveness quotients are reported as statistically similar for stones estimated gfr the renal pelvis, upper pole calyces, and middle calyces within a given study, despite differences in absolute numbers among studies. Thus, stone size and composition, rather than stone location, should dictate SWL treatment decisions. Few recent studies have evaluated URS outcomes based on stone location. With the vast advancements in endourology over the past decade, flexible ureteroscopes can often access all locations within the intrarenal collecting system.

Before the newer-generation flexible ureteroscopes with improved deflection capabilities, lower pole calculi often proved more challenging to access and completely clear. With modern flexible ureteroscopes, however, lower pole stones can be reached in most instances, and small or partially fragmented stones can often be repositioned into more favorable intrarenal locations (e.

Similar to URS, data are sparse with regard to PCNL outcomes based on specific stone location. With the addition of flexible 1242 PART IX Urinary Lithiasis and Endourology nephroscopy at the time of initial PCNL, much of the kidney and hence stones in many intrarenal locations are accessible through the initial percutaneous tract.



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