Note from the National Guideline Clearinghouse: The recommendations without the associated supporting text have been excerpted from the guideline. For full context, please refer to the original guideline document.
Definitions for the treatment guideline statements (standard, recommendation, and option) and "index patient" are given at the end of the "Major Recommendations" field.
Treatment Guidelines for the Index Patient
Standards
- A newly diagnosed patient should be actively treated.
- The patient must be informed about the relative benefits and risks associated with the active treatment modalities.
Recommendations
- Percutaneous nephrolithotomy should be the first treatment utilized for most patients.
- If combination therapy is undertaken, percutaneous nephroscopy should be the last procedure for most patients.
- Shock-wave lithotripsy monotherapy should not be used for most patients; however, if it is undertaken adequate drainage of the treated renal unit should be established before treatment.
- Open surgery (nephrolithotomy by any method) should not be used for most patients.
Options
- Shock-wave lithotripsy monotherapy may be considered in patients with small-volume staghorn calculi with normal collecting-system anatomy.
- Open surgery can be considered for patients in whom the stone is not expected to be removed by a reasonable number of less invasive procedures.
Recommendations for Non-index Patients
- Nephrectomy should be considered when the involved kidney has negligible function.
- Shock-wave lithotripsy monotherapy should not be used for patients with staghorn or partial staghorn cystine stones.
Option for Non-index Patients
- Shock-wave lithotripsy monotherapy or percutaneous-based therapy may be considered for children.
Definitions:
Treatment Guideline Statements
The present treatment guideline statements are graded with respect to three levels of flexibility: A "standard" has the least flexibility as a treatment policy; a "recommendation" has significantly more flexibility; and an "option" is even more flexible. These three levels of flexibility are defined as follows:
- Standard: A guideline is a standard if (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions, and (2) there is virtual unanimity about which intervention is preferred;
- Recommendation: A guideline is a recommendation if (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions, and (2) an appreciable but not unanimous majority agrees on which intervention is preferred; and
- Option: A guideline is an option if (1) the health outcomes of the alternative interventions are not sufficiently well known to permit meaningful decision, or (2) preferences are unknown or equivocal.
Index Patient
Standards, recommendations, and options for the treatment of patients with staghorn calculi apply to an "index patient." In this guideline, the index patient is defined as an adult with a staghorn stone (non-cystine, non-uric acid) who has two functioning kidneys (function of both kidneys is relatively equal) or a solitary kidney with normal function, and whose overall medical condition, body habitus, and anatomy permit performance of any of the four accepted active treatment modalities, including the use of anesthesia.
