Purpose: We determined the immediate and long-term efficacy of combination "sandwich" therapy for management of large, extensively branched calculi in 100 consecutively treated patients.
Materials and methods: We treated 61 women and 39 men for stones ranging from 2.2 to 66 cm2 (mean 20.8) with percutaneous debulking followed by shock wave lithotripsy and, when necessary, secondary nephroscopy via the mature tract. The primary debulking was performed via 1 to 3 tracts (total 106, mean 1.06 per patient), following which 1 to 3 shock wave treatments (total 127, mean 1.3 per patient) were administered. Subsequently, 62 patients underwent 71 secondary or tertiary percutaneous procedures (mean 1.1 per patient).
Results: Total hospital stay ranged from 3 to 44 nights (mean 12.2) and decreased with experience. In 34 patients 40 complications developed, the most frequent of which were bleeding requiring transfusion in 14 patients and fever or sepsis delaying a planned procedure or hospital discharge in 20 patients. For patients with struvite stones the transfusion rate and fever/sepsis rate was 20 and 33%, respectively, compared to only 10 and 12%, respectively, for those patients with noninfection related stones. Of 87 patients available for 1-month radiographic followup 55 (63%) were stone-free, while 32 (37%) had discrete residual gravel. With time and experience, the stone-free rate improved from 52 to 70%. Of 55 patients followed for a mean of 40.5 months ipsilateral stones recurred in 13 (22.8%). Of 39 patients with struvite calculi 11 (28%) had recurrent bacteriuria or infection. Renal function, defined by serum creatinine, ranged from 0.6 to 3.9 mg./dl. (mean 1.3) before treatment and from 0.5 to 6.4 mg./dl. (mean 1.4) 1 to 101 months (mean 31) after treatment.
Conclusions: This combined sandwich approach offers immediate and long-term results comparable to other forms of management currently available for these challenging cases. Furthermore, this approach may be applied successfully to virtually any patient with large, extensively branched or otherwise complex stones.