The endoscopic management of staghorn calculi is very challenging owing to its complex anatomical configuration. We present our experience on the clinical efficacy and safety of a single upper pole access PCNL (SUPA-PCNL) for Guy Stone Score (GSS) 3-4 staghorn calculi.

The study aimed to determine the clinical utility of a single upper pole-PCNL on complex staghorn stones. Prospective data collection was done on 56 consecutive patients who were diagnosed with GSS 3-4 staghorn calculi based on a non-contrast CT. In all cases, we utilized a standard technique of a single upper pole access PCNL. The patient demographics, stone characteristics, parameters and postoperative outcomes were then analyzed.

The patient cohort exhibited diversity in age (51.7 + 12), gender (55% male, 45% female) comorbidities, and stone burden (4.82 cm + 1.96 cm). SUPA-PCNL demonstrated a high median Stone Free Rate (99.5%, IQR 90-100) with minimal complications, low blood loss with a median of 200 cc (IQR 100-300), and short hospital stay with a median of 3.5 days (IQR 3-5). Stone characteristics did not significantly influence outcomes. A subset required invasive secondary treatments (12%, n=7), but overall morbidity was low (16%, n=9): (7% n=4) of which required blood transfusion, and (9% n=5) due to sepsis. The study identified factors associated with increased odds of perioperative morbidity, including preoperative creatinine over 3 mg/dl (OR 4.19 95% Cl 0.59 –29.71 p=0.152) and a history of endoscopic surgery (OR 7.33 95% Cl 1.20-44.96 p=0.031).

We recommend the preferential use of the posterior upper pole calyx as a primary site for PCNL because of the following benefits: (1) short skin to calyceal distance (2) straight line to the UPJ and the lower pole (3) a panoramic view of the collecting system (4) minimal torquing of the nephroscope (5) easy antegrade insertion of an indwelling ureteral stent. These translate to a higher stone clearance and relatively low risk of complications. In a way, it also lessens the need for a multi-tract approach or an endoscopically-combined intrarenal surgery (ECIRS)