Endoscopic Guided Additional Access for Staghorn Calculi Tevfik Ziypak, MD, 1 Senol Adanur, MD, 1 Abdulkadir Tepeler, MD, 2 Mehmet Remzi Erdem, MD, 3 Muzaffer Akcay, MD, 2 Abdullah Armagan, MD, 2 Isa Ozbey, MD, 1 and Ozkan Polat, MD 1 Abstract Background and Purpose: Flexible nephroscopy is an important technique in the management of staghorn renal calculi to reach peripheral calices. In this study, we present our experience with flexible nephroscopy and fluoroscopy-guided additional access creation for staghorn renal calculi. Patients and Methods: We conducted a retrospective analysis of patients with staghorn renal calculi who were treated with multiple percutaneous renal tracts created with the guidance of flexible nephroscopy and fluo- roscopy. Additional tracts were performed with combined flexible nephroscopy and fluoroscopy guidance. Flexible nephroscopy was used to help target the calix and ensure the safety of access. Results: Additional percutaneous renal access was achieved using combined flexible nephroscopy and fluo- roscopy guidance in 26 patients with complete staghorn (n = 21) and partial staghorn (n = 5) kidney stones. The cumulative stone size was 59.3 mm. The mean procedure times, fluoroscopy times, and hospitalization times were 91.5 minutes, 3.4 minutes, and 2.7 days, respectively. The postoperative hematocrit drop was 4.96 – 3.8. Upper and lower calices were the most common primary access tracts in 11 and 15 patients, respectively. Stone- free status was achieved in 22 (84.6%) patients with a mean 2.1 – 0.3 tract number. Postoperative complications were observed in six (23.1%) patients. Conclusions: In the requirement of additional access for staghorn renal calculi, use of flexible nephroscopy with fluoroscopy increases the safety of the procedure by confirmation of precise renal access. Introduction A merican and European urology guidelines recom- mend percutaneous nephrolithotomy (PCNL) for the surgical management of staghorn calculi that fill the entire renal pelvis and some calices. 1,2 PCNL for staghorn stones is associated with lower success rates, higher complication rates, and longer operative and hospitalization times com- pared with nonstaghorn stones. 1,3 Although stone removal through a single renal tract with flexible instruments and laser lithotripsy is popular, multiple renal accesses may sometimes be needed for a large caliceal stone burden or an inaccessible renal calix. In these situa- tions, multiple-tract PCNL is an indispensible management option for staghorn calculi. Some authors recommend mak- ing punctures to the potential calices at the outset of the pro- cedure and inserting guidewires to stabilize the tract before dilating the main tract. 4 On the other hand, making subsequent punctures if necessary is also reasonable, because laser litho- tripsy with flexible nephroscopy may remove some of the satellite stones. The creation of additional tracts can be more technically challenging; the renal collecting system cannot be distended or opacified through the ureteral catheter because of extrav- asation from the main tract. Moreover, confirmation of precise renal access may be difficult. Flexible nephroscopy is an ad- ditional imaging guidance method for this challenging issue. In this study, we present the safety and efficacy of endoscopy- verified additional renal access for staghorn renal calculi. Patients and Methods We conducted a retrospective analysis of patients with staghorn renal calculi treated with multiple percutaneous renal tracts created with guidance of combined flexible ne- phroscopy and fluoroscopy in two referral centers between 2010 and 2013. The procedures were performed by experi- enced senior urologists (TZ, AT). The patients’ demographics (age, sex, body mass index (BMI), stone size, cumulative stone size) and perioperative and postoperative outcomes (operation, fluoroscopy, hospitalization time, hemoglobin drop, success and complication rates) were also analyzed. 1 Department of Urology, Ataturk University, Erzurum, Turkey. 2 Department of Urology, Bezmialem Vakif University, Istanbul, Turkey. 3 Department of Urology, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey. JOURNAL OF ENDOUROLOGY Volume 28, Number 10, October 2014 ª Mary Ann Liebert, Inc. Pp. 1192–1196 DOI: 10.1089/end.2014.0189 1192