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Renal struvite stones—pathogenesis, microbiology, and management strategies

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Key Points

  • Struvite stones form a subset of kidney stones that are exclusively associated with urease-producing bacteria

  • Stone culture at the time of treatment or urine culture from the renal pelvis provides useful clinical information for directing antibiotic therapy

  • Percutaneous nephrolithotomy (PCNL) is the gold-standard approach for treatment of staghorn infection calculi but other interventions might have an adjunctive role in therapy

  • Residual stone fragments can be removed using urease inhibitors, acidification therapy, dissolution therapy, extracorporeal shockwave lithotripsy, ureteroscopy, PCNL, or anatrophic nephrolithotomy

  • Repeat imaging and urine cultures should be performed within 3 months of the procedure to confirm a stone-free status or identify recurrence


Infection stones—which account for 10–15% of all urinary calculi—are thought to form in the presence of urease-producing bacteria. These calculi can cause significant morbidity and mortality if left untreated or treated inadequately; optimal treatment involves complete stone eradication in conjunction with antibiotic therapy. The three key principles of treating struvite stones are: removal of all stone fragments, the use of antibiotics to treat the infection, and prevention of recurrence. Several methods to remove stone fragments have been described in the literature, including the use of urease inhibitors, acidification therapy, dissolution therapy, extracorporeal shockwave lithotripsy, ureteroscopy, percutaneous nephrolithotomy (PCNL), and anatrophic nephrolithotomy. PCNL is considered to be the gold-standard approach to treating struvite calculi, but adjuncts might be used when deemed necessary. When selecting antibiotics to treat infection, it is necessary to acquire a stone culture or, at the very least, urine culture from the renal pelvis at time of surgery, as midstream urine cultures do not always reflect the causative organism.

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Figure 1: The process of biofilm formation.
Figure 2: A proposed algorithm for the management of struvite stones.

Change history

  • 27 May 2014

    In the version of this article initially published online Wai Ho Choy's name was spelled incorrectly. The error has been corrected for the print, HTML and PDF versions of the article.


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R.F. and D.L. researched, wrote, edited, reviewed, and discussed the Review with colleagues. W.H.C. helped to research and edit the article. B.C. contributed towards writing and editing.

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Correspondence to Dirk Lange.

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B.C. declares consulting associations with Boston Scientific, Cook Medical, Olympus ACMI, PercSys and Bard Medical. D.L. declares consulting associations with Boston Scientific, Olympus, Cook Medical, PercSys, and Bard Medical. R.F. and W.H.C. declare no competing interests.

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Flannigan, R., Choy, W., Chew, B. et al. Renal struvite stones—pathogenesis, microbiology, and management strategies. Nat Rev Urol 11, 333–341 (2014).

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