合併心衰竭且使用 Edoxaban 之高風險患者左側鹿角狀結石之輸尿管鏡治療：
病例報告

黃品叡^1,2,3、蕭亞芝⁴、陳曉芳⁴、鄭如惠⁵、李建儀⁶

1李綜合醫療社團法人大甲李綜合醫院 外科部 泌尿外科

2國立陽明交通大學 跨領域醫學博士學位學程

3亞洲大學 食品營養與保健生技學系

4李綜合醫療社團法人苑裡李綜合醫院 醫療部 專科護理師小組

5李綜合醫療社團法人苑裡李綜合醫院 護理部

6台中榮民總醫院 泌尿醫學部

Pin-Jui Huang^1,2,3, Ya-Chih Hsiao⁴, Hsiao-Fang Chen⁴, Ru-Hui Cheng⁵, Jian-Ri Li⁶

1Division of Urology, Department of Surgery, Dajia Lee Hospital

2Ph.D. Program in Interdisciplinary Medicine, National Yang Ming Chiao Tung University, Taipei

3Department of Food Nutrition and Health Biotechnology, Asia University, Taichung

4Division of Nursing Participants, Department of Medical Affairs, Yuanli Lee Hospital

5Nursing Department, Yuanli Lee Hospital

6Department of Urology, Taichung Veterans General Hospital

Introduction:
Staghorn calculi are typically managed with percutaneous nephrolithotomy (PCNL), which is considered the gold standard treatment. However, PCNL may not be suitable for patients with significant comorbidities, bleeding risks, or poor cardiopulmonary reserve. In such high-risk patients, retrograde intrarenal surgery (RIRS) or ureteroscopic lithotripsy (URSL) may serve as alternative treatment options. We present a case of a large staghorn calculus managed with staged ureteroscopic lithotripsy in a patient with severe heart failure receiving anticoagulant therapy.

Case Presentation:
A 75-year-old male presented with intermittent left flank discomfort. His medical history included congestive heart failure with reduced ejection fraction (LVEF 32.5%) and chronic anticoagulation therapy with edoxaban (Lixiana). Imaging studies, including computed tomography, revealed a left staghorn calculus occupying the renal pelvis and multiple calyces. Due to his poor cardiac function and high anesthetic risk, percutaneous nephrolithotomy was considered high risk for bleeding and cardiopulmonary complications. After multidisciplinary evaluation, staged ureteroscopic lithotripsy (URSL) was chosen as an alternative treatment strategy. The patient underwent left ureteroscopic lithotripsy under general anesthesia. A flexible ureteroscope was used to access the renal pelvis and calyces, and laser lithotripsy was performed using a holmium laser. The procedure was performed in staged sessions to reduce operative time and minimize perioperative risk. A double-J stent was placed after each procedure.

Results:
The patient tolerated the procedures well without major complications such as bleeding, sepsis, or cardiac events. Gradual fragmentation and clearance of the stone burden were achieved after multiple URSL sessions. Follow-up imaging showed significant reduction of stone burden and relief of symptoms. Renal function remained stable throughout treatment.

Discussion:
Although PCNL remains the standard treatment for staghorn calculi, URSL may be a viable alternative in patients who are poor candidates for percutaneous surgery due to severe cardiopulmonary disease or anticoagulation therapy. Staged URSL can reduce surgical risk while still achieving acceptable stone clearance rates. Careful patient selection and staged procedures are key to successful outcomes.

Conclusion:
Staged ureteroscopic lithotripsy is a safe and feasible alternative for managing staghorn calculi in high-risk patients who are not suitable candidates for PCNL. This approach may reduce perioperative risks while still providing effective stone management.