Anti-Helicobacter pylori activity of the metabolites of poncirin from Poncirus trifoliata by human intestinal bacteria

Poncirin was isolated from water extract of the fruits of Poncirus trifoliata and metabolized by human intestinal bacteria. The inhibitory effect of poncirin and its metabolites by these bacteria on the growth of Helicobacter pylori (HP) was investigated. Among them, ponciretin (5,7-dihydroxy-4'-methoxyflavanone), the main metabolite most potently inhibited the growth of HP, with a minimum inhibitory concentration (MIC) of 10-20 microg/ml. However, poncirin and its metabolites except ponciretin did not inhibit the growth of HP, nor did they inhibit HP urease.

Purification, characterization, and application of an acid urease from Arthrobacter mobilis

It has been shown that urea in fermented beverages and foods can serve as a precursor of ethylcarbamate, a potential carcinogen, and acid urease is an effective agent for removing urea in such products. We describe herein the purification and characterization of a novel acid urease from Arthrobacter mobilis SAM 0752 and show its unique application for the removal of urea from fermented beverages using the Japanese rice wine, sake, as an example. The purified acid urease showed an optimum pH for activity at pH 4.2. The enzyme exhibited an apparent K(m) for urea of 3.0 mM and a Vmax of 2370 mumol of urea per mg and min at 37 degrees C and pH 4.2. Gel permeation chromatographic and sodium dodecyl sulfate gel electrophoretic analyses showed that the enzyme has an apparent native molecular weight (M(r)) of 290,000 and consisted of three types of subunit proteins (M(r), 67,000, 16,600, 14,100) denoted by alpha, beta, and gamma. The most probable stoichiometry of the subunits was estimated to be alpha: beta: gamma = 1:1:1, suggesting the enzyme subunit structure of (alpha beta gamma)3. The enzyme also existed as an aggregated form with an M(r) of 580,000. The purified enzyme contained 2 g-atom of nickel per alpha beta gamma unit of the enzyme. Enzyme activity was inhibited by acetohydroxamic acid, HgCl2, and CuCl2. The isoelectric point of the native enzyme was estimated by gel electrofocusing to be 6.8. Urea (50 ppm), which was exogenously added to sake (pH 4.4, 17 +/- 1% (v/v) ethanol), was completely decomposed by incubation with the enzyme (0.09 U ml-1) at 15 degrees C for 13 days. The enzyme was unstable at temperatures higher than 65 degrees C and pHs lower than 4, and was completely inactivated under the conditions of a pasteurization step involved in the traditional sake-making processes. These results indicate that the enzyme is applicable to the elimination of urea in fermented beverages with minimal modification to the conventional process.

Anti-Helicobacter pylori agents from the cashew apple

Anacardic acids and (E)-2-hexenal characterized from the cashew Anacardium occidentale L. (Anacardiaceae) apple have been found to exhibit antibacterial activity against the Gram-negative bacterium Helicobacter pylori, which is now considered to cause acute gastritis. The same antibacterial compounds have also been found to inhibit urease (EC 3.5.1.5).

Helicobacter pylori containing only cytoplasmic urease is susceptible to acid

Helicobacter pylori, an important etiologic agent in a variety of gastroduodenal diseases, produces large amounts of urease as an essential colonization factor. We have demonstrated previously that urease is located within the cytoplasm and on the surface of H. pylori both in vivo and in stationary-phase culture. The purpose of the present study was to assess the relative contributions of cytoplasmic and surface-localized urease to the ability of H. pylori to survive exposure to acid in the presence of urea. Toward this end, we compared the acid resistance in vitro of H. pylori cells which possessed only cytoplasmic urease to that of bacteria which possessed both cytoplasmic and surface-localized or extracellular urease. Bacteria with only cytoplasmic urease activity were generated by using freshly subcultured bacteria or by treating repeatedly subcultured H. pylori with flurofamide (1 microM), a potent, but poorly diffusible urease inhibitor. H. pylori with cytoplasmic and surface-located urease activity survived in an acid environment when 5 mM urea was present. In contrast, H. pylori with only cytoplasmic urease shows significantly reduced survival when exposed to acid in the presence of 5 mM urea. Similarly, Escherichia coli SE5000 expressing H. pylori urease and the Ni2+ transport protein NixA, which expresses cytoplasmic urease activity at levels similar to those in wild-type H. pylori, survived minimally when exposed to acid in the presence of 5 to 50 mM urea. We conclude that cytoplasmic urease activity alone is not sufficient (although cytoplasmic urease activity is likely to be necessary) to allow survival of H. pylori in acid; the activity of surface-localized urease is essential for resistance of H. pylori to acid under the assay conditions used. Therefore, the mechanism whereby urease becomes associated with the surface of H. pylori, which involves release of the enzyme from bacteria due to autolysis followed by adsorption of the enzyme to the surface of intact bacteria ("altruistic autolysis"), is essential for survival of H. pylori in an acid environment. The ability of H. pylori to survive exposure to low pH is likely to depend on a combination of both cytoplasmic and surface-associated urease activities.

The physiologic approach to the medical management of stone disease

The cause of urinary stone disease can now be detected in approximately 80% of patients. Effective treatment can substantially reduce the recurrence of urinary calculi. Proper therapy depends on a thorough understanding of the physiology of calcium, oxalate, uric acid, cystine, and struvite formation and the medication developed for prevention. This article reviews the physiologic basis of urinary stone management in a straightforward, understandable fashion.

The effect of urease inhibitors on the encrustation of urethral catheters

Encrustation and blockage of indwelling urethral catheters is primarily brought about by infection of the urinary tract by Proteus mirabilis or other urease-producing species. The bacteria colonise the catheter forming a biofilm community within a polysaccharide matrix. The activity of the urease drives up the urinary pH and causes the crystallisation of calcium and magnesium phosphates in the biofilm. We have used a simple physical model of the catheterised bladder to investigate the ability of urease inhibitors to control encrustation. It was observed that acetohydroxamic acid (1.0 mg/ml) and fluorofamide (1.0 microg/ml) restricted the increase in pH of P. mirabilis-infected urine from 9.1 to 7.6. Significant reductions in the deposition of calcium and magnesium salts were also recorded on the silicone catheters. Electron microscopy confirmed that encrustation and occlusion of the catheter lumen was minimal in the presence of the urease inhibitors. The data from this in vitro study suggests that urease inhibitors, particularly fluorofamide, could have clinical applications in the prevention of catheter encrustation and blockage.

Urease plays an important role in the chemotactic motility of Helicobacter pylori in a viscous environment

Helicobacter pylori exhibits chemotactic responses to urea, flurofamide, acetohydroxamic acid, and sodium bicarbonate. In buffer, the chemotactic activities of a urease-positive strain were higher than those of the isogenic urease-negative strain. Moreover, the chemotactic activities of the urease-positive strain were increased in a viscous solution containing 3% polyvinylpyrrolidone, whereas those of the urease-negative mutant were not. These results are in accordance with the fact that the mutant strain did not show swarming in motility agar regardless of having flagella. Incubation of the wild-type strain with flurofamide resulted in partial inhibition of the chemotactic activities in the viscous solution. In addition, incubation with acetohydroxamic acid, a low-molecular-weight, diffusible urease inhibitor, resulted in complete loss of chemotactic activity in the viscous solution. The inhibition of the chemotactic activity by urease inhibitors paralleled the inhibition of urease. The chemotactic activity of H. pylori was also inhibited by the proton carrier carbonyl cyanide m-chlorophenylhydrazone, showing that H. pylori utilizes proton motive force for motility. These results indicate that cytoplasmic urease plays an important role in the chemotactic motility of H. pylori under a condition that mimics the ecological niche of the bacterium, the gastric mucous layer.

Anti-Helicobacter pylori activity of herbal medicines

The extracts of Coptidis japonica (rhizoma), Eugenia caryophyllata (flower), Rheum palmatum (rhizoma), Magnolia officinalis (cortex) and Rhusjavanica (galla rhois) potently inhibited the growth of Helicobacter pylori (HP). However, these herbal extracts showed no inhibitory effect on HP urease except Galla rhois. Among the components separated from active herbal extracts by silica gel column chromatography, the inhibitory effects of decursinol angelate and decursin on the growth of HP were the most potent, followed by magnolol, berberine, cinnamic acid, decursinol and gallic acid. Minimum inhibitory concentrations (MICs) of decursin and decursinol angelate were 6-20 microg/ml.

Helicobacter pylori and plasma ammonia levels in cirrhotics: role of urease inhibition by acetohydroxamic acid

BACKGROUND AND AIMS

The role of Helicobacter pylori as a cause of hyperammonaemia in cirrhotics has still not been fully clarified. This study was aimed at evaluating the effect of acute Helicobacter pylori urease inhibition by oral acetohydroxamic acid administration on blood ammonia levels in cirrhotic patients.

METHODS

Twenty-nine cirrhotics (14 males, 15 females; mean age: 63 years; Child-Pugh class: 14 A, 9 B, and 6 C) undergoing upper gastrointestinal endoscopy were enrolled in the study. The presence of Helicobacter pylori infection was assessed by rapid urease test and histology. A semi-quantitative grading of bacterial density was also performed at histology. All patients received oral acetohydroxamic acid 750 mg, and blood samples for assessment of ammonia levels were taken before and at 15, 30, 60 and 90 minutes after administration.

RESULTS

Helicobacter pylori infection was detected in 20 patients, while 9 patients were uninfected. Acetohydroxamic acid administration led to a significant reduction in blood ammonia levels at 15 and 30 minutes (mean +/- SD, 113 +/- 44 vs 101 +/- 43 and 93 +/- 38 micrograms/dl, respectively; p = 0.002) only in patients with Helicobacter pylori infection. Moreover, the reduction was statistically significant only in Child-Pugh B/C class patients and in those with moderate/marked Helicobacter pylori density in gastric mucosa. Basal ammonia levels did not differ between Helicobacter pylori positive and negative patients, nor in patients with mild and moderate/marked Helicobacter pylori density in gastric mucosa, while Child-Pugh class B/C cirrhotics had higher basal ammonia levels than class A cirrhotics, in both Helicobacter pylori positive and negative groups.

CONCLUSIONS

Our data showed that Helicobacter pylori urease inhibition by acetohydroxamic acid administration significantly reduces blood ammonia levels in patients with more advanced liver cirrhosis and in those with a high bacterial density in gastric mucosa.

Crystallization and preliminary high-resolution X-ray diffraction analysis of native and beta-mercaptoethanol-inhibited urease from Bacillus pasteurii

Hexagonal crystals of urease from Bacillus pasteurii have been obtained by vapour diffusion at 293 K in 20 mM Tris-HCl, neutral pH, containing 50 mM Na2SO3. Isomorphous crystals of urease inhibited with beta-mercaptoethanol were also obtained by including 4 mM of the inhibitor in the enzyme solution. Crystals of the native and inhibited enzyme diffract respectively to 2.00 A (96.7% completeness) and to 1.65 A (98.7% completeness) using synchrotron X-ray cryogenic (100 K) conditions. The space group is P6322 for both forms, and the unit-cell parameters are a = b = 131.36, c = 189. 76 A for native urease and a = b = 131.34, c = 190.01 A for inhibited urease. Under the same conditions, single crystals of B. pasteurii urease inhibited with acetohydroxamic acid, cisteamine, and phenylphosphorodiamidate were also obtained.

Biochemical identification and biological origin of key odor components in livestock waste

Animal production results in conversion of feeds into valuable products such as meat, milk, eggs, and wool as well as into unavoidable and less desirable waste products. Intensification of animal numbers and increasing urbanization has resulted in considerable attention to odorous gases produced from animal wastes. It is clear that animal manure was, and still is, a valuable resource. However, it may be a major obstacle to future development of the animal industry if its impact on the environment is not properly controlled. Poor odor prevention and control from animal wastes is related to a lack of knowledge of the fundamental nature of odor and its production by farm animals. Odor, like noise, is a nuisance or disturbance and there is no universally accepted definition of an objectionable odor. Thus, regulation and control of odors in the environment is difficult because of the technical difficulties of defining odor limits and their measurement and evaluation. A variety of direct (sensory) and indirect (analytical instruments) methods for measuring odor intensity and determination of individual or key odor components are discussed. The biological origins of the four principal classes of odor compounds, namely branched- and straight-chain VFA, ammonia and volatile amines, indoles and phenols, and the volatile sulfur-containing compounds, are reviewed. Because more than 50% of N from animals is excreted as urea, one strategy to conserve N in waste is to inhibit the urease enzyme that converts urea to ammonia. Laboratory studies to evaluate di- and triamide compounds to control urea hydrolysis in slurries of cattle and swine wastes are presented. Finally, a brief overview of various intervention strategies is provided. Multiple combinations of nutritional management, housing systems, treatment options as well as storage and disposal of animal wastes will be required to reduce environmental pollution and provide for long-term sustainable growth.

Screening system for urease inhibitors using 13C-NMR

Urease inhibitors are candidate drugs to treat infection with the human pathogen, Helicobacter pylori, which produces a potent urease [urea amidohydrolase; EC 3.5.1.5]. We developed a screening system based on 13C-NMR measurement of the time course of decrease in the signal of 13C-urea in the presence of urease. The effect on urease activity of known inhibitors, hydroxamic acids, L-ascorbic acid, 2,2'-dipyridyl disulfide and ninhydrin, was speedily and conveniently measured by this method.

Ecabet sodium, a locally acting antiulcer drug, inhibits urease activity of Helicobacter pylori

In order to clarify the mechanism of the anti-Helicobacter pylori action of ecabet sodium (ecabet), a locally acting antiulcer drug, we evaluated the effects of ecabet on H. pylori urease activity in vitro. H. pylori was cultured and a crude preparation of urease was made. Urea-dependent survival of H. pylori at acid pH was significantly inhibited by ecabet. The urease activity of intact cells and a crude enzyme preparation from H. pylori had two pH optima: pH 4.5-5.0 and 8.0. Ecabet (1-4 mg/ml) concentration dependently inhibited the urease activity of both preparations at pH 5.0, but there was no inhibition at pH 8.0. The enzyme activity was inhibited by ecabet gradually and was not restored by dilution, in contrast to the inhibition elicited by benzohydroxamic acid, a specific and reversible urease inhibitor. These results suggest that irreversible inhibition of H. pylori urease activity contributes to the anti-H. pylori action of ecabet.

Omeprazole may exert both a bacteriostatic and a bacteriocidal effect on the growth of Helicobacter pylori (NCTC 11637) in vitro by inhibiting bacterial urease activity

AIMS

To assess the potential antibacterial effect of omeprazole, a benzimidazole proton pump inhibitor, on the growth of Helicobacter pylori in vitro and to evaluate the effect of this compound on bacterial urease activity.

METHODS

The growth of H pylori was observed in liquid culture in the presence and absence of omeprazole (0.8 mg/ml). Urease activity was evaluated in aliquots removed from two hour cultures by monitoring the initial change in absorbency at 560 nm in the presence of 0.02% phenol red.

RESULTS

The minimum inhibitory concentration of omeprazole against H pylori was 0.8 mg/ml. The concentration of omeprazole required to inhibit growth was dependent on inoculum density: omeprazole (0.8 mg/ml) prevented growth from a 1 x 10(6) cfu/ml inoculum, but not from the higher inocula of 10(7) or 10(8) cfu/ml. This is the first study to demonstrate that omeprazole exerts a bacteriocidal effect against low bacterial densities and a bacteriostatic effect when bacterial density is high. When used at the onset of growth, this concentration of omeprazole has a bacteriocidal effect after four hours, although it exerts a bacteriostatic effect when added to cultures after the exponential phase. Bacterial urease activity is competitively inhibited by omeprazole in a dose dependent manner.

CONCLUSION

The results suggest that omeprazole exerts both a bacteriocidal and a bacteriostatic effect against H pylori and competitively inhibits bacterial extracellular urease activity.

A study of inhibition of urease from seeds of the water melon (Citrullus vulgaris)

Urease from seeds of the water melon was found to be inhibited by various salts of sodium. Sodium fluoride strongly inhibited the activity in the low urea concentration range. The enzyme was also inhibited by a high concentration of urea which was completely abolished in the presence of 10 mM sodium fluoride. Time-dependent inactivation of urease with iodoacetic acid, N-ethylmaleimide and p-hydroxymercuribenzoate exhibited biphasic kinetics in which half of the initial activity was lost in the fast phase and the remainder in a slow phase. Each phase exhibited first-order kinetics. These observations are suggestive of the existence of half-and-half distribution of sites.

Inhibitory action of YJA20379, a new proton pump inhibitor on Helicobacter pylori growth and urease

The activities of two types of antiulcer agents against 9 strains of Helicobacter pylori (H. pylori) were determined by the agar dilution method. The antiulcer agents were YJA20379, a newly synthesized proton pump inhibitor developed by Yung-Jin Pharmaceutical company, and omeprazole. Both compounds were found to have significant activities against this organism. The MIC values of YJA20379 and omeprazole were 11.7 and 31.25 micrograms/ml, respectively. In addition, the inhibitory potency of both compounds was investigated on H. pylori urease which is believed to be an important colonization and virulence factor in the pathogenesis of gastritis and peptic ulcers. These compounds dose-dependently inhibited urease extracted with distilled water and their IC50 values were 16.4 x 10(-5) M and 14.3 x 10(-5) M, respectively. In addition, a pH-dependent study to determine whether inhibitory potency would be activated by acid condition was performed. It was found that unlike omeprazole, YJA20379 was not affected by acid condition. To determine the inhibition pattern and optimal concentration of substrate, kinetics were evaluated at various pH levels (pH 5.0, 7.0, and 8.5). The data show that YJA20379 noncompetitively inhibited H. pylori urease and KM/Ki values were 0.96 mM/60 microM (pH 5.0), 0.56 mM/141.5 microM (pH 7.0), and 1.94 mM/34 microM (pH 8.5), respectively. Based on data obtained, it is concluded that YJA20379 is a significant inhibitor of H. pylori growth and urease and therefore, taking these results into consideration, YJA20379 might be a beneficial therapy for gastritis and peptic ulcers induced by H. pylori.

Effect of potent urease inhibitor, fluorofamide, on Helicobacter sp. in vivo and in vitro

The therapeutic potential of urease inhibition of Helicobacter pylori has been studied by examining the effect of the potent urease inhibitor, fluorofamide (N-(diaminophosphinyl)-4-fluorobenzenamide), on urease activity and bacterial survival in vivo and in vitro. In culture, acid protection in H. pylori was shown to be due to changes in the pH of the medium brought about by the release of ammonia. Both the acid protection and the ammonia release were completely blocked by fluorofamide at low doses (ED50 = approximately 100 nM). However, fluorofamide was unstable under acidic conditions (T1/2 = 5.7 min at pH 2). Despite this, fluorofamide was the best available compound to test in vivo. In ferrets naturally infected with H. mustelae, a single dose (50 mg/kg, per os) of fluorofamide completely inhibited bacterial urease. In repeat dosing studies, fluorofamide (50 mg/kg per os, three times a day) was compared with the Helicobacter triple therapy regime (amoxycillin, metronidazole, and bismuth subcitrate). Fluorofamide failed to eradicate the H. mustelae infection, compared to 80% eradication with triple therapy. However, histological samples showed a profound reduction in bacterial numbers following fluorofamide treatment. A combination of fluorofamide and amoxycillin was dosed to ferrets (seven days of treatment with 50 mg/kg fluorofamide plus 10 mg/kg amoxycillin per os twice a day); however, this failed to eradicate the infection, despite there being a reduction in bacterial numbers in 3/5 ferrets after 21 days after dosing stopped. It was concluded that urease inhibitors (either alone or in combination with antibiotics) are unlikely to have therapeutic potential for Helicobacter pylori infections. This is probably because, in vivo, some bacteria (perhaps dormant forms) are not entirely dependent upon urease for survival. However, given the acid instability of fluorofamide, the possibility that more stable urease inhibitors might have therapeutic potential, cannot be excluded.

Substitution of the urease active site carbamate by dithiocarbamate and vanadate

Urease possesses a dinuclear nickel active site with the metals bridged by a carbamylated lysine residue. In vitro activation of apoprotein (Apo) is achieved by incubation with Ni(II) and bicarbonate as a source of CO2. Analogues of CO2 and bicarbonate were examined for their effects on the Apo activation process. While SO2 had little effect, CS2 was shown to inhibit Apo activation via its ability to substitute for CO2 to yield an inactive dithiocarbamate-containing protein. Sulfur-to-Ni charge-transfer transitions arising from this species yielded an electronic absorption band at 324 nm with a shoulder at 382 nm. Borate, sulfate, phosphate, and molybdate had essentially no effect on Apo activation and did not substitute for bicarbonate, while treatment of Apo with Ni(II) plus vanadate led to the production of active urease containing two Ni and one V per active site. Vanadate-dependent activation of Apo resembled the normal activation process in terms of concentration of anion required, optimal pH, and incubation time needed. Furthermore, the UV-visible spectrum, maximal specific activity [386 +/- 26 U.(mg of protein)-1], Km (1.83 +/- 0.20 mM urea), and pH dependence for the vanadate-containing urease were essentially identical to properties observed for bicarbonate-activated enzyme. Vanadate-activated Apo is proposed to possess a vanadylated lysine that bridges the two Ni ions comprising its metallocenter.

A simple novel method for determination of an inhibition constant by isothermal titration microcalorimetry. The effect of fluoride ion on urease

A simple novel method was introduced for determination of an inhibitor binding constant (Ki) and enthalpy of binding by isothermal titration microcalorimetry technique. This method was applied to the binding of fluoride ion, as an inhibitor, with the active sites of jack bean urease at pH = 7.0 (Tris 30 mM) and T = 300 degrees K. The dissociation equilibrium constant measured by this method was markedly consistent with the inhibition constant obtained from assay of enzyme activity in the presence of fluoride ion.

Structures of Cys319 variants and acetohydroxamate-inhibited Klebsiella aerogenes urease

Cys319 is located on a mobile flap covering the active site of Klebsiella aerogenes urease but does not play an essential role in catalysis. Four urease variants altered at position C319 range from having high activity (C319A) to no measurable activity (C319Y), indicating Cys is not required at this position, but its presence is highly influential [Martin, P. R., & Hausinger, R. P. (1992) J. Biol. Chem. 267, 20024-20027]. Here, we present 2.0 A resolution crystal structures of C319A, C319S, C319D, and C319Y proteins and the C319A variant inhibited by acetohydroxamic acid. These structures show changes in the hydration of the active site nickel ions and in the position and flexibility of the active site flap. The C319Y protein exhibits an alternate conformation of the flap, explaining its lack of activity. The changes in hydration and conformation suggest that there are suboptimal protein-solvent and protein-protein interactions in the empty urease active site which contribute to urease catalysis. Specifically, we hypothesize that the suboptimal interactions may provide a significant source of substrate binding energy, and such hidden energy may be a common phenomenon for enzymes that contain mobile active site loops and undergo an induced fit. The acetohydroxamic acid-bound structure reveals a chelate interaction similar to those seen in other metalloenzymes and in a small molecule nickel complex. The inhibitor binding mode supports the proposed mode of urea binding. We complement these structural studies with extended functional studies of C319A urease to show that it has enhanced stability and resistance to inhibition by buffers containing nickel ions. The near wild-type activity and enhanced stability of the C319A variant make it useful for further studies of urease structure-function relationships.

Suppression of Helicobacter pylori urease activity by sucralfate and sulglycotide

The effect of gastroprotective agents, sucralfate and sulglycotide, on the in vitro activity of H. pylori urease was investigated. The bacterium was subjected to sonication, centrifuged, and the supernatant used as an enzyme source. The assays revealed that the rate of urea degradation was proportional to enzyme protein up to 100 micrograms and remained constant with time for 10 min. Introduction of sucralfate or sulglycotide to the assay system led to the reduction in the rate of ammonia production. With both drugs the optimal inhibition was attained at 10 micrograms/ml, at which dose a 63.1% decrease in urease activity occurred with sucralfate and a 70.2% inhibition was obtained with sulglycotide. The findings demonstrate that the inhibitory action of sucralfate and sulglycotide on H. pylori urease activity may be of value in the treatment of gastric disease associated with H. pylori infection.

Urease-independent chemotactic responses of Helicobacter pylori to urea, urease inhibitors, and sodium bicarbonate

Helicobacter pylori CPY3401 and an isogenic urease-negative mutant, HPT73, showed chemotactic responses to urea, flurofamide (a potent urease inhibitor), and sodium bicarbonate. Since urea and sodium bicarbonate are secreted through the gastric epithelial surface and hydrolysis of urea by urease on the bacterial surface is essential for colonization, the chemotactic response of H. pylori may be crucial for its colonization and persistence in the stomach.

Treatment options in struvite stones

Urinary calculi have plagued man over the centuries. The epidemiology and pathogenesis of infection have been studied. The curative treatment remains problematic. Without therapy, a vicious cycle of stone formation occurs. This results in renal damage and even death. Multimodality therapy is the key. Nonoperative treatment leads to progressive renal damage. The combination of maximal surgical ablation and medical therapy is synergistic. The combination of PCNL-ESWL has not appeared to produce ill effects. PCNL-ESWL is a less morbid surgical alternative than open surgical procedures. Adjunctive medical therapy, such as culture-specific antibiotics and urease inhibitors, complements surgical ablation by reducing the morbidity with persistent UTIs and stone recurrence. The urologist today must approach struvite staghorns with a vast armamentarium of surgical and medical techniques. Each patient requires a unique solution.