Do renal stones that fail lithotripsy require treatment?

Abstract

The rates of extracorporeal shock wave lithotripsy (SWL) appear stable in the UK. However, there is little evidence on the natural history of these calculi if SWL fails. We set to look at the effectiveness of SWL in patients with a single, previously untreated renal stone and the natural history of those stones that failed treatment. We retrospectively reviewed all data from our prospectively collected database of patients undergoing a first treatment for a single renal stone between October 2010 and November 2013. Outcomes after SWL were categorised as success, subsequent intervention needed or conservative management. The medical records of patients managed conservatively were reviewed to determine whether further intervention was required and why. We further sought to define, in those patients where SWL failed, whether subsequent active intervention was needed. For the remainder, we examined whether conservative management was a reasonable management option. 313 patients fitted the inclusion criteria. Of these, 144 were treated successfully. Of the 170 patients with a residual stone, 51 went on to flexible ureteroscopy directly at their next clinical review mainly due to persistent symptoms. 79 patients were managed conservatively, and for 39 follow-up data were unavailable as their follow-up was at a different hospital. 63 patients (80%) were successfully managed conservatively with no recurrence of symptoms over the follow-up period (mean 2 years 4 months). 16 (20%) patients that were initially managed conservatively required subsequent intervention. Of these, 87% had a stone in an upper pole calyx. Conservative management of renal stones after failed SWL is a suitable option for asymptomatic patients with stones not located in the upper pole. For patients with upper pole stones, early intervention is warranted due to the high risk of requiring intervention.

Natural history of small asymptomatic kidney and residual stones over a long‐term follow‐up: systematic review over 25 years

“…Risk of developing symptoms over at least 24 months of follow‐up in patients who were asymptomatic at baseline with stones or residual fragments of ≤10 mm was described by eight of the included studies [26,28–33,35]. Rates of symptoms were reported between 0% and 59.4% [30,32].…”

“…[34] also failed to find a significant difference between rates of intervention according to stone size, with rates of 5%, 9.5% and 14.3% for stones of <5, 5–10 and >10 mm, respectively ( P = 0.477). One study suggested that intervention is frequently triggered by pain symptoms and reported this to be the case in 73% (27/51) of interventions in a total of 169 patients [35]. The Kang et al .…”

“…[30] discern between ‘active indications’ (i.e. those suggested by the EAU) and ‘all’ indications for intervention in their study [11,30,31,35]. It is recognised that these aforementioned objective measures are not the sole reason patients have active management of KSD and that patient‐reported outcome measures (PROMs) also contribute to patient management, as well as patient preference [40].…”

“…Our literature search identified 2247 articles of interest, of which 130 abstracts were reviewed and 47 manuscripts underwent full-text review. This process identified 10 studies for inclusion in the present systematic review (Figure 1) (Table 1) [26][27][28][29][30][31][32][33][34][35]. These studies comprised four cohort studies, one case-control study and five case series.…”

The utility of automated volume analysis of renal stones before and after shockwave lithotripsy treatment

“…However, studies of the natural history of CIRFs after SWL and RIRS have shown that that the majority of CIRFs (approx. 56-78%) do spontaneously pass or requires no further treatment [8,[26][27][28][29]. This still leaves a significant proportion (approx.…”