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Sener NC et al, 2015: Asymptomatic lower pole small renal stones: shock wave lithotripsy, flexible ureteroscopy, or observation? A Prospective randomized trial.

Sener NC, Bas O, Sener E, Zengin K, Ozturk U, Altunkol A, Evliyaoglu Y
Department of Urology, Numune Teaching and Research Hospital, Yuregir, Adana, Turkey.
Department of Urology, Onkoloji Education and Research Hospital, Ministry of Health, Ankara, Turkey.
Department of Radiology, Ceyhan State Hospital, Ceyhan, Adana, Turkey.
Department of Urology, Bozok University, Yozgat, Turkey.
Department of Urology, Diskapi Yildirim Beyazid Education and Research Hospital, Ministry of Health, Ankara, Turkey.
Department of Urology, Numune Teaching and Research Hospital, Yuregir, Adana, Turkey.

Abstract

OBJECTIVE: To present the outcomes of flexible ureteroscopy (F-URS), shock wave lithotripsy (SWL), and observation in the management of asymptomatic lower calyceal stones.
METHODS: A total of 150 patients with asymptomatic lower calyceal stones were randomized into F-URS (group 1), SWL (group 2), and observation (group 3) groups. The main criteria for patient enrollment were having asymptomatic single lower pole stones <1 cm.
RESULTS: In F-URS, the mean stone-free rate was 92% (46 of 50). The mean number of sessions for the SWL group was 1.48 ± 0.65. Stone-free rate was 90% (45 of 50). In the observation group, patients were followed up for a mean of 21.02 ± 3.65 months. Three stones passed spontaneously without any symptoms. Pain developed in 3 patients during follow-up, and 2 of them passed a stone and responded to analgesics without further treatment. Complication rates for groups 1 and 2 were similar, but group 2 had higher Clavien grades.
CONCLUSION: For asymptomatic small-sized lower calyceal stones, SWL and F-URS are established treatment modalities. However, with low auxiliary treatment rates, observation may be an option for the management of nonsymptomatic small-sized lower pole kidney stones. 

Urology. 2015 Jan;85(1):33-7. doi: 10.1016/j.urology.2014.08.023. Epub 2014 Oct 18.

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Comments 1

Hans-Göran Tiselius on Monday, 20 April 2015 10:25

In this article the authors report on the outcome of SWL and f-URS as recorded in a prospective randomized control study of small (%) were similar in the two groups. These data are in accordance with previous observations.

More interesting is that this report also included findings in patients who were left without active stone removal and only followed by observation during 24 months. During that period 5 stones passed spontaneously and 6 patients developed symptoms that had to be dealt with. But overall it was concluded that 88% of the conservatively treated patients had an uneventful course of their disease during the 2 years.

Although 2 years is a short period for conclusions on the usefulness of just observing patients with asymptomatic stones this result throws some light on how we need to deal with asymptomatic residual fragments. It is mentioned that stones measuring 8.0 mm at start of follow-up had a size of 8.1 mm after 2 years. This is indeed a small average increase in size close to the accuracy by means of which stone size can be measured. But inasmuch as it was stated that 34% of the patients had no stone growth at all it can be concluded that stone size in other patients was slightly increased. Unfortunately there is no information on the stone composition.

These findings suggest that many patients with asymptomatic stones in the kidney might be over-treated and it would indeed be of great interest to see further long-term follow-up studies of conservatively treated patients with and without recurrence preventive treatment.

In this article the authors report on the outcome of SWL and f-URS as recorded in a prospective randomized control study of small (%) were similar in the two groups. These data are in accordance with previous observations. More interesting is that this report also included findings in patients who were left without active stone removal and only followed by observation during 24 months. During that period 5 stones passed spontaneously and 6 patients developed symptoms that had to be dealt with. But overall it was concluded that 88% of the conservatively treated patients had an uneventful course of their disease during the 2 years. Although 2 years is a short period for conclusions on the usefulness of just observing patients with asymptomatic stones this result throws some light on how we need to deal with asymptomatic residual fragments. It is mentioned that stones measuring 8.0 mm at start of follow-up had a size of 8.1 mm after 2 years. This is indeed a small average increase in size close to the accuracy by means of which stone size can be measured. But inasmuch as it was stated that 34% of the patients had no stone growth at all it can be concluded that stone size in other patients was slightly increased. Unfortunately there is no information on the stone composition. These findings suggest that many patients with asymptomatic stones in the kidney might be over-treated and it would indeed be of great interest to see further long-term follow-up studies of conservatively treated patients with and without recurrence preventive treatment.
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