Sarkissian C et al, 2013: Patient decision making for asymptomatic renal calculi: balancing benefit and risk
Sarkissian C, Noble M, Li J, Monga M
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
OBJECTIVE: To evaluate which variables affect patients' decisions on the management of asymptomatic renal calculi.
MATERIALS AND METHODS: We hypothesized that patients who had experienced greater pain, passed larger or more stones, or passed stones more recently would be more likely to choose surgical intervention (ureteroscopy [URS] or shock wave lithotripsy [ESWL]) instead of observation (OBS). The survey was distributed to 101 patients in our stone clinic. The patients were given a hypothetical scenario of an asymptomatic 8-mm lower pole stone and descriptions for OBS (annual radiography, 40% chance of growth >10 mm within 4 years, 20% chance of passage), ESWL (65% success rate), and URS (90% success rate, with stent placement for 1 week). The patients were also asked whether they would rather defer the decision to their physician.
RESULTS: Of the patients, 22.8% chose OBS, 29.7% chose URS, and 47.5% chose ESWL. The patients who had passed larger stones (P = .029) were less likely to choose OBS over surgery. Of the 78 patients who chose intervention, 61.5% preferred ESWL. The patients were more likely to choose URS if they had previously undergone URS (P = .0064) and stent placement (P = .048), and the patients were more likely to choose ESWL if they had a previously undergone ESWL (P = .019). Surgical choice was not affect by size of the largest stone passed (P = .46), date of last passage (P = .080), previous pain intensity (P = .11), previous percutaneous nephrolithotomy (P = .73), or number of stones passed (P = .51). Finally, 56.4% of patients deferred the decision of the treatment approach to the physician.
CONCLUSION: Previous stone experience and treatment significantly affected treatment choice. Patients rely on their physician to educate them on the alternatives and play an active role in selecting the treatment approach.
Urology. 2013 Feb;81(2):236-40. doi: 10.1016/j.urology.2012.10.032
PMID:23374767 [PubMed - indexed for MEDLINE]
It is interesting to note that in this survey carried out in 101 patients presented the same hypothetical scenario, most patients (47.5%) chose SWL. This outcome was achieved despite the fact that the patients were informed about the local restrictive use of SWL. That stones in the kidney growing to a size of >10 mm and the stones passing to the ureter would exclude SWL is not generally accepted. Neither is it understood why patients need to refrain from physical activities during a 2-week period following the SWL session. It has been my own assumption that physical activity immediately after SWL improves stone clearance. But the mentioned prerequisites provided the background against which the patients had to make their decision.
Not unexpectedly did those patients who had experience of stone removing procedures give preference to the same technology. Another important observation was that more than half of the patients would follow the advice given by the physician. With information that SWL can be carried out without general anaesthesia (at least outside USA) and that ureteral stones are an excellent indication for SWL, it is likely that even more patients would have chosen the non-invasive treatment or a conservative option.