Yamashita S et al, 2017: Upper urinary tract stone disease in patients with poor performance status: active stone removal or conservative management?
Yamashita S, Kohjimoto Y, Hirabayashi Y, Iguchi T, Iba A, Higuchi M, Koike H, Wakamiya T, Nishizawa S, Hara I.
Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayaka, 641-0012, Japan. Department of Urology, Hashimoto Municipal Hospital, 2-8-1 Ominedai, Hashimoto City, Wakayama, 648-0005, Japan.
Department of Urology, Kinan Hospital, 46-70 Shinjyo, Tanabe City, Wakayama, 646-8588, Japan.
Department of Urology, Rinku General Medical Center, 2-23 Rinkuouraikita, Izumisano City, Osaka, 598-8577, Japan.
BACKGROUND: It remains controversial as to whether active stone removal should be performed in patients with poor performance status because of their short life expectancy and perioperative risks. Our objectives were to evaluate treatment outcomes of active stone removal in patients with poor performance status and to compare life prognosis with those managed conservatively.
METHODS: We retrospectively reviewed 74 patients with Eastern Cooperative Oncology Group performance status 3 or 4 treated for upper urinary tract calculi at our four hospitals between January 2009 and March 2016. Patients were classified into either surgical treatment group or conservative management group based on the presence of active stone removal. Stone-free rate and perioperative complications in surgical treatment group were reviewed. In addition, we compared overall survival and stone-specific survival between the two groups. Cox proportional hazards analysis was performed to investigate predictors of overall survival and stone-specific survival.
RESULTS: Fifty-two patients (70.3%) underwent active stone removal (surgical treatment group) by extracorporeal shock wave lithotripsy (n = 6), ureteroscopy (n = 39), percutaneous nephrolithotomy (n = 6) or nephrectomy (n = 1). The overall stone-free rate was 78.8% and perioperative complication was observed in nine patients (17.3%). Conservative treatment was undergone by 22 patients (29.7%) (conservative management group). Two-year overall survival rates in surgical treatment and conservative management groups were 88.0% and 38.4%, respectively (p < 0.01) and two-year stone-specific survival rates in the two groups were 100.0% and 61.3%, respectively (p < 0.01). On multivariate analysis, stone removal was not significant, but was considered a possible favorable predictor for overall survival (p = 0.07). Moreover, stone removal was the only independent predictor of stone-specific survival (p < 0.01).
CONCLUSIONS: Active stone removal for patients with poor performance status could be performed safely and effectively. Compared to conservative management, surgical stone treatment achieved longer overall survival and stone-specific survival.
BMC Urol. 2017 Nov 16;17(1):103. doi: 10.1186/s12894-017-0293-4.
It is of no surprise that survival was higher in patients who were actively treated. This is particularly obvious for patients with ureteral stones.
In view of the retrospective character of the study it is difficult to draw conclusions, because the grounds for referring patients to conservative treatment are not clear and obviously made without strict criteria.
That patients with pyelonephritis, most commonly found during conservative treatment, had a less favourable survival might also be expected.
How the authors came to the conclusion that URS is preferable to SWL is difficult to understand given that only 6 patients were treated with SWL compared with 39 patients treated with URS.
Overall the number of complications was low and intuitively the recommendation should be to remove stones actively also in patients with poor performance status, particularly when the stones are located in the ureter. Unfortunately, without a strict randomization there is little solid evidence for such a conclusion.