When surgeons remove patients’ kidney stones, they typically leave behind small stones that don’t seem to cause any problems.
However, a new randomized controlled study showed that leaving these asymptomatic stones significantly increases a patient’s risk of a relapse in the following five years. The findings were published today in the New England Journal of Medicine.
Generally, stones under 6 mm in diameter that are not the primary target of a procedure are not removed, but monitored, because “secondary” stones have high rates of successful passage when they move into the ureter, he said. lead author Dr. Mathew Sorensen, a urologist at the University of Washington School of Medicine.
Before this study, clinical opinions were quite mixed about whether some of these stones should be treated. Most clients would decide, based on the size of the stone, whether it hit the bar for treatment, and if it didn’t, you’d often ignore the small stones.”
Dr. Mathew Sorensen, Urologist, University of Washington School of Medicine
The researchers examined the 75 patients who were treated in multiple institutions over a span from 2015 to 2021. About half of the patients had only their large primary stone treated, while the others had primary and secondary stones removed. Relapse was defined as having to go to the emergency room or undergo an additional procedure due to a recurrence or if a follow-up CT scan revealed that the secondary stones were growing.
Removing the secondary stones reduced the recurrence rate by 82%, the researchers found, leading the authors to recommend that smaller stones should not be left behind.
“Results of our trial support the removal of small asymptomatic renal stones at the time of surgery with a larger stone,” their paper concluded. The authors noted that while removing smaller stones could add to the duration and cost of the procedure, those costs are likely to be less than those associated with a patient’s repeat procedure or emergency room visit. Some patients in the study visited the emergency department multiple times and then required surgery, the report noted.
Sorensen said he would share the study results with colleagues in hopes of changing their sensitivity to smaller stones. Further study is needed to determine whether treatment of small stones alone is justified, as technology improves and reduces the costs and risks of intervention, he said.
“I think we have proven through this rigorous study that removing the small asymptomatic stones is beneficial when possible and in patients who are candidates to treat all their stones in one procedure,” he noted. “Leaving the stones behind risks problems in the future.”
The study received funding from the National Institute of Diabetes and Digestive and Kidney Diseases and the Veterans Affairs Puget Sound Health Care System.
Sorensen, MD, and others. (2022) Removal of small, asymptomatic kidney stones and incidence of recurrence. New England Journal of Medicine. doi.org/10.1056/NEJMoa2204253.
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