Women's Health

Removing other small kidney stones may reduce relapses


August 17, 2022 – If you’re having surgery to remove a kidney stone and doctors find other smaller stones nearby, it’s safest to go ahead and have them all removed at once, according to a new study.

According to a small randomized study published on August 10 in TheNew England Journal of Medicine.

“The question of whether removal of small, asymptomatic kidney stones is a common surgical decision that currently lacks specific guidelines,” wrote Mathew D. Sorensen, MD, of Washington University School of Medicine in St. Louis. , and his colleagues. The debate “has even extended to duel editorials from experts in the field”.

The new study results add “to a growing body of evidence” that supports the simultaneous elimination of all known kidney stones, they wrote.

In an editorial published alongside the study, David S. Goldfarb, MD, wrote that the tools used by doctors to remove stones have become smaller and more flexible, helping to make these types of procedures more effective. .

The findings are important because “there is a high likelihood that ‘silent’ stones will become symptomatic,” and removing them early is better for the patient’s health and wallet, said Goldfarb, of the Port Veterans Health System. of New York and the NYU Grossman School. of medicine in New York.

Additionally, “patients who have had symptomatic stones often recall distressing emergency room visits and fear a lack of appropriate pain relief.”

“One can imagine,” Goldfarb said, “that elective withdrawal may allow these patients to avoid pain and trauma, ineffective and costly emergency room visits, infections, receiving pain medications, and studies. additional imagery.”

Additional surgery takes 25 minutes longer, but saves money in the long run

Sorensen and colleagues recruited patients 21 years of age and older who were scheduled for endoscopic surgery for a primary kidney or ureteric stone in major US urban centers from May 2015 to May 2020.

Scans showed the patients also had at least one other small kidney stone that was not causing symptoms.

Thirty-eight patients had secondary stones removed (treatment group) and 35 patients did not (control group).

After 4 years, six of 38 patients (16%) in the treatment group and 22 of 35 patients (63%) in the control group had a relapse – that is, a future emergency room visit, surgery or growth of secondary stones.

The risk of relapse was 82% lower in the treatment group compared to the control group.

The time to relapse was also 75% longer in the treatment group than in the control group (4.5 years versus 2.6 years).

Treatment of the secondary stones added approximately 25 minutes to the operating time.

“The additional 25 minutes required to remove small, asymptomatic kidney stones at the time of surgery for a primary stone…should be weighed against the potential need for repeat surgery in the 63% of patients who had a relapse,” Sorensen and colleagues wrote.

Questions remain, possible future non-surgical approaches

The researchers acknowledged that the study was relatively small and that few patients were non-white.

Several questions remain, according to Goldfarb.

He wondered if general urologists would be as capable as endourologists – the specialists who performed the procedure in this study; whether the procedure can be applied to secondary stones larger than 6 millimetres; and whether the number of secondary stones affects the time of surgery.

Only about 25% of patients in both groups were prescribed preventative drugs, he also noted, and greater use of these may have altered the results.

“Finally, and more provocatively,” Goldfarb asked, “when should asymptomatic stones be removed endoscopically?

“Asymptomatic stones are frequently identified and, more often than not, surgery is not recommended,” he noted.

“An alternative to preventative surgery,” he suggested, “would be to finally figure out how to get these little stones to break loose and pass spontaneously.”

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