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Grand Rounds

RCT Results: Should Small Asymptomatic Kidney Stones be Surgically Removed or Observed?

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BACKGROUND AND PURPOSE:

  • Small (≤6 mm), asymptomatic kidney stones may be removed surgically or managed conservatively 
  • Sorensen et al. (NEJM, 2022) sought to determine whether small kidney stone removal vs observation result in in fewer relapses

METHODS:

  • Multicenter, randomized, controlled trial
  • Participants
    • Scheduled for endoscopic surgical treatment of a primary stone
  • Interventions
    • Removal of small, asymptomatic secondary stones
    • No removal (control)
  • Primary outcome
    • Relapse: Future emergency department visits, surgeries, or growth of secondary stones

RESULTS:

  • Removal group: 38 patients | Control group: 35 patients
    • Mean follow-up: 4.2 years
  • The treatment group had a longer time to relapse than the control group
    • P<0.001
  • The restricted mean time to relapse was 75% longer in the treatment group than in the control group
    • Removal group: 1631.6 days
    • Control group: 934.2 days
  • The risk of relapse was 82% lower in the treatment group than the control group
    • Removal group: 16% relapsed
    • Control group: 63% relapsed
    • Hazard ratio (HR) 0.18 (95% CI, 0.07 to 0.44)
  • Additional surgery time in the removal group
    • 25.6 (IQR, 18.5 to 35.2) minutes
  • Adverse events
    • Emergency department visits within 2 weeks of surgery
      • Removal group: 5 patients
      • Control group: 4 patients
    • Patient reported passing kidney stones
      • Removal group: 8 patients
      • Control group: 10 patients

CONCLUSION:

  • For patients undergoing endoscopic removal of primary kidney stones, removing small, secondary, asymptomatic stones at the time of surgery reduced the risk of relapse, and lengthened the time to relapse
  • Additional surgery time for the treatment group was minimal
  • The authors state

Results of our prospective, randomized trial support removal of small, asymptomatic renal stones at the time of surgery to remove a symptomatic stone

The additional 25 minutes needed to remove small, asymptomatic renal stones at the time of surgery for a primary stone (extending the procedure by 38%) should be weighed against the potential need for repeat surgery in the 63% of patients who had a relapse

Learn More – Primary Sources:

Removal of Small, Asymptomatic Kidney Stones and Incidence of Relapse

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Related ObG Topics:

Kidney Stones: Diagnosis, Work Up and Management
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