Patient decision making for asymptomatic renal calculi: balancing benefit and risk

Abstract

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.