title: The natural history of nonobstructing asymptomatic renal stones managed with active surveillance.
abstract: OBJECTIVE
  We documented the natural history of asymptomatic nonobstructing renal calculi managed with active surveillance and explored factors predicting stone related events to better inform shared decision making.
  
  
  METHODS
  Patients with asymptomatic nonobstructing renal calculi electing active surveillance of their stone(s) were retrospectively reviewed. Stone characteristics, patient characteristics, and stone related events were collected. We evaluated the effects of stone size and location on development of symptoms, spontaneous passage, requirement for surgical intervention, and stone growth.
  
  
  RESULTS
  We identified 160 stones with an average size of 7.0 ± 4.2 mm among 110 patients with average followup of 41 ± 19 months. Forty-five (28% of total) stones caused symptoms during followup. Notably 3 stones (3% of asymptomatic subgroup, 2% of total stones) caused painless silent obstruction necessitating intervention after an average of 37 ± 17 months. The only significant predictor of spontaneous passage or symptom development was location. Upper pole/mid renal stones were more likely than lower pole stones to become symptomatic (40.6% vs 24.3%, p = 0.047) and to pass spontaneously (14.5% vs 2.9%, p = 0.016).
  
  
  CONCLUSIONS
  Among asymptomatic nonobstructing renal calculi managed with active surveillance, most remained asymptomatic through an average followup of more than 3 years. Less than 30% caused renal colic, less than 20% were operated on for pain and 7% spontaneously passed. Lower poles stones were significantly less likely to cause symptoms or pass spontaneously. Despite 3 stones causing silent hydronephrosis suggestive of obstruction, regular followup imaging facilitated interventions that prevented renal loss.
authors.affiliation: Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Electronic address: Benjamin.m.dropkin.med@dartmouth.edu.
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Dropkin
authors.affiliation: Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Moses
authors.affiliation: Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
authors.forename: Devang
authors.initials: D
authors.lastname: Sharma
authors.affiliation: Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Vernon M
authors.initials: VM
authors.lastname: Pais
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D058070:Asymptomatic Diseases; D005260:Female; D006801:Humans; D007669:Kidney Calculi / Q000175:diagnosis* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D057832:Watchful Waiting; D055815:Young Adult
keywords: asymptomatic diseases; kidney calculi; watchful waiting