Urolithiasis/Endourology

The Natural History of Nonobstructing Asymptomatic Renal

Stones Managed with Active Surveillance
Benjamin M. Dropkin,* Rachel A. Moses, Devang Sharma and
Vernon M. Pais, Jr.
From the Geisel School of Medicine at Dartmouth, Hanover (BMD, DS, VMP), and Section of Urology, Dartmouth
Hitchcock Medical Center, Lebanon (RAM, VMP), New Hampshire

Purpose: 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.
Materials and 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.

Abbreviations
and Acronyms
ARC asymptomatic
nonobstructing renal calculi
AS active surveillance
BMI body mass index
CT computerized tomography
KUB plain x-ray of the kidneys,
ureters and bladder
Accepted for publication November 10, 2014.
Nothing to disclose.
* Correspondence: 14 Sachem Circle, Apt. 8,
West Lebanon, New Hampshire 03784
(FAX: 518-489-1768; e-mail: Benjamin.m.dropkin.
med@dartmouth.edu).

See Editorial on page 1086.

For another article on a related
topic see page 1409.
Editors Note: This article is the
fourth of 5 published in this issue
for which category 1 CME credits
can be earned. Instructions for
obtaining credits are given with
the questions on pages 1448 and
1449.

Key Words: kidney calculi, asymptomatic diseases,

watchful waiting

THE age controlled prevalence of kidney stones in the United States has
increased markedly from 5.2% in
1994 to 8.4% in 2010.1 Associated
health care costs are estimated at well
over $2 billion annually.2 The proportion of kidney stones that are

asymptomatic nonobstructing renal

calculi found incidentally on unrelated imaging is unknown but is
presumably increasing as the use
of radiologic services continues to
increase.3,4 Therefore, optimizing
management of ARC is paramount to

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THE JOURNAL OF UROLOGY
2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.

http://dx.doi.org/10.1016/j.juro.2014.11.056
Vol. 193, 1265-1269, April 2015
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1265

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NATURAL HISTORY OF ASYMPTOMATIC RENAL STONES

maximizing patient outcomes and minimizing unnecessary stone related spending.

Available literature on active surveillance as a
management strategy for ARC is limited to a small
number of retrospective5e7 and prospective8e10
studies that have reported spontaneous passage
rates of 3% to 20% and intervention rates of 7% to
26%. Keeley et al compared AS to prophylactic
extracorporeal shock wave lithotripsy in patients
with small ARC and found no significant differences
in stone-free rate, quality of life, renal function,
symptoms or hospital admissions between the
2 groups during an average of followup of 2 years.10
However, a policy of observation may ultimately
necessitate the use of more invasive therapies when
compared with prophylactic interventions.
Prior studies have also suggested that lower pole
location and smaller stone size may be protective
against adverse outcomes.5e7 In 2013 the European
Association of Urology issued a grade C recommendation that asymptomatic calyceal stones can
be followed with AS including annual followup
imaging for 2 to 3 years while intervention should
be considered after this period.11 The American
Urological Association has not yet released a
guideline statement on this issue. We documented
the natural history of ARC managed with AS, and
explored predictive factors for stone related events
to add to the existing literature and better inform
shared decision making.

MATERIALS AND METHODS

We retrospectively identified all patients with documented ARC seen by a single surgeon between June 25,
2008 and December 28, 2010 who elected AS of their
stone(s) with routine followup imaging. All patients with
ARC were counseled regarding management options
including AS and possible surgical interventions as
dictated by stone size and location. Our AS protocol consisted of recommended renal ultrasound 6 months after
initial presentation with continued followup renal ultrasound every 6 months in cases of increasing stone size or
burden or every 12 months in cases of stone stability with
the intention to treat if the patient experienced severe
pain attributable to obstruction or silent hydronephrosis.
Patients with at least 6 months of documented followup
were eligible for study inclusion. When possible, we
reviewed documented medical encounters from before
June 25, 2008 to identify the first radiologic observation of
the ARC(s). Patients were not excluded from study based
on a history of stone related intervention(s). However,
asymptomatic stones that were believed to be fragments
from prior stone related intervention were excluded.
CT, ultrasound and KUB images from our institution
and from outside institutions were used as methods of
diagnostic and followup imaging. We collected data on
stone characteristics (size, location, and date and modality of first radiographic visualization for the largest

nonobstructing stone present in each kidney), patient

characteristics (age, BMI at inclusion, gender, and history
of prior stones) and stone related events (elective stone
removal, stone growth, spontaneous passage, development of renal colic defined as ipsilateral abdominal or
flank pain that a medical provider thought was most
likely attributable to nephrolithiasis, development of
silent obstruction, emergency department visits and
surgical intervention for pain). We then compared the
effects of stone size (less than 1 cm, or 1 cm or greater) and
location (upper/mid renal and lower pole) on development
of symptoms, spontaneous passage, requirement for
surgical intervention and stone growth greater than 50%
of initial size using chi-square and bivariate logistic
regression analysis. Patients who electively underwent
intervention without symptoms or in whom silent hydronephrosis developed were included in the natural history
analysis and excluded from the predictive analyses.

RESULTS
Baseline Patient and Stone Demographics
Table 1 presents baseline characteristics of the
entire cohort. We identified 160 stones (84 left and
76 right) with an average size of 7.0
4.2 mm
among 110 patients (60 male and 50 female).
Average patient age was 56
14 years and average
BMI was 30
9 kg/m2. Stones were initially identified using CT (79, 49.4%), ultrasound (78, 48.8%)
or KUB (3, 1.8%). No renal units were lost during
followup.
Natural History of ARC
The supplementary table (http://jurology.com/)
presents the clinical outcomes of our stone cohort.
Overall 115 stones (72% of total) did not cause renal
colic. Eighteen stones (11% of total) were followed
and then treated electively. Notably 3 stones (2% of
total) caused painless silent hydronephrosis necessitating intervention and 45 stones (28% of total) did
cause symptoms. There were 27 stones (17% of
total) that required surgery for renal colic or
symptomatic obstruction, and 33 stones (21% of
total) grew to greater than 50% of their initially
documented size. The majority of these high growth
Table 1. Baseline patient demographics and stone
characteristics
Mean
SD mos followup (range)
Mean
SD pt age (range)
Mean
SD mm initial stone diameter (range)
Mean
SD kg/m2 BMI (range)
No. male (%)
No. stone history (%)
No. multiple stones (%)
No. stone location (%):
Lower pole
Mid calyx
Upper calyx
Renal pelvis

40.6
55.8
7.0
30.0
60
140
122
41
35
81
3

18.6
13.8
4.2
9.3

(7e86)
(19e82)
(1e25)
(17e85)
(55)
(87)
(76)
(25)
(22)
(51)
(2)

NATURAL HISTORY OF ASYMPTOMATIC RENAL STONES

Table 2. Effect of ARC location on clinical outcome

No./Total No.
Lower Pole (%)
Became symptomatic
Spontaneous passage
Required surgical intervention
Growth greater than 50%
of size on first visualization

17/70
2/70
13/70
13/70

(24.3)
(2.9)
(18.6)
(18.6)

No./Total No.
Nonlower Pole (%)
28/69
10/69
14/69
13/69

(40.6)
(14.5)
(20.3)
(18.8)

Table 4. Logistic regression of predictors of symptom

development
p Value
0.047
0.016
0.830
1.000

stones (66% of high growth subgroup) remained

asymptomatic through the end of followup while
2 (6% of high growth subgroup) caused symptoms
requiring surgical management. Twelve stones (8%
of total) passed spontaneously during followup and
22 stones (14% of total) led to hydronephrosis.
Effect of ARC Location and Size on Clinical
Outcome
Table 2 summarizes the effect of ARC location on
clinical outcome. Lower pole stones were significantly less likely than nonlower pole stones to cause
symptoms (24.3% vs 40.6%, p0.047) or to pass
spontaneously (2.9% vs 14.5%, p0.016). We did not
find a significant difference in rates of surgical
intervention or growth to greater than 50% of initial
size between the lower pole and nonlower pole stone
groups. Table 3 summarizes the effect of ARC size
on clinical outcome. We did not find ARC size to be a
predictor of any of our documented clinical outcomes. Table 4 presents our multivariate analysis.
Controlling for age, stone size, stone location, history of stones, multiple stones on first imaging and
stone growth, the only factor independently predictive of symptom development was stone location in
the lower pole. Kaplan-Meier analysis revealed that
lower pole stones were significantly less likely to
require surgical intervention or pass spontaneously
during followup (log rank p 0.04, see figure).

DISCUSSION
In one of the largest retrospective studies to date,
we evaluated the natural history of ARC as well as
the effects of ARC location and size on clinical
outcome. We found that among our cohort of 160
stones with a mean size of 7.0 mm followed for an
average of 41
19 months, 28% of the stones
Table 3. Effect of ARC size on clinical outcome
No./Total No.
No./Total No.
Less than 10 mm 10 mm or Greater
(%)
(%)
p Value
Became symptomatic
Spontaneous passage
Required surgical intervention
Growth greater than 50%
of size on first visualization

36/116
11/116
19/116
23/116

(31.0)
(9.5)
(16.4)
(19.8)

9/23
1/23
8/23
3/23

(39.1)
(4.3)
(34.8)
(1.3)

1267

0.471
0.690
0.079
0.568

Age:
20e34
35e49
50e64
65e85
Female
Stones larger than 1 cm
Lower pole stone
History of stones
Multiple stones
Stone growth greater than 50%

OR

CI: Lower

CI: Upper

1.00
0.34
0.35
0.92
1.26
1.35
0.34
0.51
1.19
0.46

0.06
0.08
0.35
0.51
0.36
0.14
0.19
0.32
0.12

2.00
1.52
2.40
3.12
5.02
0.81
1.36
4.34
1.73

p Value
0.38

0.61
0.66
0.02
0.18
0.80
0.25

became symptomatic with 17% requiring surgical

intervention. The only significant predictor of
spontaneous passage or symptom development was
stone location.
In one of the first retrospective reviews of ARC
Glowacki et al examined 107 ARC with an average
followup of 31.6 months, and found that ARC were
more likely to remain asymptomatic than to cause
symptoms (68% vs 34%), with 17% of the total
cohort requiring surgery.6 While there was a trend
for higher stone related events in patients with
previous stone events, multiple stones at study
initiation and larger stones, none of these associations were statistically significant. Similarly, these
characteristics were not predictive of stone migration in our cohort (table 4). In contrast to our study
Glowacki et al did not evaluate stone location as a
predictor of stone events.6
More recently Koh et al examined a cohort of 85
stones with a mean size of 5.7 mm followed for an
average of 46 months, and found that 20% passed
spontaneously and 7% required surgical intervention.7 Similarly we found that 28% of our cohort
exhibited symptomatic stone migration with 8%
passing spontaneously and 17% requiring surgical
intervention for symptomatic obstruction. Koh et al
also examined the effect of stone size on clinical
outcome, and found that rates of spontaneous passage for stones less than 5 mm were higher than for
stones 5 to 10 mm and stones greater than 10 mm
(28%, 5% and 0%, p not reported).7 They also found
a trend for larger stones to necessitate surgical
intervention more frequently (rates for stones less
than 5 mm, 5 to 10 mm and greater than 10 mm
were 5%, 10% and 14%, respectively, p0.477) and
to progress clinically (rates of progression for stones
less than 5 mm, 5 to 10 mm and greater than 10 mm
were 40%, 52% and 71%, respectively, p0.282).
While neither the study by Koh et al nor our study
revealed statistically significant relationships
between stone size and the need for surgical intervention, both studies suggest that larger stones are
more likely to require surgical intervention, and

NATURAL HISTORY OF ASYMPTOMATIC RENAL STONES

1.0

1268

Time to Event

0.0

0.2

0.4

Survival
0.6

0.8

NonLower Pole
Lower Pole

20

40

60

80

Time (Months)

Kaplan-Meier survival analysis of stone location in predicting probability of not having intervention or spontaneous passage of initially
asymptomatic stones.

both may have reached this conclusion with larger

stone cohorts.
In contrast to our study Koh et al found no statistically significant relationship between stone
location and migration.7 However, lower pole stones
in their series were less likely than middle or upper
pole stones to pass spontaneously (11.5% vs 16.2%
vs 36.4%, p0.092). While an important study, their
series included only 85 stones, which likely
impacted their ability to demonstrate significant
differences between groups.
Burgher et al studied a cohort of 300 patients
with a mean stone size of 10.8 mm followed for an
average of 39 months.5 In contrast to our study,
they found that the majority of ARC (77%) progressed clinically (stone growth, pain or need for
surgical intervention). Burgher et al did not look at
stone location as a predictor of stone migration.5
They did find that lower pole stones were significantly more likely than mid and upper pole stones
to grow during followup (61% vs 47%, p 0.002).
Conversely we found no association between stone
location and growth rate. Burgher et al also found
initial ARC size to be predictive of progression with
stones 4 mm or greater on presentation being 26%
more likely to fail observation than smaller stones
(p 0.012).5 Although not significant, we also found
that larger stones were more likely to fail active
surveillance and require surgical intervention
(34.8% vs 16.4%, p0.079) with our AS protocol.
In contrast to the studies by Koh7 and Burgher5
et al, previous studies have singularly evaluated

management strategies for lower pole ARC. Yuruk

et al randomized 94 patients with asymptomatic
lower pole stones to observation or shock wave
lithotripsy and followed them for an average of
19
5 months.9 Of the 34 stones managed with
observation 22% had symptoms due to spontaneous
passage (3.1%) or required surgical intervention
(19%). Similar to our cohort, the majority of the
observed lower pole stones (greater than 80%) in
their study remained asymptomatic through the
end of followup.
Inci et al evaluated 27 lower pole ARC with a
mean size of 8.8 mm followed for an average of
52 months.8 They found that 33% progressed (stone
growth, pain or need for surgical intervention) and
11% required surgical intervention. The findings of
these prior asymptomatic stone cohorts are echoed
in our survival analysis which shows that lower pole
stones were less likely to have an event during our
comparable followup period (see figure).
Additionally, Raman and Pearle conducted a
meta-analysis seeking optimum management of
lower pole calculi.12 Their study revealed that lower
pole stones larger than 2 cm treated with percutaneous nephrolithotomy had less morbidity. However, consistent with our study, they also concluded
that lower pole stones less than 1 cm may be
observed with equivalent morbidity outcomes as
shock wave lithotripsy and ureteroscopy with laser
lithotripsy. They also found observation to have
the least cost and surgical risk among available
management stratgeies.12

NATURAL HISTORY OF ASYMPTOMATIC RENAL STONES

Importantly we also found that 2% of our stone

cohort caused asymptomatic hydronephrosis detected on routine imaging and was subsequently
treated surgically. The decision was made to exclude
these individuals from the statistical analysis as we
wanted to specifically identify which patients may
use health care resources for symptomatic stones.
However, the possibility of the development of silent
hydronephrosis supports the role of continued followup for patients with ARC.
This retrospective study had several important
limitations. Almost half of the stones in our cohort
had size initially evaluated on renal ultrasound,
which is less reliable than CT or KUB for estimating stone size. Patients who were excluded from
study due to a lack of 6 months of followup may
have sought treatment elsewhere or remained
asymptomatic. Some patients chose to treat
asymptomatic stones after initially electing active
surveillance so we cannot know how these stones
would have fared if left untreated. Finally, some
patients may have been considered symptomatic

1269

from a renal stone when in fact the symptoms were

due to another cause of pain such as gastrointestinal or other genitourinary or musculoskeletal
pathology.

CONCLUSIONS
Among our cohort of 160 ARC managed with active
surveillance about 60% remained asymptomatic
through an average followup of more than 3 years,
while 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 than stones outside of the lower pole to
cause symptoms or pass spontaneously. Our results
were generally consistent with the findings of prior
studies. Despite 3 stones causing silent obstruction,
regular followup imaging facilitated interventions
that prevented renal loss. These data can help
patients and providers make informed decisions
regarding the management of asymptomatic nonobstructing renal stones.

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2. Pearle MS, Calhoun EA, Curhan GC et al:

Urologic diseases in America project: urolithiasis. J Urol 2005; 173: 848.

6. Glowacki LS, Beecroft ML, Cook RJ et al:

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