Study identifies optimal ureteral colic patients for early surgical intervention

December 17, 2020
Jason M. Broderick

Existing evidence does not clarify which patients with acute ureteral colic would benefit most from early surgical intervention.

Research published in the Journal of Urology identified the ideal patient population to receive early surgical intervention for acute ureteral colic.1

Using multivariable regression of patient data, the researchers concluded that “Early intervention improves outcomes for patients with large (>7 mm) ureteral stones or 5 to 7 mm proximal or mid ureteral stones.” However, the authors also noted that, “Early intervention may increase morbidity for patients with stones smaller than 5 mm.”

Using administrative data and structured chart review, the researchers compiled a study population of 3081 patients with acute ureteral colic. The patients had been seen at 9 emergency departments across 2 Canadian provinces and underwent either early surgical intervention (n = 1168) or spontaneous passage (n = 1913). All patients had confirmed ureteral stones with a width of 2 to 9.9 mm.

The mean age in the spontaneous passage arm was 49.7 years, 73.2% were male, and 44.5% had a kidney stone. The median stone width was 3.6 mm. The percentage of patients with small (<5 mm), medium (5-6.9 mm), and large (7-9.9 mm) stones was 76.4%, 19%, and 4.6%, respectively. Overall, 73.1% of patients had distal stones, and 26.9% of patients had proximal or middle stones. Incidence of hydronephrosis included none (14.7%), mild (57.6%), moderate (25.7%), and severe (2%). Across the subgroup, 58.7% of patients had stranding (edema).

In the early intervention arm, the mean age was 51.9 years, 67.4% were male, and 53.5% had a kidney stone. The median stone width was 5 mm. The percentage of patients with small, medium, and large stones was 40%, 38.5%, and 21.5%, respectively. Overall, 50.4% of patients had distal stones, and 49.6% of patients had proximal or middle stones. Incidence of hydronephrosis included none (8.8%), mild (43.1%), moderate (41.8%), and severe (6.3%). Across the subgroup, 58.9% of patients had stranding (edema).

These data showed that, “Intervention patients were older, more often female, and had larger more proximal stones with more prominent hydronephrosis,” the authors wrote.

The primary outcome measure for the study was treatment failure, which the trial design defined as the need for intervention or hospitalization within 60 days. The key secondary outcome measure was emergency department revisit rate.

Among the group with stones ≥7 mm, 34.7% of patients with early intervention experienced treatment failure compared with 58.6% with spontaneous passage (risk difference, 23.9%). Emergency department revisit rates were similar in the large stone group, regardless of whether or not a patient received early intervention.

In patients with medium-sized stones of 5 to 6.9 mm in width, those receiving early intervention had a lower treatment failure rate than those in the spontaneous passage group, at 37.4% versus 55.5% (risk difference, 18.1%) respectively, if the stones were located in the proximal or middle ureter.

In contrast, early intervention led to more treatment failures and emergency department visits versus spontaneous passage in patients with stones <5 mm in width. The treatment failure rates and emergency department visit rates were 31.5% versus 9.9 and 38.5% versus 19.7%, respectively.

“Our recommendations apply as an initial approach to patients with ureteral colic, and not to those already failing a trial of passage. Future studies should assess the impact of ureteral stents in stone subgroups, the modifying effects of pharmacological treatments, as well as cost-effectiveness and patient reported outcomes for patients having early intervention versus spontaneous passage,” the authors wrote in their conclusion.

Reference

1. Innes GD, Scheuermeyer FX2, McRae AD, et al. Which patients should have early surgical intervention for acute ureteral colic? J Urol. 2021;205(1):152-158. doi: 10.1097/JU.0000000000001318