Asymptomatic Renal Stones—to Treat or Not to Treat

  • Necole M. Streeper
Endourology (P Mucksavage, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Endourology


Purpose of Review

There are no current guidelines on the optimal management of asymptomatic renal stones. This review summarizes the current literature, focusing on more recent studies that have been done to grow the body of evidence on this topic.

Recent Findings

Recent studies have found that stone size is a significant predictor of need for future surgical intervention, with > 7 mm for pediatric population and > 4 mm for residual fragments after both PNL and ureteroscopy (URS). The role of URS has been better defined with a recent RCT concluding that URS and SWL had comparable outcomes for an asymptomatic lower pole stone < 1 cm.


The treatment decision for asymptomatic renal stones should take into consideration a variety of relevant patient and stone factors; however, ultimately, a shared decision-making approach should be used. In the properly counseled patient, active surveillance or prophylactic surgical intervention may be appropriate.


Renal stones Treatment Asymptomatic Observation Residual fragments 


Compliance with Ethical Standards

Conflict of Interest

Necole M. Streeper declares no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the author.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Scales CD, Smith AC, Hanley JM, Saigal CS. Urologic diseases in America project. Prevalence of kidney stones in the United States. Eur Urol. 2012;62(1):160–5.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Pearle MS, Calhoun EA, Curhan GC. Urologic diseases in America project: urolithiasis. J Urol. 2005;173:848–57.CrossRefPubMedGoogle Scholar
  3. 3.
    Boyce CJ, Pickhardt PJ, Lawrence EM, Kim DH, Bruce RJ. Prevalence of urolithiasis in asymptomatic adults: objective determination using low dose noncontrast computerized tomography. J Urol. 2010;183:1017–21.CrossRefPubMedGoogle Scholar
  4. 4.
    • Dropkin BM, Moses RA, Devang S, Pais VM Jr. The natural history of nonobstructing asymptomatic renal stones managed with active surveillance. J Urol. 2015;193:1265–9. Retrospective review of 110 patients with 160 renal stones, 72% remained asymptomatic with average follow up of over 3 years CrossRefPubMedGoogle Scholar
  5. 5.
    Glowacki LS, Beecroft ML, Cook RJ, Pahl D, Churchill DN. The natural history of asymptomatic urolithiasis. J Urol. 1992;147(2):319–21.CrossRefPubMedGoogle Scholar
  6. 6.
    Kang HW, Lee SK, Kim WT, Kim YJ, Yun SJ, Lee SC, et al. Natural history of asymptomatic renal stones and prediction of stone related events. J Urol. 2013;189(50):1740–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Koh LT, Ng FC, Ng KK. Outcomes of long-term follow-up of patients with conservative management of asymptomatic renal calculi. BJU Int. 2012;109:622–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Burgher A, Beman M, Holtzman JL, Monga M. Progression of nephrolithiasis: long-term outcomes with observation of asymptomatic calculi. J Endourol. 2004;18:534–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Goldsmith ZG, Lipkin ME. When (and how) to surgically treat asymptomatic renal stones. Nat Rev Urol. 2012;9:315–20.CrossRefPubMedGoogle Scholar
  10. 10.
    • Telli O, Hamidi N, Bagci U, Demirbas A, Hascicek AM, Soygur T, et al. What happens to asymptomatic lower pole kidney stones smaller than 10 mm in children during watchful waiting? Pediatr Nephrol. 2017;32(5):853–7. Retrospective review of 242 pediatric patients with asymptomatic lower pole renal stones < 10 mm in size, estimated stone progression rate of 61.2%. Stone size > 7mm, renal anomalies, and cystine or struvite composition were statistically significant predictors of need for future surgical intervention CrossRefPubMedGoogle Scholar
  11. 11.
    • Dos Santos J, Lopes RI, Veloso AO, Harvey E, Farhat WA, Papanikolaou F. Outcome analysis of asymptomatic lower pole stones in children. J Urol. 2016;195:1289–93. Retrospective review of 224 pediatric patients, reported a 53.6% rate of spontaneously passed stones, 25% remained asymptomatic and 21.4% ultimately required surgical intervention CrossRefPubMedGoogle Scholar
  12. 12.
    Assimos D, Krambeck A, Miller NL, Monga M, Murad MH, Nelson CP, et al. Surgical management of stones: American Urological Association/Endourological Society guideline. J Urol. 2016;196(4):1153–69.CrossRefPubMedGoogle Scholar
  13. 13.
    Inci K, Sahin A, Islamoglu E, Eren MT, Bakkaloglu M, Ozen H. Prospective long-term followup of patients with asymptomatic lower pole caliceal stones. J Urol. 2007;177:2189–92.CrossRefPubMedGoogle Scholar
  14. 14.
    Raman JD, Pearle MS. Management options for lower pole renal calculi. Curr Opin Urol. 2008;18(2):214–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Omar M, Tarplin S, Brown R, Sivalingam S, Monga M. Shared decision making: why do patients choose ureteroscopy? Urolithiasis. 2016;44(2):167–72.CrossRefPubMedGoogle Scholar
  16. 16.
    Sarkissian C, Noble M, Li J, Monga M. Patient decision making for asymptomatic renal calculi: balancing benefit and risk. Urology. 2013;81:236–40.CrossRefPubMedGoogle Scholar
  17. 17.
    Turk C, Petrik A, Sarica K, Seitz C, Skolarikos A, Straub M, et al. EAU guidelines on diagnosis and conservative management of urolithiasis. Eur Urol. 2016;69(3):468–74.CrossRefPubMedGoogle Scholar
  18. 18.
    Skolarikos A, Laguna MP, Alivizatos G, Kural AR, de la Rosette JJ. The role for active monitoring in urinary stones: a systematic review. J Endourol. 2010;24(6):923–30.CrossRefPubMedGoogle Scholar
  19. 19.
    Pearle MS, Goldfarb DS, Assimos DG, Curhan G, Denu-Ciocca CJ, Matlaga BR, et al. Medical management of kidney stones: AUA guideline. J Urol. 2014;192:316–24.CrossRefPubMedGoogle Scholar
  20. 20.
    Yuruk E, Binbay M, Sari E, Akman T, Altinyay E, Baykal M, et al. A prospective randomized trial of management for asymptomatic lower pole calculi. J Urol. 2010;183(4):1424–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Keely FX Jr, Tilling K, Elves A, Menezes P, Wills M, Rao N, et al. Preliminary results of a randomized controlled trail of prophylactic shock wave lithotripsy for small asymptomatic renal calyceal stones. BJU Int 2001; 87 (1): 1–8.Google Scholar
  22. 22.
    •• Sener NC, Bas O, Sener E, Zengin K, Ozturk U, Altunkol A, et al. Asymptomatic lower pole small renal stones: shock wave lithotripsy, flexible ureteroscopy or observation? A prospective randomized trail. Urology. 2015;85:33–7. RCT randomizing patients with asymptomatic single lower pole stones <1cm to ureteroscopy, shockwave lithotripsy, and observation. The stone free rate for URS was 92% and 90% for SWL after an average of 1.48±0.65 sessions. Observation group had a 12% rate of stone progression over 2 year follow-up CrossRefPubMedGoogle Scholar
  23. 23.
    • Olvera-Posada D, Ali SN, Dion M, Alenezi H, Denstedt JD, Razvi H. Natural history of residual fragments after percutaneous nephrolithotomy: evaluation of factors related to clinical events and intervention. Urology. 2016;97:46–50. Retrospective review of 44 out of 781 patients with residual fragments after PNL. Residual fragments > 4mm, and struvite or apatite composition, were associated with higher likelihood to require surgical intervention during mean follow up of 57.9 months CrossRefPubMedGoogle Scholar
  24. 24.
    • Chew BH, Brotherhood HL, Sur RL, Wang AQ, Knudsen BE, Yong C, et al. Natural history, complications, and re-intervention rates of asymptomatic residual stone fragments after ureteroscopy: a report from the EDGE Research Consortium. J Urol. 2016;195:982–6. A multicenter retrospective review of the natural history of asymptomatic residual fragments following ureteroscopy, including 232 patients. They reported that 56% of patients remained asymptomatic with a mean follow up of 16.8 months. 29% of patients required a secondary procedure. In addition, they concluded that residual fragment size > 4mm after ureteroscopy was associated with significantly higher rate of stone growth and need for re-intervention CrossRefPubMedGoogle Scholar
  25. 25.
    Rebuck DA, Macejko A, Bhalani V, Ramos P, Nadler RB. The natural history of renal stone fragments following ureteroscopy. Urology. 2011;77(3):564–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of UrologyPenn State Milton S. Hershey Medical CenterHersheyUSA

Personalised recommendations