Imagine this: It’s the middle of the night and the pain is horrific. It’s 10 out of 10 in severity and it grabs and stabs you at the side of your back. The doctor in the Emergency Department tells you that it might be a kidney stone and a CT scan confirms her suspicion. She gives you pain medications that work for a while. You are discharged home, “in a stable condition.” She tells you to see the urologist the next day, at his office, first thing in the morning.

The following day, at his office, the urologist wears a serious expression. He looks at the images taken the night before and declares, “You have an obstructing stone in your ureter. The stone blocks the passage of urine. It’s too big to pass on your own. We can give it a chance to pass, but, to be honest, the stone is quite big, 9 millimeters. It looks like it’s stuck pretty well, and the chance it will pass on its own is slim. If I were you, I would just want it out, and the sooner the better.”

Now, the pain returns with a vengeance. The doctor says, “The pain is unbearable, I know. Women who delivered babies tell me that the pain from a stone is much worse.” You nod in agreement.

The doctor tells you how the surgery will be performed. “There will be no incision,” he says, “We are going to pass a small-caliber scope, a tiny video camera, through your urethra (the tube through which you pee), into your bladder, and then up to your ureter. We will see the whole thing, as we go, on a high-resolution, large screen, as if we were watching a football game on the TV, and when we reach the stone, we will break it with a laser fiber–it’s like a miniature hammer chiseling a rock. We will dust the stone and break it. And we will remove the fragments, one by one, using a miniature basket.”

He says, “There is one more decision we need to make.” There are three more stones inside your kidney, above the stone in your ureter. These are smaller stones that, if they start moving, will most likely pass on their own, but they can also get larger, or pass into the ureter and cause an obstruction the way the stone that currently blocks you does. We need to decide whether to remove these as well.”

And he keeps going, “On one hand, if we are already there, doing surgery, why wouldn’t we take out the smaller stones as well? On the other hand, it will make the procedure longer, and perhaps, we just don’t know, it might result in a higher rate of complications. And if these smaller stones are destined to pass on their own, why fix what isn’t broken?”

This a dilemma. How can patients and their doctors make up their minds in situations like this? How can they make the right decision? One option is to rely on the doctor’s own experience which may, at times, be either insufficient or biased. A better way is to conduct research.

Michael D. Sorensen from the Department of Urology, at the University of Washington School of Medicine and his colleagues attempted to answer this question in an article published in the New England Journal of Medicine on August 11, 2022.

The researchers collected information on 73 patients with a ureteral stone and, in addition, several small kidney stones (6 mm or less). The researchers randomized the patients into two groups. In one group, only the ureteral stone was surgically treated. In the other, the ureteral stone and all the kidney stones were removed.

The researchers then observed their patients for a mean period of 4.2 years. The procedure to remove all of the stones (ureteral stone and the additional kidney stones) took 25.6 minutes longer but resulted in impressively better results: The risk of additional visits to the emergency room related to a stone, subsequent surgery to treat a stone, or growth of the stones in the kidney was 82% lower. And there was no difference in the rate of complications among the groups. Looking at these results, the decision to treat the additional stone is made easier.

Medicine is a series of questions in need of answers, and a myriad of dilemmas in search of resolutions. In this series of three articles, I will tell you about three such questions, all related to kidney stones. My goal isn’t merely to describe the latest research about the prevention and treatment of kidney stones, but to show how researchers and doctors try to simplify their management considerations by asking, then answering, a series of simple questions.

Shahar Madjar, MD, MBA, is a urologist and an author. He practices in Michigan, at Schoolcraft Memorial Hospital in Manistique, and in Baraga County Memorial Hospital in L’Anse. Find his books on Amazon. Contact him at smadjar@yahoo.com