Active Surveillance Stone Protocol Reduces Endourologic Interventions
Alejandra Balen, MD1, Ohad Kott, MD1, Osama Al-Alao, MD1, Eric Jung, MD1, Timothy O'Rourke, MD1, Meredith Wasserman, MD1, Christopher Tucci, RN1, Jie Tang, MD2, Gyan Pareek, MD1
1Minimally Invasive Urology Institute, The Miriam Hospital; Department of Urology, The Warren Alpert Medical School of Brown University, Providence, RI, 2Department of Medicine (Nephrology), The Warren Alpert Medical School of Brown University, Providence, RI
Introduction: Surgical management of nephrolithiasis (NL) is generally efficacious and well tolerated by patients, but is associated with risks including bleeding, perforation, infection, and those related to anesthesia. There is also a significant financial burden associated with surgery. High-risk kidney stone formers make up less than 20% of the NL patient population, yet they account for over 80% of the surgical procedures. Our institution applies an active surveillance multidisciplinary approach to provide a close follow up and treatment plan for high-risk kidney stone formers. We sought to compare the incidence of surgical intervention within the multidisciplinary kidney stone center (MSC) to the incidence of surgical intervention in a urology practice (UP) that uses a non-multidisciplinary approach. Both the MSC and the UP are affiliated with the same academic urology department, and therefore differ only by the treatment approach.
Materials and Methods: We identified 366 patients treated at the UP and 153 patients at the MSC with greater than 12 months of clinical follow up between January 1, 2015 and September 1, 2018. Patients were excluded if they were treated at both centers. Patients were referred to the MSC if they had a total bilateral stone burden greater than 10mm, medical co-morbidities and previous stone surgery. We retrospectively reviewed patient records and calculated the annual incidence rate of surgical intervention for stone disease during the follow up period. At the MSC, patients were seen every 3 months by a team that included a urologist, nephrologist, dietitian, nurse, and renal ultrasonographer. Patients met with all disciplines during every office visit. These providers worked in collaboration to form custom treatment plans focusing on improvement in quality of life, dietary changes, reduction in stone burden and prevention of surgical interventions.
Results: During follow-up, 230 out of 366 (62.8%) UP patients underwent surgical stone treatment compared to 45 out of 153 (29.4%) MSC patients. The cumulative incidence of surgical intervention for stone treatment among the MSC and UP group was 0.294 and 0.628, respectively. Multidisciplinary treatment resulted in a 53% decrease in the excess risk of incident surgical interventions compared to the UP group (Risk Ratio= 0.47; 95% CI: 0.36, 0.61; p-value=<0.001).
This study demonstrates that MSC patients treated with an active surveillance multidisciplinary approach had a statistically significant lower incidence of surgical interventions compared to UP patients, despite being high-risk stone formers and prone to higher rate of surgical interventions. These results indicate that using an active surveillance multidisciplinary approach in the management of kidney stone disease may reduce incidence of endourologic interventions. Further study is required to evaluate additional factors that may affect stone burden and incidence of surgical treatments over a longer period of follow up.
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