Presentation Authors: Grant Innes, Alec Mitchell*, Bryce Weber, Calgary, Canada, Joel Teichman, Kevin Carlson, Vancouver, Canada, Andrew McRae, Calgary, Canada, Michael Law, Frank Scheuermeyer, Eric Grafstein, Vancouver, Canada, James Andruchow, Calgary, Canada
Introduction: Ureteric colic is a common condition that causes severe pain and generates substantial health system utilization. Traditional management includes analgesia and a trial of spontaneous passage, which can succeed, but passage may take weeks and cause severe morbidity. Early stone removal is an alternative, but uptake is variable. Stone removal rapidly improves patient outcomes by relieving obstruction and pain, but to date there has not been a study comparing early intervention with spontaneous passage, and there is little evidence clarifying patients most likely to benefit.
Methods: We looked at two health regions, Calgary Health Region, which serves 1.4 million people and Vancouver Coastal Health (VCH) region which serves 1.2 million. Using regional admin databases we identified all emergency department (ED) patients with a diagnosis of renal colic based on ICD-10 codes. Eligible patients had CT to confirm a stone 2.0-9.9mm in size. Exclusion criteria were used based on stone and patient specific factors. Two cohorts were studied; an early intervention group, which underwent surgical intervention within 3 days of ED presentation and a trial of spontaneous passage group, which did not receive intervention for >5 days.
Results: We studied 3081 ED patients with well-characterized ureteral stones. 1168 (37.9%) underwent early surgical intervention and 1913 (62.0%) had a trial of spontaneous passage. Patients that underwent spontaneous passage saw adverse outcomes increase in linear fashion with increasing stone width and proximal location. In early intervention patients, outcomes are relatively constant regardless of stone size, but worse with proximal location. See table 1.
Conclusions: This study provides strong evidence for specific stone parameters to guide early intervention in patients presenting with ureteral colic. This data suggests that patients having low risk stones (width < 5mm) undergo a trial of spontaneous passage, that patients having high-risk stones (width >7.0mm or proximal-middle >5mm) be offered early surgical intervention, and that those with medium-risk stones (distal, >5.0mm) be managed on a case-by-case basis. These recommendations are more aggressive than current American guidelines, which recommend a trial of spontaneous passage at < 10mm.