Editorial Comment on: “Should Asymptomatic Renal Stones Be Surgically Treated? Pro Treatment” by Bhalla et al. and “Should Asymptomatic Renal Stones Be Surgically Treated? Pro-Observation” by Streeper et al.

Surgical intervention for asymptomatic nonobstructing renal stones is controversial, as demonstrated by authors from both sides of the “debate” making compelling arguments to intervene or observe. ^1,2 Indeed, both authors cited some of the same articles on the natural history of stone fragments as evidence “for” their sides, such as the Darrard article that found that 30.7% of patients developed symptoms or had surgery within a 5 year surveillance article. That they both did so demonstrates the conundrum that we as urologists face in counseling our stone patients: how much risk is too much to take and when should that risk be taken? Ureteral stone events cause significant morbidity in patient suffering, financial cost, and unplanned and inconvenient lost work days. The “ticking time bomb” aspect of renal calculi can be a significant stressor to many patients. In contrast, if fewer than half of patients will develop symptoms from renal stones over 5 years, early intervention on all comers would mean the majority of patients would undergo potentially unnecessary surgery.

In the end, the management decisions for patients with asymptomatic renal stones should be individualized, with urologists helping patients understand the risks and benefits of each approach in the context of the patient's personal preferences and values. For some this will mean early surgical intervention, whereas for others a strategy of surveillance and medical management of risk factors will best fit the patient's needs. Given the disappointing “true stone-free rates” associated with stone surgery suggesting up to half of patients are left with residual stone, future research studying treatment outcomes other than stone-free rate are needed to improve our ability to counsel our patients.