Does Having an Asymptomatic Renal Stone Increase Morbidity after Radical Cystectomy?

The management of asymptomatic renal stones remains a gray area in clinical guidelines, particularly in complex surgical populations such as those undergoing radical cystectomy (RC) with urinary diversion. Although expert recommendations tend to favor observation for small stones (<1 cm), the lack of high-quality evidence leaves clinicians navigating this space with uncertainty. This is especially challenging in the setting of RC, where postoperative anatomical changes can complicate future stone management.

Our study aimed to fill this knowledge gap by evaluating whether untreated, asymptomatic renal stones predispose patients to increased morbidity following RC. In a retrospective longitudinal cohort of 606 RC patients, 47 individuals with preoperative asymptomatic renal stones were followed postoperatively. We tracked stone-related complications, spontaneous stone passage (SSP), and overall 90-day morbidity.

Interestingly, asymptomatic stones did not correlate with increased postoperative complications compared to patients without stones. Nearly half of the renal stones passed spontaneously within one year, while only 10% of patients experienced stone-related events. Notably, elevated BMI was independently associated with SSP, and larger stones (≥1 cm) had a higher—but still relatively low—risk of adverse events. The rapid SSP observed in our study may be attributed to the refluxing nature of the Wallace ureteroileal anastomosis used in our robotic urinary diversions, which may facilitate passive stone washout.

These findings have several important implications. First, they challenge the assumption that a history of prior RC is a risk factor for stone-related events and that all stones should be preemptively treated prior to RC to avoid postoperative complications. Second, they suggest that conservative management of asymptomatic renal stones <1 cm is reasonable—even in this high-risk surgical population—particularly when weighed against the potential delay in oncologic treatment. Finally, our data provide a nuanced foundation for shared decision-making, especially for patients with borderline indications for intervention.

In summary, our study supports a more conservative, observation-based approach for small, asymptomatic renal stones in RC candidates. While individualized patient care remains paramount, these findings argue against routine preoperative intervention in the absence of other risk factors, offering reassurance that watchful waiting does not compromise oncologic or urologic outcomes.

Written by: Ziv Savin, Reuben Ben-David, Vinay Durbhakula, Kavita Gupta, Eve Frangopoulos, Blair Gallante, Sarah Lidagoster, Kyrollis Attalla, Peter Wiklund, Reza Mehrazin, John P. Sfakianos, William M. Atallah, Natasha Kyprianou, Mantu Gupta.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, USA

Read the Abstract

Login