0022-5347/99/1623-0688/0

THE JOURNAL OF U R O W Y
Vol. 162,688-691,September 1999
A ~ ~ ~ ~ I A Th cI.O N ,
Copyright 8 1999 by AMERICANUROLOGICAL Printed in U.S.A.

TIME TO STONE PASSAGE FOR OBSERVED URETERAL CALCULI: A

GUIDE FOR PATIENT EDUCATION
OREN F. MILLER* AND CHRISTOPHER J. KANE
From the Departments of Urology and Clinical Research, Naval Medical Center Sun Diego, Sun Diego, California

ABSTRACT
Purpose: We analyze the natural history of stone passage in patients with ureterolithiasis, and
define factors predictive of spontaneous passage.
Materials and Methods: A total of 75 patients with ureteral calculi were prospectively followed
for stone passage. Clinical data included patient gender and age, stone size and location, pain
medication requirements and interval to stone passage. Of the 75 patients 13 (17%)required in-
tervention and 62 (83%)were followed until spontaneous stone passage. Stones requiring inter-
vention were not included in the time to passage analysis.
Results: Of the 75 patients 41 (55%)had ureteral stones 2 mm. or smaller with an average time
to stone passage of 8.2 days and only 2 (4.8%)required intervention, 18 (24%)had stones between
2 and 4 mm. with an average time to stone passage of 12.2 days and 3 (17%)required interven-
tion, and 16 had stones 4 mm. or greater with an average time to stone passage of 22.1 days and
8 required intervention. For 95%of stones to pass it took 31 days for those 2 mm. or less, 40 days
for those 2 t o 4 mm. and 39 days for those 4 to 6 mm. Multivariate analysis revealed that size,
location and side were statistically related to stone passage interval (p = 0.012). Stones that were
smaller, more distal and on the right side were more likely to pass spontaneously and required
fewer interventions.
Conclusions: Interval to stone passage is highly variable and dependent on stone size, location
and side. Degree of pain, and patient gender and age had no bearing on the time to stone passage.
Of ureteral stones 95%2 to 4 mm. pass spontaneously but passage may take as long as 40 days.
Intervention may be required in 50% of ureteral calculi greater than 5 mm.
KEY WORDS:
ureter, calculi

Urolithiasis is a common condition affecting up to 12% of weeks in duration versus 7% if symptoms lasted less than
the population and accounting for 12W100,OOO outpatient 4weeks.5 In their study no calculus larger than 6 mm. passed
visits in the United States.’.* Recent advances in minimally spontaneously. The time to spontaneous stone passage aver-
invasive procedures for ureteral calculi have led to increasing aged 1.6 weeks for stones less than 4 and 2.8 weeks for those
success with intervention. The temptation exists to intervene 4 to 6 mm. Patient and physician decision for intervention is
even in the absence of absolute indications, which include influenced by many factors, including among others likeli-
infection, severe obstruction, renal impairment and uncon- hood and time to passage, pain and narcotic requirements.
trollable pain. Relative indications have included stone size, We performed a prospective study to determine the interval
location and failure of progression. A recent consensus article to stone passage and factors predictive of successful sponta-
on management of ureteral stones revealed that the majority neous ureteral stone passage.
of distal ureteral stones 5 mm. or less passed spontaneously
and conservative therapy was recommended if symptoms
were ~ontrolled.~ Recommendations for larger stones in the METHODS
proximal ureter included shock wave lithotripsy, percutane-
ous nephrostomy and ureteroscopy. That study revealed a A study was recently completed at our institution in which
large range of reported spontaneous passage rates in the patients presenting with acute flank pain were prospectively
literature. Distal ureteral stones less than 5 and those 5 to 10 evaluated with noncontrast computerized tomography (CT)
mm. had spontaneous passage rates of 71 to 98 and 25 to and excretory urography (IVP).6 Inclusion criteria were age
53%, respectively. Factors predictive of spontaneous stone older than 18 years and flank pain with or without microhe-
passage for stones 10 mm. or less include duration of pain maturia (greater than 3 red blood cells per high power field).
less than 30 days, pyuria less than 100 white blood cells per Exclusion criteria were age younger than 18 years, preg-
high power field, lack of irregular stone surface and partial nancy, allergy to radiocontrast material or iodine and creat-
obstruction.4 However Hubner et a1 showed that the rate of inine greater than 2.0 mg./dl. Between July and September
complications reached 20% when symptoms exceeded 4 1997 data were accrued on 106 consecutive patients, of whom
75 were diagnosed with ureterolithiasis. Clinical data in-
Accepted for publication A ril 23, 1999. cluded patient gender and age, stone size and location, pain
The Chief, Bureau of Megcine and Surgery, Navy Department,
Washington, D. C., Clinical Investigation Program, sponsored this medication requirements and interval to stone passage. Ure-
report #S-98-133 as required by HSETCINST 6000.41A. The views terolithiasis was diagnosed only if there was unequivocal
expressed in this article are those of the authors and do not reflect evidence on noncontrast CT or Tvp. All patients were evalu-
the official tplicy or position of the Department of the Navy, Depart- ated by a urologist at initial diagnosis and followup was
ment of De ense or the United States Government.
* Re uests for reprints: c/o Department of Clinical Research, Na- obtained every 2 weeks until spontaneous stone passage or
val Melical Center San Diego, 34800 Bob Wilson Drive, San Diego, intervention. Followup consisted of a genitourinary history
California 92134-5000. with emphasis on pain, narcotic requirements, stone passage
688
 TIME TO STONE PASSAGE FOR URETERAL CALCULI 689
or recovery, physical examination and urinalysis, Plain radi- TABLE2
ography was performed in most cases. Limited IVP was ob- Ureteral Location Av. No. Days % Intervention
tained when the stone was not easily visualized on plain (No.) (range) (No.)
radiography. The date of stone passage was the day the 2 Mm. or less:
patient stated that a stone had passed or was recovered. The Distal (35) 8.2 (036) 2.8(1)
stone size reported was the dimension perpendicular to the Mid (3) 4.5 (3-6) 33 (1)
Proximal (3) 5.7 (1-14) - (0)
long axis of the ~ r e t e rStatistical
.~ analysis was performed 2-4 Mm:
with computer software, and included multivariate and uni- Distal (14) 14.5 (0-40) 14.2(2)
variate analyses. Mid (0) - -
Proximal (4) 7 (2-11) 25 (1)
4 Mm. or greater:
RESULTS Distal ( 8 ) 5.5 (0-17) 50 (4)
A total of 55 men (average age 38 years) and 20 women Mid (2) 6 (-) 50 (1)
Proximal (6) 53 (15-105) 50 (3)
(average age 35.7) were identified with ureterolithiasis. Of
the 75 patients 13 (17%)required intervention and 62 (83%)
were followed until spontaneous stone passage. The number
and location of the 75 ureteral stones are shown in table 1.
Calculi were physically recovered in 33 of 75 patients (44%).
Of the patients followed until spontaneous stone passage 20
of 62 (32%)physically recovered stones and 42 (68%)reported
passage of stones without recovery. Of the latter 42 patients
24 were pain-free and visualized passage of the calculus. A
total of 18 patients were unsure of stone passage, despite
being pain-free and having resolution of hematuria. For
these patients the date of stone passage was recorded as the
date the patient became pain-free. Followup diagnostic stud-
ies were available in 16 of the 18 patients and consisted of
IVP in 7, plain radiography in 7, ultrasound in 1 and retro-
grade pyelography in 1. None of these patients was subse- Stone Size
quently seen for recurrent pain or hematuria. FIG.1. Average b u g . ) days to stone passage
Of the 75 ureteral stones 41 (55%)were 2 mm. or smaller,
of which 35 were distal, with an average time to stone pas-
sage of 8.2 days (range 0 to 36, table 2). For 3 mid and 3
proximal ureteral stones 2 mm. or less the average time to
stone passage was 4.5 and 5.7 days, respectively. Only 2 of
the 41 (9%)ureteral stones 2 mm. or less (1 distal and 1 mid
ureteral) required intervention for ongoing pain. Average
time to stone passage for each size range is shown in figure 1.
Of the 75 ureteral stones 18 (24%)were between 2 and 4
mm. (14 distal and 4 proximal) with an average time to stone
passage of 14.5 and 7 days, respectively, and 3 (17%)required
intervention after failure to progress (range 23 to 59 days). Of
the 16 ureteral stones 4 mm. or greater 8 (50%) required
intervention, including 7 that were 5 to 6 mm. (fig. 2). Inter-
vention was required secondary to poor pain control or failure
to progress. The remaining patient had a 4 mm. distal ure-
teral calculus removed after 41 days of observation. There Stone Size
were 3 proximal stones of the 16 ureteral stones 4 mm. or
greater, which passed spontaneously at an average of 53 days FIG. 2. Intervention rate by stone size
(range 15 to 105). The remaining 4 distal and 1mid ureteral
stones greater than 4 mm. passed on average in 5.5 and 6
days (table 2).
For 95%of stones to pass it took 31 days for those 2 mm. or significantly predicted stone passage (p = 0.012).A multiple
less, 40 days for those 2 to 4 mm. and 39 days for those 4 to linear regression model for days to stone passage can be
6 mm. (fig. 3). In a multivariate regression analysis variables shown as days to pass = 20.21 + 5.01 X size - 4.23 X
not predictive for interval to stone passage were pain (p = position - 7.25 X side, where size is 1 to 2, 3 or 4 (greater
0.9161,gender (p = 0.582) and age (p = 0.564). Independently than 4 mm.), position is 1-proximal, 2-mid ureteral and
side (p = 0.07), position (p = 0.124) and size (p = 0.057) 3-distal, and side is 1 for left 2 for right (see Appendix).
approached significance but on multivariate analysis all 3 Average days to spontaneous stone passage for left and right
calculi are shown in figure 4. There were no complications in
the 62 patients followed for spontaneous stone passage.
TABLE1
DISCUSSION
No. Men No. Women Total No
Size (mm.): The widespread availability of extracorporeal shock wave
2 or Less 32 9 41 lithotripsy and ureteroscopy has expanded the indications for
24 10 8 18 intervention for ureteral calculi. These procedures are not
4 or Greater 13 3 16 without risk, inconvenience and expense. Observation of ure-
Side (lt.ht.1 30125 10110 40135
Ureteral location: teral calculi, although attractive since it avoids invasive pro-
Proximal 10 2 12 cedures, is associated with pain, uncertainty, potential risks
Mid 3 2 5 to renal function and occasionally loss of work. To assist
Distal 42 16 58 patients in making an informed decision concerning inter-
690 TIME TO STONE PASSAGE FOR URETERAL CALCULI
v)
2
n CONCLUSIONS
Stone Size
FIG. 3. Number of days for 95% of stones to pass spontaneously
Side
FIG. 4. Average days to stone passage by side
vention versus observation the likelihood of success and the
interval to passage of observed ureteral calculi were evalu-
ated.
Spontaneous ureteral stone passage rates vary widely in
the literature.8-1° In this study every attempt was made to
allow patients to pass ureteral stones spontaneously. Each
patient was followed every 2 weeks or as needed until pas-
sage or intervention. Of the patients who required interven-
tion the average interval of observation was 25 days. Fol-
lowup was available in 74 of 75 patients (98%).
Multivariate analysis revealed that patient gender and
age, and degree of pain were unrelated t o interval to stone
passage. Together size, location and side were statistically
related to stone passage interval (p = 0.012). Stones that
were smaller, more distal and on the right side were more
likely to pass spontaneously and require fewer interventions.
It may take up to 30 to 40 days for a stone to pass sponta-
neously (table 2). There were no complications in patients
followed for spontaneous stone passage. In our cohort the
percent requiring intervention increased from 4.8% with
stones less than 2 up to 50%with those 4 to 6 mm. (fig. 2).
Observation was encouraged and the average interval of ob-
servation before intervention was 24.2 days. These percent-
ages reflect patient desire, failure to progress, pain and phy-
sician input with none of these patients having renal
impairment. If some of these patients had been followed
further they may have passed stones spontaneously.
The decision to proceed with intervention, shock wave lith-
otripsy or ureteroscopy, or to continue observation of small
ureteral calculi is complex. Patient factors that must be con-
sidered include degree of pain, narcotic requirements, work
requirements, family commitments and personal preference.
We have noted that patients often consider the predicted
interval to stone passage a key datum that guides the deci-
sion for intervention versus observation of ureteral calculi.
The impact of size and location on interval to stone passage
was expected but we are uncertain why side had a role. No
other investigators have made this observation. It could be
related to renal position, with the right kidney slightly more
caudad, or it could be a statistical anomaly. We will continue
to study the significance of these various factors and test the
equation in new patients presenting with urolithiasis.
Interval to stone passage is highly variable and dependent
on stone size, location and side. Degree of pain, and patient
gender and age have no bearing on the time to stone passage.
Of ureteral stones 2 to 4 mm. 95% pass spontaneously b u t
passage may take as long as 40 days. Intervention may be
required in 50%of ureteral calculi greater than 5 mm.
APPENDIX: MULTIPLE LINEAR REGRESSION MODEL FOR
PREDICTING DAYS TO STONE PASSAGE
Days t o stone passage = 20.21 + 5.01 X size - 4.23 x PO-
sition - 7.25 X side
Size is 1, 2, 3 or 4 mm. (for 4 to 6 mm. stones)
Position is equal to 1 for proximal, 2 for mid ureteral and 3
for distal stones
Side is 1for left or 2 for right
REFERENCES
1. Sierakowski, R., Finlayson, B., Landes, R. R., Finlayson, C. D.
and Sierakowski, N.: The frequency of urolithiasis in hospital
discharge diagnoses in the United States. Invest. Urol., 15:
438, 1978.
2. Hiatt, R. A,, Dales, L. G., Friedman, G . D. and Hunkeler, E. M.:
Frequency of urolithiasis in a prepaid medical care program,
Amer. J. Epidemiol., 1 1 5 255, 1982.
3. Segura, J. W.,Preminger, G. M., Assimos, D. G., Dretler, S. P.,
Kahn, R. I., Lingeman, J. E. and Macaluso, J. N.: Ureteral
stones clinical guidelines panel summary report on the man-
agement of ureteral calculi. J. Urol., 1 5 8 1915, 1997.
4. Ibrahim, A. I. A., Shetty, S. D., Awad, R. M. and Patel, K. P.:
Prognostic factors in the conservative treatment of ureteric
stones. Brit. J. Urol., 67: 358, 1991.
5. Hubner, W. A., Irby, P. and Stoller, M. L.: Natural history and
current conceDts for the treatment of small ureteral calculi.
Eur. Urol., 2 4 172, 1993.
6. Miller, 0. F., Rineer, S. K., Reichard, S. R., Buckles, R. G..
Donovan, M. S., Graham, I. R., Goff, W. B. and Kane, C. J.:
Prospective comparison of unenhanced spiral computed to-
mography and intravenous urogram in the evaluation of acute
flank pain. Urology, 5 2 982, 1998.
7. Ueno, A,, Kawamura, T., Ogawa, A. and Takayasu, H.: Relation
of spontaneous passage of ureteral calculi to size. Urology, 1 0
544,1917.
8. Morse, R. M. and Resnick, M. I.: Ureteral calculi: natural history
and treatment in a n era of advanced technology. J. Urol., 1 4 5
263, 1991.
9. OFlynn, J. D.: The treatment of ureteric stones: report on 1120
patients. Brit. J. Urol., 5 2 436, 1980.
10. Prince, C.L. and Scardino, P. L.: A statistical analysis of ureteral
calculi. J. Urol., 83: 561, 1960.
EDITORIAL COMMENT
Before 1980 the only options available for the management of
ureteral calculi were blind basket extraction and open ureterolitho-
tomy. With the advent of shock wave lithotripsy and mrect vision
ureteroscopy, we have minimally invasive alternatives to treat
symptomatic ureteral stones. However, this report again reminds us
that the majority of ureteral stones are small enough to pass spon-
taneously, with a controllable degree of patient dscomfort. A num-
ber of studies have previously attempted to predict whether ureteral
calculi will pass spontaneously. Using a multiple linear regression
model in a group of prospectively studied patients with ureteral
calculi, the authors have provided us with a useful tool to help one
predict the number of days it will take for a stone to pass spontane-
ously. It is no surprise that stone size and location are the 2 most
important factors in predicting spontaneous passage. Unexpectedly,
patients with right calculi appeared to pass stones approximately 1
week earlier than those with stones in the left ureter.
 TIME TO STONE PASSAGE FOR URETERAL CALCULI
Of course active intervention should be instituted immediately in
patients with intractable discomfort, profound obstruction, signifi-
cant infection, a solitary kidney or renal insufficiency. However, for
individuals with stones less than 6 mm. in diameter the current
study allows one to predict the incidence and time frame of sponta-
neous passage. Armed with a copy of figure 1and the multiple linear
regression model, we can now better educate o u r patients with ure-
teral calculi as to the chance of spontaneous stone passage.
An important take home point reiterates that average stone pas-
69 1
sage can take anywhere from 3 to 4 weeks. However, the mathemat-
ical model and clinical experience suggest that even if a small ure-
teral stone has not passed after 2 months, spontaneous passage
appears unlikely and intervention is probably warranted.
Glenn M.Preminger
Duke Comprehensive Kidney Stone Center
Duke University Medical Center
Durham, North Carolina