Shared decision making: why do patients choose ureteroscopy?

To evaluate patient's characteristics that affects their decision on the management of asymptomatic renal calculi, and to determine the impact of anesthetic on the selection of shockwave lithotripsy (SWL). A survey was distributed to 100 patients in our multi-disciplinary stone clinic. The patients were given a hypothetical scenario of an asymptomatic 8 mm lower pole stone and descriptions for managements options including active surveillance (annual radiography, 40% chance of growth >10 mm within 4 years, 20% chance of passage), SWL under conscious sedation (65% success rate), and URS (90% success rate, with stent placement for 1 week). Patients were asked what was the most important variable impacting the choice of treatment. Patients preferred SWL (45%) over URS (32%) and active surveillance (23%). Patients with a previous experience with URS were more likely to choose it again (p = 0.0433). Decisions were driven primarily by success rate (52%), followed by risk of complications (29%), postoperative pain (7%) and others (12%). Patients choosing URS had the highest magnitude of history of pain (p = 0.03) and were more likely to prioritize success (78%) and less likely to prioritize surgical risk (13%) or anticipated pain after surgery (0%) (p = 0.01). Most (85%) of the patients would rely on the physician's recommendation for the treatment modality. Patients place differing value on risk versus success. As they rely heavily on the physician's recommendation, it is important that their urologist determine whether risk or success is of highest priority for them to facilitate a shared medical decision.