Response to Hamilton et al. re: Conservative Management of Staghorn Calculi: When Is It Safe? by Morgan et al.

Dear Editor:

We very much appreciate the comments regarding our article. Treatment of staghorn calculi is complex and proper treatment often requires multistage percutaneous procedures. The evidence for the effect of frailty on perioperative outcomes is strengthening ^1,2 and surgical treatment of staghorn calculi is no exception. ³ Moreover, intervention is simply unwanted by some asymptomatic or minimally symptomatic patients. Data in the literature for conservative management of this condition are very limited, making treatment decisions and discussions with these patient groups difficult. We thus sought to assess our institutional experience managing a small group of such patients conservatively.

We agree with the very thoughtful commentators ⁴ that this is an important topic, relevant to many practicing endourologists who will also see older patients with many comorbidities presenting with large multifaceted staghorn calculi similar to those in our cohort. The commentators highlight that infection/struvite stones and noninfectious stones are almost certain to behave differently, with nonstruvite stones resulting in even better outcomes when managed nonoperatively. Unfortunately, we could not make this distinction without stone analyses in our study cohort, but this remains an important consideration.

The commentators address that quantity and quality of life are of utmost importance to this patient group and their providers. They inventively apply the concept of value = outcome/cost and highlight that in this group, the denominator can quickly overwhelm the numerator because of the high price of complications and multiple procedures. Achieving high value in medicine is becoming the overarching goal of healthcare delivery, benefiting patients, providers, and payers alike all while increasing the sustainability of the healthcare system. ⁵ It is our duty as providers to pause when treating this group, to ensure that we are providing the highest possible value of care to each patient. It is our hope that this study will raise awareness and prompt urologists to thoughtfully weigh quality and quantity of life along with overall value of care.