Urolithiasis

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

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C. Türk (Chair), A. Neisius, A. Petrik, C. Seitz, A. Skolarikos, K. Thomas
Guidelines Associates: J.F. Donaldson, T. Drake, N. Grivas, Y. Ruhayel

1.INTRODUCTION

1.1.Aims and scope

The European Association of Urology (EAU) Urolithiasis Guidelines Panel has prepared these guidelines to help urologists assess evidence-based management of stones/calculi in the urinary tract and incorporate recommendations into clinical practice. Management of bladder stones is not addressed in these guidelines. This document covers most aspects of the disease, which is still a cause of significant morbidity despite technological and scientific advances. The Panel is aware of the geographical variations in healthcare provision.

It must be emphasised that clinical guidelines present the best evidence available to the experts but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account.

Guidelines are not mandates and do not purport to be a legal standard of care.

1.2.Panel composition

The EAU Urolithiasis Guidelines Panel consists of an international group of clinicians with particular expertise in this area. All experts involved in the production of this document have submitted potential conflict of interest statements which can be viewed on the EAU website Uroweb: http://uroweb.org/guideline/urolithiasis/.

1.3.Available publications

A quick reference document (Pocket guidelines) is available, both in print and as an app for iOS and Android devices. These are abridged versions which may require consultation together with the full text versions. Also a number of scientific publications are available [1-3]. All documents can be accessed through the EAU website: http://uroweb.org/guideline/urolithiasis/.

1.4.Publication history and summary of changes

1.4.1.Publication history

The EAU Urolithiasis Guidelines were first published in 2000. This 2018 document presents a limited update of the 2017 publication of the EAU Urolithiasis Guidelines.

1.4.2.Summary of changes

The literature for the entire document has been assessed and updated, whenever relevant (see Methods section below).

New sections and recommendations have been included in the 2018 publication in sections:

3.4.1.1 Summary of evidence and guidelines for the management of renal colic

Summary of evidence

LE

Non-steroidal anti-inflammatory drugs are very effective in treating renal colic and are superior to opioids.

1b

Recommendation

Strength rating

Non-steroidal anti-inflammatory drugs are very effective in treating renal colic and are superior to opioids.

Strong

3.4.4.1 Summary of evidence and guidelines for chemolysis

Summary of evidence

LE

Irrigation chemolysis has been in limited clinical use to dissolve struvite stones.

3

Uric acid stones can be dissolved based on oral alkalinisation of the urine above 7.0.

3

For obstructing uric acid stones, a combination of oral chemolysis with Tamsulosin is more effective than each substance alone, in particular in stones > 8 mm.

1b

Recommendation (oral chemolysis of uric acid stones)

Strength rating

Combine oral chemolysis with Tamsulosin in case of (larger) ureteral stones (if active intervention is not indicated).

Weak

3.4.6.1 Summary of evidence and guidelines for retrograde URS, RIRS and antegrade ureteroscopy

Summary of evidence

LE

Medical expulsion therapy following Ho:YAG laser lithotripsy accelerates the spontaneous passage of fragments and reduces episodes of colic.

1b

The most effective lithotripsy system for flexible ureteroscopy is the Ho:YAG laser.

2a

Pneumatic and US systems can be used with high disintegration efficacy in rigid URS.

2a

Medical expulsion therapy following Ho:YAG laser lithotripsy increases SFRs and reduces colic episodes.

1b

Percutaneous antegrade removal of proximal ureter stones or laparoscopic ureterolithotomy are feasable alternatives to retrograde ureteroscopy in selected cases.

1a

Recommendation

Strength rating

Offer MET for patients suffering from stent-related symptoms and after Ho:Yag laser lithotripsy for the passage of fragments.

Strong

3.4.9.4.1 Summary of evidence and guidelines for selection of procedure for active removal of ureteral stones

Summary of evidence

LE

Observation is feasible in informed patients who develop no complications (infection, refractory pain, deterioration of renal function).

1a

Compared with SWL, URS was associated with significantly greater SFRs up to four weeks, but the difference was not significant at three months in the included studies.

1a

Ureterorenoscopy was associated with fewer re-treatments and need for secondary procedures, but with a higher need for adjunctive procedures, greater complication rates and longer hospital stay.

1a

Recommendations

Strength rating

Offer α-blockers as MET as one of the treatment options for (distal)ureteral stones > 5 mm.

Strong

In cases of severe obesity use ureterorenoscopy as first-line therapy for ureteral (and renal) stones.

Strong

3.4.13.1 Summary of evidence and guideline for management of patients with residual stones

Summary of evidence

LE

To detect residual fragments after SWL, URS or PNL, deferred imaging is more appropriate than immediate imaging post intervention.

3

Recommendations

Strength rating

Perform imaging after SWL, URS or PNL to determine presence of residual fragments.

Strong

3.4.15.6 Summary of evidence and guidelines for the management of stones in children

Summary of evidence

LE

Ureterorenoscopy has become the treatment of choice for larger distal ureteral stones in children.

1a

Recommendations

Strength rating

Offer children with ureteral stones shockwave lithotripsy as first-line option but consider ureterorenoscopy if SWL is not possible and larger distal ureteral stones.

Strong

Offer children with renal pelvic or calyceal stones with a diameter > 20 mm (~300 mm2) percutaneous nephrolithotomy.

Strong

4.7.4 Summary of evidence and guideline for the management of uric acid- and ammonium urate stones

Summary of evidence

LE

Potassim citrate can be beneficial to alkalinise the urine in urate stone formers.

3

Allopurinol can be beneficial in hyperuricosuric urate stone formers.

1b

Recommendations

Strength rating

Prescribe potassim citrate to alkalinise the urine in urate stone formers.

Strong

Prescribe allopurinol in hyperuricosuric urate stone formers.

Strong

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