Plenary debates: a critical look at standard therapies

Challenging established wisdom and standard therapies was the central theme in the first Plenary Session with EAU Guidelines Office chair Prof. James N’Dow (GB) underscoring the point that every urologists’ responsibility as a practitioner is to take each patient’s individual care needs into account.

Non-adherence must of course be justifiable, only done with consent of the patient and strictly documented. The session was chaired by N’Dow and by Joan Palou (ES), Chairman of the European School of Urology (ESU) who both led the discussion and debates among the invited experts.

Several speakers took a critical look at various issues such as managing ureteral stones using case discussions to trigger the exchange of insights and clinical experience. The session also featured the American Urological Association (AUA) Lecture on “Testosterone Therapy” with a personal narrative by Dr. Abraham Morgentaler (US).

Ureteral stone management and METThe first topic took up the opposing results of the existing meta-analysis for the use of MET or medical expulsive therapy (benefit), and those of recent high-quality, double-blinded studies (no benefit, even harm) from the UK, Australia and the USA.

The resulting dilemma for the EAU Guidelines offices was laid bare in the following discussion between Prof. Christian Seitz (AT), who defended the Guidelines’ standpoint, and Prof. Samuel McClinton (GB) who seriously challenged prior evidence and continued recommendation of MET with the use of alpha blockers.

McClinton: “It’s largely a methodological problem: Is one good study good enough to overturn the meta-analysis of multiple weaker studies? Now it’s up to the EAU Guidelines to grade the evidence and re-evaluate earlier recommendations. Old evidence keeps alpha blockers in the Guidelines; another point is that as urologists we may have grown too comfortable in prescribing tamsulosin. I’m hopeful that the EAU Guidelines will be taking these new trials on board in the coming years.”

Both McClinton and Seitz agreed that small stones (<5mm) have a high expulsion rate, and probably do not need the prescription of alpha blockers. However, the debate remained regarding their efficacy with larger stones, where further high-quality studies are required.

Seitz reiterated the recommendation will remain optional for larger stones in the foreseeable future. “We cannot recommend it any more for smaller stones or for pain relief medication. These new trials will naturally be assessed and incorporated in future updates of the EAU Guidelines.”