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Summary of Changes
The literature throughout the entire document has been reassessed and updated. For 2021 the content of each chapter has been rephrased and re-assessed; in particular the discussion ofmetabolic factors in section “3.1, Prevalence, aetiology and risk factors” has seen significant revision. New table in the form of Table 3.1 Bladder stones classified by aetiology has been added, along with a new figure “3.4 Management of Bladder stones”. Finally, the summary of evidence and recommendations tables have been completely rephrased and updated.
1.4.2 Summary of Changes
The literature throughout the entire document has been reassessed and updated (see Methods section below).
For 2020, the content of each chapter has been rephrased and reassessed; in particular the discussion of metabolic factors in section 3.1, Prevalence, aetiology and risk factors has seen significant revision. The summary of evidence and recommendations tables have been completely revised and updated.
Updated summaries of evidence and recommendations include the following:
|Summary of evidence||LE|
|The aetiology of bladder stones is typically multi-factorial. Bladder stones can be classified as primary (endemic), secondary (associated with lower urinary tract abnormalities e.g. BPO, neuropathic bladder, foreign body, chronic bactiuria) or migratory (having formed in the upper tract).||4|
|Metabolic abnormalities are also likely to contribute to bladder stone formation in patients with secondary bladder stones.||2b|
|In adults, US has a sensitivity of 20-83% for diagnosing bladder stones.|
|In adults, X-Ray KUB has a sensitivity of 21-78%; sensitivity increases with stone size.||2b|
|Computerised tomography has a higher sensitivity than ultrasound (US) for the detection of bladder stones.||2b|
|Cystoscopy has a higher sensitivity than XR-KUB or US for the detection of bladder stones.||2b|
|Bladder stone removal with concomitant treatment for BOO is associated with no significant difference in major post-operative complications when compared to BOO treatment alone in adults. However, concomitant bladder stone treatment does increase the rates of short-term post-operative incontinence and urinary infection.||2b|
|The absolute annual risk of stone formation in spinal cord injury patients is significantly higher with an indwelling catheter compared to those voiding with clean intermittent self-catheterisation (CISC). Suprapubic and urethral catheters have equal rates of bladder stone formation in spinal cord injury patients.||2b|
|The incidence of bladder stone formation after bladder augmentation or vesicoenterocystostomy is between 2-53% in adults and children.||2b|
|Urinary diversion including orthotopic ileal neobladders, ileocaecal continent cutaneous urinary diversion and rectosigmoid reservoirs is associated with stone formation in 0-43%.||2b|
|Primary (endemic) bladder stones typically occur in children in areas with poor hydration, recurrent diarrhoea and a diet deficient in animal protein. The following measures are proposed to reduce their incidence: maintenance of hydration, avoidance of diarrhoea, and a mixed cereal diet with milk and Vitamins A and B supplements; with the addition of eggs, meat and boiled cows’ milk after one year of age.||5|
|Use ultrasound as a first line imaging in adults with symptoms suggestive of a bladder stone.||Strong|
|Use cystoscopy or computer tomography (CT) kidney ureter bladder (KUB) to investigate
adults with persistent symptoms suggestive of a bladder stone if US is negative.
|Use US as first-line imaging in children with symptoms suggestive of a bladder stone.||Strong|
|Use X-Ray KUB for adults with confirmed bladder stones to guide treatment options and
|All patients with bladder stones should be examined and investigated for the cause of
bladder stone formation, including:
• uroflowmetry and post-void residual;
• urine dipstick, pH, ± culture
• metabolic assessment and stone analysis (see sections 220.127.116.11 and 4.1 of the
Urolithiasis guideline for further details).
In selected patients, consider:
• upper tract imaging (in patients with a history of urolithiasis or loin pain);
• cysto-urethroscopy or urethrogram.
|Offer oral chemolitholysis for radio-lucent or known uric acid bladder stones in adults.||Weak|
|Offer adults with bladder stones transurethral cystolithotripsy where possible.||Strong|
|Perform transurethral cystolithotripsy with a continuous flow instrument in adults (e.g.
nephroscope or resectoscope) where possible.
|Suggest open cystolithotomy as an option for very large bladder stones in adults and children.||Weak|
|Offer children with bladder stones transurethral cystolithotripsy where possible||Weak|
|Offer children percutaneous cystolithotripsy where transurethral cystolithotripsy is not possible or is associated with a high risk of urethral stricture (e.g. young children, previous urethral reconstruction and spinal cord injury).||Weak|
|Open, laparoscopic and extracorporeal shock wave lithotripsy are alternative treatments where endoscopic treatment is not possible in adults and children.||Weak|
|Prefer “tubeless” procedure (without placing a catheter or drain) for children with primary
bladder stones and no prior infection, surgery or bladder dysfunction where open
cystolithotomy is indicated.
|Perform procedures for the stone and underlying BOO simultaneously in adults with bladder
stones secondary to bladder outlet obstruction (BOO), where possible.
|Individualise imaging follow up for each patient as there is a paucity of evidence.
Factors affecting follow up will include :
• whether the underlying functional predisposition to stone formation can be treated (e.g. TURP);
• metabolic risk.
|Recommend regular irrigation therapy with saline solution to adults and children with bladder augmentation, continent cutaneous urinary reservoir or neuropathic bladder dysfunction, and no history of autonomic dysreflexia, to reduce the risk of recurrence.||Weak|
The 2019 text is the first version of the EAU Guidelines on Bladder Stones.