Urolithiasis

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

2021

Summary of changes

The literature for the entire document has been checked and, wherever relevant, updated (see Methods section 2.1). For 2021, conclusions and recommendations have been rephrased and strength ratings reassessed across several sections. References and supporting text have also been refreshed. Additional information has been added to the chapter on “Prevalence, aetiology, risk of recurrence” including “Table 3.4 Risk factors for chronic kidney disease and end stage kidney disease in stone formers” and “Table 3.5 Risk factors for chronic kidney disease and renal stones”. A consultant nephrologist has now been added to the panel and has reviewed the entire text. Updated recommendation strength ratings include the following:

 

3.3.2.3 Guidelines for laboratory examinations and stone analysis

Recommendations Strength rating
Blood
Serum blood sample:

• creatinine;

• uric acid;

• (ionised) calcium;

• sodium;

• potassium;

• blood cell count;

• C-reactive protein.

 Strong

 

4.6.5.1 Guidelines for the management of tubular acidosis

Recommendations Strength rating
Prescribe alkaline citrates for distal renal tubular acidosis. Strong

 

2020

Summary of changes

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

For 2020, conclusions and recommendations have been rephrased and strength ratings reassessed across a number of sections. Updated recommendations include the following:

 

3.3.2.3 Guidelines for laboratory examinations and stone analysis

Recommendations Strength rating
Urine
Dipstick test of spot urine sample:

• red cells;

• white cells;

• nitrite;

• approximate urine pH;

• urine microscopy and/or culture.

 Weak
Blood
Serum blood sample:

• creatinine;

• uric acid;

• (ionised) calcium;

• sodium;

• potassium;

• blood cell count;

• C-reactive protein.

 Weak

 

3.4.10.5 Summary of evidence and guidelines for the management of renal stones

Recommendations Strength rating
Consider the stone composition before deciding on the method of removal, based on patient history, former stone analysis of the patient or Hounsfield unit (HU) on unenhanced computed tomography (CT). Stones with density > 1,000 HU (and with high homogeneity) on non-contrast-enhanced CT are less likely to be disintegrated by shock wave lithotripsy. Strong

 

2019

For the 2019 Urolithiasis Guidelines, new and relevant evidence has been identified, collated and appraised through a structured assessment of the literature with a total of 25 new papers having been added to the Urolithiasis 2019 Guidelines publication.

For 2019, conclusions and recommendations have been rephrased and amended throughout the current document, including the sections on high-risk stone formers, anti-coagulation. The section on paediatric urolithiasis has been completely revised.

Updated summaries of evidence and recommendations include the following:

 

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

Recommendation Strength rating
Offer opiates (hydromorphine, pentazocine or tramadol) as a second choice. Weak

 

3.4.5.1 Summary of evidence and guidelines for shock wave lithotripsy

Summary of evidence LE
Proper acoustic coupling between the cushion of the treatment head and the patient’s skin is important. 2
Careful imaging control of localisation of stone contributes to outcome of treatment. 2a
Careful control of pain during treatment is necessary to limit pain-induced movements and excessive respiratory excursions. 1a
Antibiotic prophylaxis is recommended in the case of internal stent placement, infected stones or bacteriuria. 1a

 

3.4.8.4 Stone composition

Recommendation Strength rating
Consider the stone composition before deciding on the method of removal, based on patient history, former stone analysis of the patient or Hounsfield unit (HU) on unenhanced computed tomography (CT). Strong

 

3.4.11.1 Summary of evidence and guidelines for laparoscopy and open surgery

Recommendation Strength rating
Offer laparoscopic or open surgical stone removal in rare cases in which shock wave lithotripsy (SWL), retrograde or antegrade ureteroscopy and percutaneous nephrolithotomy fail, or are unlikely to be successful. Strong

 

3.4.14.4.1   Summary of evidence and guidelines for the management of stones in patients with transplanted kidneys

Summary of evidence LE
Shock wave lithotripsy for small calyceal stones is an option with minimal risk of complication, but localisation of the stone can be challenging and SFRs are poor. 4

 

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

Summary of evidence LE
In children, the indications for SWL, URS and PNL are similar to those in adults. 1b

 

Recommendations Strength rating
Offer children with single ureteral stones less than 10 mm shock wave lithotripsy (SWL) if localisation is possible as first line option. Strong
Ureteroscopy is a feasible alternative for ureteral stones not amenable to SWL. Strong
Offer children with renal stones with a diameter of up to 20 mm (~300 mm2) shock wave lithotripsy. Strong
Offer children with renal pelvic or calyceal stones with a diameter > 20 mm (~300 mm2) percutaneous nephrolithotomy. Strong
Retrograde renal surgery is a feasible alternative for renal stones smaller than 20 mm in all locations. Weak

 

Table 3.3: High-risk stone formers has been updated to include:

Diseases associated with stone formation
Increased levels of vitamin D
Environmental factors
High ambient temperatures
Chronic lead and cadmium exposure

 

2018

For the 2018 edition of the EAU Urolithiasis Guidelines the Guidelines Office have transitioned to a modified GRADE methodology. For each recommendation within the guidelines there is an accompanying online strength rating form which addresses a number of key elements namely:

  1. the overall quality of the evidence which exists for the recommendation;
  2. the magnitude of the effect (individual or combined effects);
  3. the certainty of the results (precision, consistency, heterogeneity and other statistical or study related factors);
  4. the balance between desirable and undesirable outcomes;
  5. the impact of patient values and preferences on the intervention;
  6. the certainty of those patient values and preferences.

These key elements are the basis which panels use to define the strength rating of each recommendation. The strength of each recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence, and nature and variability of patient values and preferences. The strength of each recommendation is represented by the words ‘strong’ or ‘weak’.

In addition, new and relevant evidence has been identified, collated and appraised through a structured assessment of the literature. A broad and comprehensive literature search, covering all sections of the Urological Trauma Guidelines was performed.  Additional references and text updates have been incorporated throughout the text as a result of this search. Furthermore, all recommendations have been rephrased throughout the current document to aid in their implementation.

 

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

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

 

Recommendations 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

 

Recommendations (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

 

Recommendations 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 a significantly greater SFR 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

 

Recommendation 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
Ureterenoscopy 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 uretero-renoscopy 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

 

2017

New relevant references have been identified through a structured assessment of the literature and incorporated in the various chapters of the 2017 Urolithiasis Guidelines.

Key changes for the 2017 publication:

3.4.1.1 Renal colic

Summary of evidence LE
Administration of daily α-blockers seems to reduce colic episodes, although controversy remains in the published literature. 1b

 

 

3.4.2.1.3.2 Best clinical practice

Summary of evidence – Number of shock waves, energy setting and repeat treatment sessions LE
Stepwise power ramping prevents renal injury. 1b
Clinical experience has shown that repeat sessions are feasible (within one day for ureteral stones). 4
Optimal shock wave frequency is 1.0 to 1.5Hz. 1a

 

3.4.2.2 Indication for active stone removal of renal stones

Recommendation GR
Offer active treatment for renal stones in case of stone growth, de novo obstruction, associated infection, and acute and/or chronic pain. C

 

 

3.4.3.1.2 Pharmacological treatment, Medical expulsive therapy (MET)

Summary of evidence LE
Medical expulsion therapy (MET) seems to be efficacious treating patients with ureteric stones who are amenable to conservative management. The greatest benefit might be among those with larger (distal) stones. 1a

 

 

Recommendations LE GR
Select patients for an attempt at spontaneous passage or MET, based on well-controlled pain, no clinical evidence of sepsis, and adequate renal functional reserve. 4 C
Offer α-blockers as MET as one of the treatment options, in particular for (distal) ureteral stones > 5 mm. 1a A
Counsel patients regarding the controversies in the literature, attendant risks of MET, including associated drug side effects. Inform the patient that α-blockers as MET are administered off-label†**. 1b A*

† It is not known if tamsulosin harms the human foetus or if it is found in breast milk.

*Upgraded based on panel consensus.

**MET in children cannot be recommended due to the limited data in this specific population.

 

3.4.3.1.4.1.2 Best clinical practice in ureterenoscopy

Summary of evidence LE
In ureterorenoscopy (URS) (in particular for renal stones), pre-stenting has been shown to improve outcome. 1b

 

3.4.3.3 Selection of procedure for active removal of ureteral stones

Recommendation GR
In obese patients ureterorenoscopy is a safe and efficient option to remove renal stones. B
Ureterorenoscopy in morbidly obese patients have significantly higher complication rates as compared to normal weight patients. A

 

 

2016

All chapters of the 2016 RCC Guidelines have been updated, based on the 2015 version of the guideline.

Conclusions and recommendations have been rephrased and added to, throughout the current document.

Key changes for the 2016 publication:

The literature for the entire document has been assessed and updated, whenever relevant.

  • Limited changes were made to the Section 3.4.1.1 – Renal colic.
  • The findings of the systematic review performed by the Panel (What are the benefit and harms of URS compared with SWL in the treatment of upper ureteral stones in children and adults? [305]) have been included in Section 3.4.3.3 – Selection of procedure for active removal of ureteral stones.
  • Section 3.4.1.3.2 – Antithrombotic therapy and stone treatment – has been expanded with new data.
    New table 3.4.1 – Risk stratification for bleeding and table 3.4.2 – Suggested therapies for antithrombotic therapy in stone removal have been added.
  • Figure 3.4.1 – Treatment algorithm for renal calculi has been amended; priority of treatment modalities has changed to shockwave lithotripsy and ureterorenoscopy as first choice of treatment modalities for small upper urinary stones.
  • The findings of a systematic review performed by the Panel (What are the comparative benefits and harms of the different percutaneous nephrolithotomy (PCNL) tract sizes? [7]) , have been included in Section 3.4.2.1.4.1 – Percutaneous nephrolithotomy.
  • Recent data has been included in Section 3.4.3.1.2 – Pharmacological treatment, Medical expulsive therapy (MET), which resulted in a lower recommendation (2015 recommendation was GR A).
Recommendations for MET LE GR
Offer α-blockers as MET as one of the treatment options. 1a C

MET = medical expulsive therapy.

2015

The literature for the complete document has been assessed and updated, whenever relevant and 46 new references have been included.

Key changes for the 2015 publication:

  • A new introductory section was added to Section 3.1(section Prevalence, aetiology, risk of recurrence), as well as a table. Additional data has been added to Table 1.2.
  • Diagnostic imaging during pregnancy (section 3.3.3.1).
Recommendation LE GR
In pregnant women, ultrasound is the imaging method of choice. 1a A*
In pregnant women, MRI should be used as a second-line imaging modality. 3 C
In pregnant women, low-dose CT should be considered as a last-line option. 3 C

 

  • In Section 3.4.1.2.1.1.1 – Conservative treatment (Observation) – a recommendation on the timing of patient follow-up has been included. 
If renal stones are not treated, periodic evaluation is recommended (after 6 months and yearly thereafter). A* 

 

  • In Section: 3.4.1.3 – Indication for active stone removal of kidney stones – a new recommendation has been added. 
Recommendation LE  GR
Radiolucent stones might be dissolvable (See Section 3.4.1.2.1.1.2.1.3). 2a B

 

  • In Section 3.4.2.3.3 – Laparoscopic ureteral stone removal – a new recommendation has been included.
LE GR
For ureterolithotomy, laparoscopy is recommended for large impacted stones when endoscopic lithotripsy or SWL has failed. 2 B

 

  • In Section 3.4.1.4.1 – Antibiotic treatment – a new recommendation has been included.
Recommendations LE GR
UTIs must be excluded or treated prior to endourologic stone removal. 1b A
In all patients undergoing endourologic treatment, perioperative antibiotic prophylaxis is recommended. 1b A*

 

  • A new Figure (3.4.2) – Recommended treatment options (if indicated for active stone removal) – has been included.
  • In Section 3.4.5 – Management of stones in patients with neurogenic bladder – the recommendation has been expanded.
Recommendation GR
In myelomeningocele patients, latex allergy is common so that appropriate measures need to be taken regardless of the treatment. For surgical interventions general anesthesia remains the only option. B

 

  • An additional recommendation was included in Table 3.4.6 – Special problems in stone removal.
Horseshoe kidneys Acceptable stone free rates can be achieved with flexible ureteroscopy [335].

 

  • Figures 4.2 – Diagnostic and therapeutic algorithm for calcium oxalate stones – and 4.3 – Diagnostic and therapeutic algorithm for calcium phosphate stones – have updated reference values included.
  • A new Section on Matrix stones has been added (4.12).
  • In Table 4.6 – Pharmacological substances used for stone prevention – characteristics, specifics and dosage – Febuxostat for the treatment of hyperuricosuria and hyperuricaemia has been added.
  • Section 4.4.4 – Recommendations for pharmacological treatment of patients with specific abnormalities in urine composition – a recommendation for Febustat has been added.
LE GR
Hyperuricosuria AllopurinolFebuxostat 1a1b AA

 

  • In Table 4.8 – Pharmacological treatment of renal tubular acidosis – additional alternatives for the treatment of hypercalciuria have been included.

2014

For this 2014 update the following changes should be noted:

Four sections of the text have been replaced:

  • 3.1 Diagnostic Imaging
  • 5.5 Extracorporeal Shockwave Lithotripsy
  • 6.3.2 Anticoagulation
  • 6.3.6 Steinstrasse)

The flowcharts included in Chapter 11 (Metabolic evaluation and recurrence prevention) have been amended, with a revisit of all references.

Recommendations have not changed, with the exception of section 6.3.2  Antithrombotic therapy and stone treatment.

2013

Changes in the following sections:
•    3.1.2 “Evaluation of patients for whom further treatment of renal stones is planned”
•    4.1.1 “Pain relief”
•    4.1.3 “Recommendations for analgesia during renal colic”
•    5.3.1 “Choice of medical agents”
•    5.6 “Endourology techniques”
•    5.6.2.1.6 “Stone extraction”
•    5.6.2.1.8 “Stenting before and after URS”
•    6.4 “Selection of procedure for active removal of kidney stones”
•    7.2 “Residual stones: therapy
•    8.2 “Diagnostic imaging for stones in pregnancy”
•    9.1 “Management of stone problems in children: aetiology”
•    9.1.1 “Nuclear imaging”
•    10.1.2 “Stones in urinary diversion and other voiding problems”
•    10.2.2 “Management of stones in patients with neurogenic bladder”
•    10.3.1 “Management of stones in transplanted kidney: Aetiology and clinical presentation”Chapter 11 “Metabolic evaluation” has been completely revised.

2012

New literature included in the following chapters:
Chapter 2
Classification of Stones: 2.3 X-ray characteristics, 2.6 Risk groups for stone formation (Table 6)
Chapter 5

Stone Relief: 5.3.4 Factors affecting success of MET, 5.5.3 Best clinical practice, 5.6.1.5.4 Puncture, 5.6.1.5.7 Management of complications following PNL (new Table 14), 5.6.2.2.1 Pre-operative work up and preparations, 5.6.2.2.6 Stone extraction new data added, 5.6.2.2.8 Stenting prior to, and after URS, 5.7.2 Laparoscopic surgery

Chapter 6
Indication for Active Stone Removal and Selection of Procedure: 6.4 Selection of procedure for active removal of kidney stones
New literature resulting in a change of LE in the recommendation sections
Chapter 3
Diagnosis: 3.1 Diagnostic imaging: Patient evaluation (3.1.2) for patients in whom treatment of renal stones is planned (NCCT recommended in favour of IVU), 3.2 Recommendations for repeat stone analysis in patients: (LE:2 – old listing LE:3)
Chapter 5
Stone Relief: 5.7.2.1 Indications for laparoscopic stone surgery – recommendations (LE: 3 – old listing LE: 4)
New literature has been including in the following sections resulting in new recommendations or a change in ranking (GR):
Chapter 5
Stone Relief: 5.7.2.1 Indications for laparoscopic stone surgery – New recommendation on large impact stones or when endoscopic lithotripsy or SWL have failed.
Chapter 6
Indication for Active Stone Removal and Selection of Procedure: 6.4.2 Selection of procedure for active removal of kidney stones.

2011

Complete update