Follow-up of urolithiasis patients after treatment: an algorithm from the EAU Urolithiasis Panel.

OBJECTIVE: To develop a follow-up algorithm for urinary stone patients after definitive treatment. MATERIALS AND METHODS: The panel performed a systematic review on follow-up of urinary stone patients after treatment (PROSPERO: CRD42020205739). Given the lack of comparative studies we critically evaluated the literature and reached a consensus on the follow-up scheme. RESULTS: A total of 76 studies were included in the analysis, including 17 RCTs. In the stone-free general population group, 71-100% of patients are stone-free at 12 months while 29-94% remain stone-free at 36 months. We propose counselling these patients on imaging versus discharge after the first year. The stone-free rate in high-risk patients not receiving targeted medical therapy is < 40% at 36 months, a fact that supports imaging, metabolic, and treatment monitoring follow-up once a year. Patients with residual fragments ≤ 4 mm have a spontaneous expulsion rate of 18-47% and a growth rate of 10-41% at 12 months, supporting annual imaging follow-up. Patients with residual fragments > 4 mm should be considered for surgical re-intervention based on the low spontaneous expulsion rate (13% at 1 year) and high risk of recurrence. Plain film KUB and/or kidney ultrasonography based on clinicians' preference and stone characteristics is the preferred imaging follow-up. Computed tomography should be considered if patient is symptomatic or intervention is planned. CONCLUSIONS: Based on evidence from the systematic review we propose, for the first time, a follow-up algorithm for patients after surgical stone treatment balancing the risks of stone recurrence against the burden of radiation from imaging studies.

Duration of Follow-up and Timing of Discharge from Imaging Follow-up, in Adult Patients with Urolithiasis After Surgical or Medical Intervention: A Systematic Review and Meta-analysis from the European Association of Urology Guideline Panel on Urolithiasis.

CONTEXT: No algorithm exists for structured follow-up of urolithiasis patients. OBJECTIVE: To provide a discharge time point during follow-up of urolithiasis patients after treatment. EVIDENCE ACQUISITION: We performed a systematic review of PubMed/Medline, EMBASE, Cochrane Library, clinicaltrials.gov, and reference lists according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Fifty studies were eligible. EVIDENCE SYNTHESIS: From a pooled analysis of 5467 stone-free patients, we estimated that for a safety margin of 80% for remaining stone free, patients should be followed up using imaging, for at least 2 yr (radiopaque stones) or 3 yr (radiolucent stones) before being discharged. Patients should be discharged after 5 yr of no recurrence with a safety margin of 90%. Regarding residual disease, patients with fragments ≤4 mm could be offered surveillance up to 4 yr since intervention rates range between 17% and 29%, disease progression between 9% and 34%, and spontaneous passage between 21% and 34% at 49 mo. Patients with larger residual fragments should be offered further definitive intervention since intervention rates are high (24-100%). Insufficient data exist for high-risk patients, but the current literature dictates that patients who are adherent to targeted medical treatment seem to experience less stone growth or regrowth of residual fragments, and may be discharged after 36-48 mo of nonprogressive disease on imaging. CONCLUSIONS: This systematic review and meta-analysis indicates that stone-free patients with radiopaque or radiolucent stones should be followed up to 2 or 3 yr, respectively. In patients with residual fragments ≤4 mm, surveillance or intervention can be advised according to patient preferences and characteristics, while for those with larger residual fragments, reintervention should be scheduled. PATIENT SUMMARY: Here, we review the literature regarding follow-up of urolithiasis patients. Patients who have no stones after treatment should be seen up to 2-3 yr, those with large fragments should be reoperated, and those with small fragments could be offered surveillance with imaging.

International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy.

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

Best Practice in Interventional Management of Urolithiasis: An Update from the European Association of Urology Guidelines Panel for Urolithiasis 2022.

PURPOSE: The European Association of Urology (EAU) has updated its guidelines on clinical best practice in urolithiasis for 2021. We therefore aimed to present a summary of best clinical practice in surgical intervention for patients with upper tract urolithiasis. MATERIALS AND METHODS: The panel performed a comprehensive literature review of novel data up to May 2021. The guidelines were updated and a strength rating was given for each recommendation, graded using the modified Grading of Recommendations, Assessment, Development, and Evaluations methodology. RESULTS: The choice of surgical intervention depends on stone characteristics, patient anatomy, comorbidities, and choice. For shockwave lithotripsy (SWL), the optimal shock frequency is 1.0-1.5 Hz. For ureteroscopy (URS), a postoperative stent is not needed in uncomplicated cases. Flexible URS is an alternative if percutaneous nephrolithotomy (PCNL) or SWL is contraindicated, even for stones >2 cm. For PCNL, prone and supine approaches are equally safe. For uncomplicated PCNL cases, a nephrostomy tube after PCNL is not necessary. Radiation exposure for endourological procedures should follow the as low as reasonably achievable principles. CONCLUSIONS: This is a summary of the EAU urolithiasis guidelines on best clinical practice in interventional management of urolithiasis. The full guideline is available at https://uroweb.org/guidelines/urolithiasis. PATIENT SUMMARY: The European Association of Urology has produced guidelines on the best management of kidney stones, which are summarised in this paper. Kidney stone disease is a common condition; computed tomography (CT) is increasingly used to diagnose it. The guidelines aim to decrease radiation exposure to patients by minimising the use of x-rays and CT scans. We detail specific advice around the common operations for kidney stones.

International Alliance of Urolithiasis (IAU) guidelines on the metabolic evaluation and medical management of urolithiasis.

The aim of this study was to construct the fourth in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis (IAU) that by providing a clinical framework for the metabolic evaluation, prevention, and follow-up of patients with urolithiasis based on the best available published literature. All recommendations were summarized following a systematic review and assessment of the literature in the PubMed database from January 1976 to June 2022. Each generated recommendation was graded using a modified GRADE methodology. Guideline recommendations were developed that addressed the following topics: initial evaluation, metabolic testing, dietary measures, medical management, and follow-up of recurrent stone formers. It was emphasized by the Panel that prevention of new stone formation is as important as the surgical removal of the stones. Although general preventive measures may be effective in reducing stone recurrence rates in some patients, specific medical and dietary management should be well considered and eventually applied in an individualized manner based on the outcomes of metabolic work-up, stone analysis and some certain patient related factors. A detailed follow-up of each case is essential depending on the metabolic activity of each individual patient.

Best practice in interventional management of urolithiasis: an update from the European Association of Urology guidelines panel for urolithiasis 2022

The European Association of Urology (EAU) has updated its guidelines on clinical best practice in urolithiasis for 2021. We therefore aimed to present a summary of best clinical practice in surgical intervention for patients with upper tract urolithiasis. The panel performed a comprehensive literature review of novel data up to May 2021. The guidelines were updated and a strength rating was given for each recommendation, graded using the modified Grading of Recommendations, Assessment, Development, and Evaluations methodology. The choice of surgical intervention depends on stone characteristics, patient anatomy, comorbidities, and choice. For shockwave lithotripsy (SWL), the optimal shock frequency is 1.0-1.5 Hz. For ureteroscopy (URS), a postoperative stent is not needed in uncomplicated cases. Flexible URS is an alternative if percutaneous nephrolithotomy (PCNL) or SWL is contraindicated, even for stones >2 cm. For PCNL, prone and supine approaches are equally safe. For uncomplicated PCNL cases, a nephrostomy tube after PCNL is not necessary. Radiation exposure for endourological procedures should follow the as low as reasonably achievable principles. This is a summary of the EAU urolithiasis guidelines on best clinical practice in interventional management of urolithiasis. The full guideline is available at https://uroweb.org/guidelines/urolithiasis. The European Association of Urology has produced guidelines on the best management of kidney stones, which are summarised in this paper. Kidney stone disease is a common condition; computed tomography (CT) is increasingly used to diagnose it. The guidelines aim to decrease radiation exposure to patients by minimising the use of x-rays and CT scans. We detail specific advice around the common operations for kidney stones.

European Association of Urology Urolithiasis Guidelines: Where Are We Going?

Urolithiasis is a clinical condition showing increasing trends, especially among European and other developed countries. The European Association of Urology (EAU), in close collaboration with experts in the field, publishes a yearly updated clinical guideline, in order to provide practicing urologists around Europe and the rest of the world a tool for optimizing patient care and decision-making. The methodological approach for developing this guide is quite rigorous and follows rigorous scientific standards. The challenges that a urologist faces are increasing; therefore, during meticulous literature search, the EAU Urolithiasis Panel identifies gaps in knowledge and conducts systematic reviews, in order to provide answers or to propose ideas for designing future research. This way, a new section was published last year, regarding diagnosis and management of bladder stones, with more systematic reviews on the way. The aim of this study is to analyze current structure and goals of the EAU Urolithiasis Panel, along with future ambitions and challenges. PATIENT SUMMARY: Increasing trends in kidney stone disease along with developments in technology necessitate systematic organization of information for urologists in order to be able to follow diagnostic and therapeutic algorithms for optimizing patient care. The role of the European Association of Urology Urolithiasis Guideline Panel is to provide such a tool by development of urolithiasis guidelines on an annual basis.

Imaging modalities and treatment of paediatric upper tract urolithiasis: A systematic review and update on behalf of the EAU urolithiasis guidelines panel.

BACKGROUND: Prompt diagnosis and treatment of paediatric urolithiasis are required to avoid long term sequelae of renal damage. OBJECTIVE: To systematically review the literature regarding the diagnostic imaging modalities and treatment approaches for paediatric urolithiasis. STUDY DESIGN: PubMed, Science Direct, Scopus and Web of Science were systematically searched from January 1980-January 2019. 76 full-text articles were included. RESULTS: Ultrasound and Kidney-Ureter-Bladder radiography are the baseline diagnostic examinations. Non-contrast Computed Tomography (CT) is the second line choice with high sensitivity (97-100%) and specificity (96-100%). Magnetic Resonance Urography accounts only for 2% of pediatric stone imaging studies. Expectant management for single, asymptomatic lower pole renal stones is an acceptable initial approach, especially in patients with non-struvite, non-cystine stones<7 mm. Limited studies exist on medical expulsive therapy as off-label treatment. Extracorporeal shock wave lithotripsy (SWL) is the first-line treatment with overall stone free rates (SFRs) of 70-90%, retreatment rates 4-50% and complication rates up to 15%. Semi-rigid ureteroscopy is effective with SFRs of 81-98%, re-treatment rates of 6.3-10% and complication rates of 1.9-23%. Flexible ureteroscopy has shown SFRs of 76-100%, retreatment rates of 0-19% and complication rates of 0-28%. SFRs after first and second-look percutaneous nephrolithotomy (PNL) are 70.1-97.3% and 84.6-97.5%, respectively with an overall complication rate of 20%. Open surgery is seldom used, while laparoscopy is effective for stones refractory to SWL and PNL. Limited data exist for robot-assisted management. CONCLUSIONS: In the initial assessment of paediatric urolithiasis, US is recommended as first imaging modality, while non-contrast CT is the second option. SWL is recommended as first line treatment for renal stones <20 mm and for ureteral stones<10 mm. Ureteroscopy is a feasible alternative both for ureteral stones not amenable to SWL as well as for renal stones <20 mm (using flexible). PNL is recommended for renal stones >20 mm.

European Association of Urology Guidelines Office Rapid Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era.

The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by modern science-based medicine. Health systems across the world are struggling to manage it. Added to this struggle are the effects of social confinement and isolation. This brings into question whether the latest guidelines are relevant in this crisis. We aim to support urologists in this difficult situation by providing tools that can facilitate decision making, and to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible. We hope that the revised recommendations will assist urologist surgeons across the globe to guide the management of urological conditions during the current COVID-19 pandemic.

Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel.

CONTEXT: Bladder stones (BS) constitute 5% of urinary stones. Currently, there is no systematic review of their treatment. OBJECTIVE: To assess the efficacy (primary outcome: stone-free rate [SFR]) and morbidity of BS treatments. EVIDENCE ACQUISITION: This systematic review was conducted in accordance with the European Association of Urology Guidelines Office. Database searches (1970-2019) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and nonrandomised studies (NRSs) with ≥10 patients per group. Quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. EVIDENCE SYNTHESIS: A total of 2742 abstracts and 59 full-text articles were assessed, and 25 studies (2340 patients) were included. In adults, one RCT found a lower SFR following shock wave lithotripsy (SWL) than transurethral cystolithotripsy (TUCL; risk ratio 0.88, p=0.03; low QoE). Four RCTs compared TUCL versus percutaneous cystolithotripsy (PCCL): meta-analyses demonstrated no difference in SFR, but hospital stay (mean difference [MD] 0.82d, p<0.00001) and procedure duration (MD 9.83min, p<0.00001) favoured TUCL (moderate QoE). Four NRSs comparing open cystolithotomy (CL) versus TUCL or PCCL found no difference in SFR; hospital stay and procedure duration favoured endoscopic surgery (very low QoE). Four RCTs compared TUCL using a nephroscope versus a cystoscope: meta-analyses demonstrated no difference in SFR; procedure duration favoured the use of a nephroscope (MD 22.74min, p<0.00001; moderate QoE). In children, one NRS showed a lower SFR following SWL than TUCL or CL. Two NRSs comparing CL versus TUCL/PCCL found similar SFRs; catheterisation time and hospital stay favoured endoscopic treatments. One RCT comparing laser versus pneumatic TUCL found no difference in SFR. One large NRS comparing CL techniques found a shorter hospital stay after tubeless CL in selected cases; QoE was very low. CONCLUSIONS: Current available evidence indicates that TUCL is the intervention of choice for BSs in adults and children, where feasible. Further high-quality research on the topic is required. PATIENT SUMMARY: We examined the literature to determine the most effective and least harmful procedures for bladder stones in adults and children. The results suggest that endoscopic surgery is equally effective as open surgery. It is unclear whether stone size affects outcomes. Shock wave lithotripsy appears to be less effective. Endoscopic treatments appear to have shorter catheterisation time and convalescence compared with open surgery in adults and children. Transurethral surgery, where feasible, appears to have a shorter hospital stay than percutaneous surgery. Further research is required to clarify the efficacy of minimally invasive treatments for larger stones and in young children.

The stone surgeon in the mirror: how are German-speaking urologists treating large renal stones today?

OBJECTIVE: To elucidate the current treatment strategies of LRS in German-speaking Europe. Little is known about the treatment of large renal stones (LRS > 3 cm) in daily urological practice. LRS therapy can be, however, challenging and hazardous. MATERIALS AND METHODS: A 39 item web-based survey was performed among urologists listed by the German, Austrian and Swiss Associations of Urology, addressing professionals treating LRS "on their own" and working in a German-speaking country. Uniparametric descriptions indicated as absolute numbers and percentages without p values, simple linear associations and bubble plots without arithmetic means or bar charts with standard deviation between targeted parameters and percentages were used. RESULTS: 266 of the 6586 responding urologists claimed to treat urinary stones on a regular basis. The majority of them were male (90.2%) and over 50 years old (42.9%). Most stones are treated in non-university hospitals (69.5%). 81.9% of all the institutions treat more than 150 cases/y. Open surgery is still performed in 45.5% of the centres, laparoscopy in 32%. Percutaneous nephrolithotomy (PNL) is the primary treatment option. Antimicrobial strategies vary considerably. Serious complications seem to be rare. However, quite a few responders reported treatment-related deaths. The main limitation is the absolute number of urologists performing LRS treatment, which is unknown. CONCLUSIONS: The German-speaking urologist treating LRS is a male and over 50. Although he performs PNL primarily, he is not averse to open surgery and SWL. He applies guidelines and employs modern equipment. Only antimicrobial strategies are out of line with the international standards.

The Role of Medical Expulsive Therapy for Ureteral Stones: Pro MET.

Medical expulsive therapy is efficacious in patients with ureteric stones who are amenable to conservative management. The greatest benefit might be among those with larger stones. Therefore, the European Association of Urology Guideline Panel has kept the recommendation to offer α-blockers for patients with distal ureteral stones of 5-10mm.

Tract Sizes in Miniaturized Percutaneous Nephrolithotomy: A Systematic Review from the European Association of Urology Urolithiasis Guidelines Panel.

CONTEXT: Miniaturized instruments for percutaneous nephrolithotomy (PNL), utilizing tracts sized ≤22 Fr, have been developed in an effort to reduce the morbidity and increase the efficiency of stone removal compared with standard PNL (>22 Fr). OBJECTIVE: We systematically reviewed all available evidence on the efficacy and safety of miniaturized PNL for removing renal calculi. EVIDENCE ACQUISITION: The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Since it was not possible to perform a meta-analysis, the data were summarized in a narrative synthesis. EVIDENCE SYNTHESIS: After screening 2945 abstracts, 18 studies were included (two randomized controlled trials [RCTs], six nonrandomized comparative studies, and 10 case series). Thirteen studies were full-text articles and five were only available as congress abstracts. The size of tracts used in miniaturized procedures ranged from 22 Fr to 4.8 Fr. The largest mean stone size treated using small instruments was 980mm2. Stone-free rates were comparable in miniaturized and standard PNL procedures. Procedures performed with small instruments tended to be associated with significantly lower blood loss, while the procedure duration tended to be significantly longer. Other complications were not notably different between PNL types. Study designs and populations were heterogeneous. Study limitations included selection and outcome reporting bias, as well as a lack of information on relevant confounding factors. CONCLUSIONS: The studies suggest that miniaturized PNL is at least as efficacious and safe as standard PNL for the removal of renal calculi. However, the quality of the evidence was poor, drawn mainly from small studies, the majority of which were single-arm case series, and only two of which were RCTs. Furthermore, the tract sizes used and types of stones treated were heterogeneous. Hence, the risks of bias and confounding were high, highlighting the need for more reliable data from RCTs. PATIENT SUMMARY: Removing kidney stones via percutaneous nephrolithotomy (PNL) using smaller sized instruments (mini-PNL) appears to be as effective and safe as using larger (traditional) instruments, but more clinical research is needed.

Medical Expulsive Therapy for Ureterolithiasis: The EAU Recommendations in 2016.

Medical expulsive therapy (MET), in particular α-blockers, have been recommended as supportive medication if observational treatment of a ureteral stone was an option. Over the years, a considerable number of randomized controlled trials (RCT) as well as several meta-analyses have been published on MET, supporting the use of α-blockers. However, several recently published high quality, large, placebo-controlled randomized trials raised serious doubts about the effectiveness of α-blockers. The contradictory results of meta-analyses of small RCTs versus the findings of large, well conducted multicenter trials show the methodological vulnerability of meta-analyses, in particular if small single center, lower quality, papers have been included. Small single center trials, for instance, tend to show larger treatment effects compared to multicenter RCTs. It also shows the responsibility of careful planning when conducting a RCT. Trial registration as a prerequisite for approval by ethics committees could in addition minimize publication bias. Weighting the current evidence on whether to use MET, or not, it seems that in distal ureteral stones larger than 5mm, there may be a potential therapeutic benefit for the use of α-blockers. Patients should be informed about the possible, but as yet unproven benefit of using α-blockers in this situation, as well as their off-label use and potential side effects.

EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis.

CONTEXT: Low-dose computed tomography (CT) has become the first choice for detection of ureteral calculi. Conservative observational management of renal stones is possible, although the availability of minimally invasive treatment often leads to active treatment. Acute renal colic due to ureteral stone obstruction is an emergency that requires immediate pain management. Medical expulsive therapy (MET) for ureteral stones can support spontaneous passage in the absence of complicating factors. These guidelines summarise current recommendations for imaging, pain management, conservative treatment, and MET for renal and ureteral stones. Oral chemolysis is an option for uric acid stones. OBJECTIVE: To evaluate the optimal measures for diagnosis and conservative and medical treatment of urolithiasis. EVIDENCE ACQUISITION: Several databases were searched for studies on imaging, pain management, observation, and MET for urolithiasis, with particular attention to the level of evidence. EVIDENCE SYNTHESIS: Most patients with urolithiasis present with typical colic symptoms, but stones in the renal calices remain asymptomatic. Routine evaluation includes ultrasound imaging as the first-line modality. In acute disease, low-dose CT is the method of choice. Ureteral stones <6mm can pass spontaneously in well-controlled patients. Sufficient pain management is mandatory in acute renal colic. MET, usually with α-receptor antagonists, facilitates stone passage and reduces the need for analgesia. Contrast imaging is advised for accurate determination of the renal anatomy. Asymptomatic calyceal stones may be observed via active surveillance. CONCLUSIONS: Diagnosis, observational management, and medical treatment of urinary calculi are routine measures. Diagnosis is rapid using low-dose CT. However, radiation exposure is a limitation. Active treatment might not be necessary, especially for stones in the lower pole. MET is recommended to support spontaneous stone expulsion. PATIENT SUMMARY: For stones in the lower pole of the kidney, treatment may be postponed if there are no complaints. Pharmacological treatment may promote spontaneous stone passage.

EAU Guidelines on Interventional Treatment for Urolithiasis.

CONTEXT: Management of urinary stones is a major issue for most urologists. Treatment modalities are minimally invasive and include extracorporeal shockwave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PNL). Technological advances and changing treatment patterns have had an impact on current treatment recommendations, which have clearly shifted towards endourologic procedures. These guidelines describe recent recommendations on treatment indications and the choice of modality for ureteral and renal calculi. OBJECTIVE: To evaluate the optimal measures for treatment of urinary stone disease. EVIDENCE ACQUISITION: Several databases were searched to identify studies on interventional treatment of urolithiasis, with special attention to the level of evidence. EVIDENCE SYNTHESIS: Treatment decisions are made individually according to stone size, location, and (if known) composition, as well as patient preference and local expertise. Treatment recommendations have shifted to endourologic procedures such as URS and PNL, and SWL has lost its place as the first-line modality for many indications despite its proven efficacy. Open and laparoscopic techniques are restricted to limited indications. Best clinical practice standards have been established for all treatments, making all options minimally invasive with low complication rates. CONCLUSION: Active treatment of urolithiasis is currently a minimally invasive intervention, with preference for endourologic techniques. PATIENT SUMMARY: For active removal of stones from the kidney or ureter, technological advances have made it possible to use less invasive surgical techniques. These interventions are safe and are generally associated with shorter recovery times and less discomfort for the patient.