march 2020 • European Association of Urology

EAU Guidelines on Urolithiasis

Türk C., et al

Content curated by:Clara Jasmins

Key message

The 2020 Urolithiasis Guidelines are developed and updated by the European Association of Urology (EAU) according to the best published evidence on the topic. For this update, new and relevant evidence has been identified, collated and appraised through a structured assessment of the literature. Each recommendation was rated according to the GRADE methodology. This guideline include recommendations on diagnosis, management and follow-up of patients with urolithiasis.

Analysis

Population

Patients with renal colic

Method

For the 2020 Urolithiasis Guidelines, new and relevant evidence has been identified, collated and appraised through a structured assessment of the literature. A broad and comprehensive scoping exercise covering all areas of the guideline was performed. The search was limited to studies representing high levels of evidence only (i.e. systematic reviews with meta- analysis (MA), randomised controlled trials (RCTs), and prospective non-randomised comparative studies) published in the English language. The search was restricted to articles published between 1st May 2018 and 2nd May 2019. Databases covered by the search included Medline, EMBASE, Ovid and the Cochrane Libraries. A total of 887 unique records were identified, and screened for relevance. For each recommendation within the guidelines there is an accompanying online strength rating form, the basis of which is a modified GRADE methodology.

Results

Diagnostic Evaluation 1. Diagnostic imaging - Immediate imaging is indicated with fever or solitary kidney, and when diagnosis is doubtful. (Strong recommendation) - Use non-contrast-enhanced computed tomography to confirm stone diagnosis in patients with acute flank pain following initial ultrasound assessment. (Strong recommendation) - Perform a contrast study if stone removal is planned and the anatomy of the renal collecting system needs to be assessed. (Strong recommendation) 2. Laboratory examinations and stone analysis - emergency urolithiasis patients 2.1 Urine - Dipstick test of spot urine sample: » red cells; » white cells; » nitrites; » approximate urine pH; » urine microscopy and/or culture. (Weak recommendation) 2.2 Blood - Serum blood sample: » creatinine; » uric acid; » (ionised) calcium; » sodium; » potassium; » blood cell count; » C-reactive protein. (Weak recommendation) - Perform a coagulation test (partial thromboplastin time and international normalised ratio) if intervention is likely or planned. (Strong recommendation) - Perform stone analysis in first-time formers using a valid procedure (X-ray diffraction or infrared spectroscopy). (Strong recommendation) - Repeat stone analysis in patients presenting with: » recurrent stones despite drug therapy; » early recurrence after complete stone clearance; » late recurrence after a long stone-free period because stone composition may change. (Strong recommendation) 3. Diagnostic imaging during pregnancy - Use ultrasound as the preferred method of imaging in pregnant women. (Strong recommendation) - In pregnant women, use magnetic resonance imaging as a second-line imaging modality. (Strong recommendation) - In pregnant women, use low-dose computed tomography as a last-line option. (Strong recommendation) 4. Diagnostic imaging in children - Complete a metabolic evaluation based on stone analysis in all children. (Strong recommendation) - Collect stone material for analysis to classify the stone type. (Strong recommendation) - Perform ultrasound as first-line imaging modality in children when a stone is suspected; it should include the kidney, fluid-filled bladder and the ureter. (Strong recommendation) - Perform a kidney-ureter-bladder radiography (or low-dose non-contrast-enhanced computed tomography) if ultrasound will not provide the required information. (Strong recommendation) Disease Management 5. Management of renal colic - Offer a non-steroidal anti-inflammatory as the first drug of choice; e.g. metamizol (dipyrone); alternatively paracetamol or, depending on cardiovascular risk factors, diclofenac, indomethacin or ibuprofen. (Strong recommendation) - Offer opiates (hydromorphine, pentazocine or tramadol) as a second choice. (Weak recommendation) - Offer renal decompression or ureteroscopic stone removal in case of analgesic refractory colic pain. (Strong recommendation) 6. Management of sepsis and anuria - Urgently decompress the collecting system in case of sepsis with obstructing stones, using percutaneous drainage or ureteral stenting. (Strong recommendation) - Delay definitive treatment of the stone until sepsis is resolved. (Strong recommendation) - Collect (again) urine for antibiogram test following decompression. (Strong recommendation) - Start antibiotics immediately (+ intensive care, if necessary). (Strong recommendation) - Re-evaluate antibiotic regimen following antibiogram findings. (Strong recommendation) 7. Medical expulsive therapy - Offer α-blockers as medical expulsive therapy as one of the treatment options for (distal) ureteral stones > 5 mm. (Strong recommendation) 8. Chemolysis - Inform the patient how to monitor urine-pH by dipstick and to modify the dosage of alkalising medication according to urine pH, as changes in urine pH are a direct consequence of such medication. (Strong recommendation) - Carefully monitor patients during/after oral chemolysis of uric acid stones. (Strong recommendation) - Combine oral chemolysis with tamsulosin in case of (larger) ureteral stones (if active intervention is not indicated). (Weak recommendation) 9. Shock wave lithotripsy - Ensure correct use of the coupling agent because this is crucial for effective shock wave transportation. (Strong recommendation) - Maintain careful fluoroscopic and/or ultrasonographic monitoring during shock wave lithotripsy (SWL). (Strong recommendation) - Use proper analgesia because it improves treatment results by limiting pain-induced movements and excessive respiratory excursions. (Strong recommendation) - Prescribe antibiotics prior to SWL in the case of infected stones or bacteriuria. (Strong recommendation) 10. Ureteroscopy (URS), Ureteroscopy for renal stones (RIRS) and antegrade ureteroscopy - Use holmium: yttrium-aluminium-garnet (Ho:YAG) laser lithotripsy for (flexible) ureteroscopy (URS). (Strong recommendation) - Perform stone extraction only under direct endoscopic visualisation of the stone. (Strong recommendation) - Do not insert a stent in uncomplicated cases. (Strong recommendation) - Pre-stenting facilitates URS and improves outcomes of URS (in particular for renal stones). (Strong recommendation) - Offer medical expulsive therapy for patients suffering from stent-related symptoms and after Ho:YAG laser lithotripsy to facilitate the passage of fragments. (Strong recommendation) - Use percutaneous antegrade removal of ureteral stones as an alternative when shock wave lithotripsy (SWL) is not indicated or has failed, and when the upper urinary tract is not amenable to retrograde URS. (Strong recommendation) - Use flexible URS in cases where percutaneous nephrolithotomy or SWL are not an option (even for stones > 2 cm). However, in this case there is a higher risk that a follow-up procedure and placement of a ureteral stent may be needed. (Strong recommendation) 11. Endourology techniques for renal stone removal - Perform pre-procedural imaging, including contrast medium where possible or retrograde study when starting the procedure, to assess stone comprehensiveness and anatomy of the collecting system to ensure safe access to the renal stone. (Strong recommendation) - Perform a tubeless (without nephrostomy tube) or totally tubeless (without nephrostomy tube and ureteral stent) percutaneous nephrolithotomy procedure, in uncomplicated cases. (Strong recommendation) 12. General recommendations and precautions for stone removal - Obtain a urine culture or perform urinary microscopy before any treatment is planned. (Strong recommendation) - Exclude or treat urinary tract infections prior to stone removal. (Strong recommendation) - Offer peri-operative antibiotic prophylaxis to all patients undergoing endourological treatment. (Strong recommendation) 13. Antithrombotic therapy and stone treatment - Offer active surveillance to patients at high risk of thrombotic complications in the presence of an asymptomatic calyceal stone. (Weak recommendation) - Decide on temporary discontinuation, or bridging of antithrombotic therapy in high-risk patients, in consultation with the internist. (Strong recommendation) - Retrograde (flexible) URS is the preferred intervention if stone removal is essential and antithrombotic therapy cannot be discontinued, since it is associated with less morbidity. (Strong recommendation) 14. Stone composition - Consider the stone composition before deciding on the method of removal, based on patient history, former stone analysis of the patient or Hounsfield unit on unenhanced computed tomography. (Strong recommendation) Attempt to dissolve radiolucent stones. (Strong recommendation) 15. Selection of procedure for active removal of ureteral stones - In patients with newly diagnosed small ureteral stones, if active removal is not indicated, observe patient initially with periodic evaluation. (Strong recommendation) - Offer α-blockers as medical expulsive therapy as one of the treatment options for (distal) ureteral stones > 5 mm. (Strong recommendation) - Inform patients that ureteroscopy (URS) has a better chance of achieving stone-free status with a single procedure. (Strong recommendation) - Inform patients that URS has higher complication rates when compared to shock wave lithotripsy. (Strong recommendation) - In cases of severe obesity use URS as first-line therapy for ureteral (and renal) stones. (Strong recommendation) 16. Management of renal stones - Follow-up periodically in cases where renal stones are not treated (initially after six months then yearly, evaluating symptoms and stone status [either by ultrasound, kidney-ureter bladder radiography or computed tomography]). (Strong recommendation) - Offer active treatment for renal stones in case of stone growth, de novo obstruction, associated infection, and acute and/or chronic pain. (Weak recommendation) - Evaluate 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 recommendation) - Perform PNL as first-line treatment of larger stones > 2 cm. (Strong recommendation) - Treat larger stones (> 2 cm) with flexible ureteroscopy or SWL, in cases where PNL is not an option. However, in such instances there is a higher risk that a follow-up procedure and placement of a ureteral stent may be needed. (Strong recommendation) - Perform PNL or RIRS for the lower pole, even for stones < 1 cm, as the efficacy of SWL is limited (depending on favourable and unfavourable factors for SWL). (Strong recommendation) 17. Laparoscopy and open surgery - Offer laparoscopic or open surgical stone removal in rare cases in which shock wave lithotripsy, retrograde or antegrade ureteroscopy and percutaneous nephrolithotomy fail, or are unlikely to be successful. (Strong recommendation) 18. Steinstrasse - Treat steinstrasse associated with urinary tract infection (UTI)/fever preferably with percutaneous nephrostomy. (Weak recommendation) - Treat steinstrasse when large stone fragments are present with shock wave lithotripsy or ureteroscopy (in absence of signs of UTI). (Weak recommendation) 19. Management of patients with residual stones - Perform imaging after shock wave lithotripsy, ureteroscopy or percutaneous antegrade ureteroscopy to determine presence of residual fragments. (Strong recommendation) 20. Management of urinary stones and related problems during pregnancy - Treat all uncomplicated cases of urolithiasis in pregnancy conservatively (except when there are clinical indications for intervention). (Strong recommendation) 21. Management of stones in patients with urinary diversion - Perform percutaneous lithotomy to remove large renal stones in patients with urinary diversion, as well as for ureteral stones that cannot be accessed via a retrograde approach, or that are not amenable to shock wave lithotripsy. (Strong recommendation) 22. Management of stones in patients with neurogenic bladder - Take appropriate measures regardless of the treatment provided since in myelomeningocele patients latex allergy is common. (Strong recommendation) 23. Management of stones in patients with transplanted kidneys - Offer patients with transplanted kidneys, any of the contemporary management options, including shock wave lithotripsy, flexible ureteroscopy and percutaneous nephrolithotomy. (Weak recommendation) 24. Management of stones in children - Offer children with single ureteral stones less than 10 mm shock wave lithotripsy (SWL) if localisation is possible as first line option. (Strong recommendation) - Ureteroscopy is a feasible alternative for ureteral stones not amenable to SWL. (Strong recommendation) - Offer children with renal stones with a diameter of up to 20 mm (~300 mm2) SWL. (Strong recommendation) - Offer children with renal pelvic or calyceal stones with a diameter > 20 mm (~300 mm2) percutaneous nephrolithotomy. (Strong recommendation) - Retrograde renal surgery is a feasible alternative for renal stones smaller than 20 mm in all locations. (Weak recommendation) Follow-up: Metabolic evaluation and recurrence prevention 25. Recurrence prevention - Advise patients that a generous fluid intake is to be maintained, allowing for a 24-hour urine volume > 2.5 L. (Strong recommendation) 26. Pharmacological treatments for patients with specific abnormalities in urine composition (based on 24-hour urine samples) - Prescribe thiazide + alkaline citrates in case of hypercalcuria. (Strong recommendation) - Advise oxalate restriction if hyperoxaluria is present. (Weak recommendation) - Offer alkaline citrates in enteric hyperoxaluria. (Weak recommendation) - Offer calcium supplement in enteric hyperoxaluria. (Weak recommendation) - Advise reduced dietary fat and oxalate in enteric hyperoxaluria. (Weak recommendation) - Prescribe alkaline citrates and sodium bicarbonate in case of hypocitraturia. (Strong recommendation) - Prescribe allopurinol in case of hyperuricosuria. (Strong recommendation) - Offer febuxostat as second-line treatment of hypericosuria. (Strong recommendation) - Avoid excessive intake of animal protein in hypericosuria. (Strong recommendation) - Advise restricted intake of salt if there is high urinary sodium excretion. (Strong recommendation) 27. Management of calcium phosphate stones - Prescribe thiazide in case of hypercalciuria. (Strong recommendation) - Advise patients to acidify their urine in case of high urine pH. (Weak recommendation) 28. Management of primary hyperoxaluria - Prescribe pyridoxine for primary hyperoxaluria. (Strong recommendation) 29. Management of enteric hyperoxaluria - Prescribe alkaline citrates for enteric hyperoxaluria. (Weak recommendation) - Advise patients to take calcium supplements with meals. (Weak recommendation) - Advise patients to follow a diet with a low fat and oxalate content. (Weak recommendation) 30. Management of tubular acidosis - Prescribe alkaline citrates for distal renal tubular acidosis. (Weak recommendation) - Prescribe thiazide and alkaline citrates for hypercalciuria. (Strong recommendation) 31. Management of uric acid and ammonium urate stones - Prescribe alkaline citrates to alkalinise the urine in urate stone formers. (Strong recommendation) - Prescribe allopurinol in hyperuricosuric urate stone formers. (Strong recommendation) 32. Management of infection stones - Surgically remove the stone material as completely as possible. (Strong recommendation) - Prescribe antibiotics in case of persistent bacteriuria. (Strong recommendation) - Prescribe ammonium chloride, 1 g, two or three times daily to ensure urinary acidification. (Weak recommendation) - Prescribe methionine, 200-500 mg, one to three times daily, as an alternative, to ensure urinary acidification. (Weak recommendation) 33. Management of cystine stones Therapeutic measures: - Urine dilution » Advise patients to increase their fluid intake so that 24-hour urine volume exceeds 3 L. (Strong recommendation) - Alkalinisation » Prescribe potassium citrate 3-10 mmol two or three times daily, to achieve pH > 7.5 for patients with cystine excretion < 3 mmol/day. (Strong recommendation) - Complex formation with cystine » For patients with cystine excretion, > 3 mmol/day, or when other measures are insufficient: prescribe in addition to other measures tiopronin, 250-2,000 mg/day. (Strong recommendation) 34. Investigation for the assessment of patients with stones of unknown composition - Take a medical history » Stone history (former stone events, family history) » Dietary habits » Medication chart (Strong recommendation) - Perform diagnostic imaging » Ultrasound in the case of a suspected stone » Un-enhanced helical computed tomography » Determination of Hounsfield units provides information about the possible stone composition (Strong recommendation) - Perform a blood analysis » Creatinine » Calcium (ionised calcium or total calcium + albumin) » Uric acid (Strong recommendation) - Perform a urinalysis » Urine pH profile (measurement after each voiding, minimum four times daily) » Dipstick test: leukocytes, erythrocytes, nitrites, protein, urine pH, specific weight » Urine cultures » Microscopy of urinary sediment (morning urine) » Cyanide nitroprusside test (cystine exclusion) »Further examinations depend on the results of the investigations listed above. (Strong recommendation)

Abstract

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. 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. Management of bladder stones are dealt with in a separate guideline authored by the same guideline group. 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. The EAU Urolithiasis Guidelines were first published in 2000. This 2020 document presents a limited update of the 2019 version. The literature for the entire document has been checked and, wherever relevant, updated.