Surgical management of urolithiasis – a systematic analysis of available guidelines

Abstract

BackgroundSeveral societies around the world issue guidelines incorporating the latest evidence. However, even the most commonly cited guidelines of the European Association of Urology (EAU) and the American Urological Association (AUA) leave the clinician with several treatment options and differ on specific points. We aimed to identify discrepancies and areas of consensus between guidelines to give novel insights into areas where low consensus between the guideline panels exists, and therefore where more evidence might increase consensus.MethodsThe webpages of the 61 members of the Societé Internationale d’Urologie were analysed to identify all listed or linked guidelines. Decision trees for the surgical management of urolithiasis were derived, and a comparative analysis was performed to determine consensus and discrepancies.ResultsFive national and one international guideline (EAU) on surgical stone treatment were available for analysis. While 7 national urological societies refer to the AUA guidelines and 11 to the EAU guidelines, 43 neither publish their own guidelines nor refer to others. Comparative analysis revealed a high degree of consensus for most renal and ureteral stone scenarios. Nevertheless, we also identified a variety of discrepancies between the different guidelines, the largest being the approach to the treatment of proximal ureteral calculi and larger renal calculi.ConclusionsSix guidelines with recommendations for the surgical treatment of urolithiasis to support urologists in decision-making were available for inclusion in our analysis. While there is a high grade of consensus for most stone scenarios, we also detected some discrepancies between different guidelines. These are, however, controversial situations where adequate evidence to assist with decision-making has yet to be elicited by further research.

Comparison of Efficacy and Complications of Holmium Laser and Pneumatic Lithotripters Used in the Ureterorenoscopic Treatment of Proximal Ureter Stones, a Multi-Center Study of Society of Urological Surgery Aegean Study Group

“…Although ESWL has been used as the first option for the treatment of proximal ureteral stones, with the recent developments in ureterorenoscopes leading to the reduction in their diameter and the emergence of flexible devices, URS has become the first treatment choice, in particular for stones >10 mm (6). The technical improvement of lithotripters used predominantly for stone fragmentation has led to an increase in the URS success rates and decrease in the complication rates (7,12).…”

“…If there is no indication for active stone removal, the first treatment option is either conservative monitoring or medical expulsive treatment. According to the European Association of Urology guidelines, if there is an indication for active stone removal (for stones that are not likely to pass spontaneously and in the presence of symptoms, such as persistent pain despite adequate analgesic treatment, persistent obstruction, and renal insufficiency), the first treatment choice for proximal ureteral stones is URS if the stone is larger than 10 mm and ESWL or URS if the stone size is less than 10 mm (6). Studies have shown that the success of URS is affected by the size, location, number and composition of the stone, whether it is impacted, and the lithotripter that is used (7,8).…”

International guidelines on stage III N2 nonsmall cell lung cancer: surgery or radiotherapy?

“…The recommendations on stage III N2 NSCLC within the guidelines were reduced to recommendations towards a definitive surgical approach (with neoadjuvant or adjuvant Ch/CRT), a definitive CRT approach or no preference (no specific recommendation for either RT or surgery and both being options). Decision criteria implemented were analysed and standardised if their meaning was not changed, as described by PANJE et al [25][26][27]. Universal criteria such as the ability to give informed consent were not included in this analysis.…”

Effect of the Anesthetic Method on the Outcomes of Ureteroscopy for Proximal Ureteral Stones: A Multi-center Study of the Society of Urological Surgery Aegean Study Group

“…Stones with a low chance of spontaneous passage, persistent pain despite adequate analgesic treatment, persistent obstruction and renal insufficiency constitute the indications for active ureteral stone removal (5). Currently, treatment options for ureteral stones are observation, medical expulsive therapy, shock wave lithotripsy (SWL), ureteroscopy (URS), percutaneous nephrolithotomy, laparoscopic surgery, and open surgery (6).…”