Geraghty RM. et al., 2023: Best Practice in Interventional Management of Urolithiasis: An Update from the European Association of Urology Guidelines Panel for Urolithiasis 2022

Monday, 26 February 2024

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Geraghty RM, Davis NF, Tzelves L, Lombardo R, Yuan C, Thomas K, Petrik A, Neisius A, Türk C, Gambaro G, Skolarikos A, Somani BK
Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK; Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK.
Department of Urology, Beaumont Hospital, Dublin 9, Co Dublin, Ireland; Department of Surgery, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland.
Department of Urology, Sismanogleio Hospital, National and Kapodistrian University of Athens, Athens, Greece.
Sant 'Andrea Hospital, Sapienza University, Rome, Italy.
Division of Gastroenterology & Cochrane UGPD Group, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, Canada.
Department of Urology, Guy's and St Thomas' Hospital, London, UK.
Department of Urology, Region Hospital, Ceske Budejovice, Czech Republic; Department of Urology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
Department of Urology, Bruederkrankenhaus Trier, Johannes Gutenberg University Mainz, Trier, Germany.
Department of Urology, Hospital of the Sisters of Charity, Vienna, Austria.
Division of Nephrology and Dialysis, Department of Medicine, University of Verona, Verona, Italy.
Department of Urology, Sismanogleio Hospital, National and Kapodistrian University of Athens, Athens, Greece. Electronic
Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK

Abstract

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.

Eur Urol Focus. 2023 Jan;9(1):199-208. doi: 10.1016/j.euf.2022.06.014. Epub 2022 Aug 1.PMID: 35927160 Review.

Comments 1

Hans-Göran Tiselius on Monday, 26 February 2024 10:00

This article summarizes the essential points formulated by the EAU Guideline Panel for Urolithiasis 2022.

The most important points related to SWL in the article are shown below:
It is stated that stents do not improve stone-free rate but can reduce formation of steinstrasse. I agree with that point because stents can maintain a reasonably normal urine flow despite accumulation of fragments in the ureter. Thereby management of fragment accumulations with repeated SWL is facilitated making URS unnecessary.

Treating patients with pace-makers nowadays apparently are more complicated than it used to be and it is obvious that patients with modern pacemakers cannot or should not be SWL-treated without presence of a cardiologist.

To improve fragmentation and stone-free rates shock waves should be delivered with a frequency of 1-1.5 Hz. The advantage of ramping is discussed and questioned. Important is, however, that the patient during stepwise increment of the shock wave power becomes adapted to shock wave administration and pain.
Interestingly and surprisingly, despite four decades of experience with SWL, there is no strong recommendation on the most appropriate interval between repeated shock wave sessions. It seems reasonable, however, to consider the healing time of 10-14 days for renal contusions (reviewer’s comment).
That optimal pain control is necessary is emphasized.

The reviewer thinks that antibiotics, only because of stent insertion, is unnecessary provided the patient is without bacteriuria/urinary tract infection and the stent insertion is made under sterile conditions.
The role of mechanical percussion is said to be of importance for fragment passage [1, 2]. It is the reviewer’s opinion that much more should be done to include such procedures as a natural part of SWL of lower calyx stones.

References

1. Zeng T, Tiselius HG, Huang J, Deng T, Zeng G, Wu W. Effect of mechanical percussion combined with patient position change on the elimination of upper urinary stones/fragments: a systematic review and meta-analysis.Urolithiasis. 2020 Apr;48(2):95-102. doi: 10.1007/s00240-019-01140-2. Epub 2019 May 6.PMID: 31062070
2. 2. Wu W, Yang Z, Tang F, Xu C, Wang Y, Gu X, Chen X, Wang R, Yan J, Wang X, Gao W, Hou C, Guo J, Zhang J, Gurioli A, Ye Z, Zeng G. How to accelerate the upper urinary stone discharge after extracorporeal shockwave lithotripsy (ESWL) for

This article summarizes the essential points formulated by the EAU Guideline Panel for Urolithiasis 2022.

The most important points related to SWL in the article are shown below:
It is stated that stents do not improve stone-free rate but can reduce formation of steinstrasse. I agree with that point because stents can maintain a reasonably normal urine flow despite accumulation of fragments in the ureter. Thereby management of fragment accumulations with repeated SWL is facilitated making URS unnecessary.

Treating patients with pace-makers nowadays apparently are more complicated than it used to be and it is obvious that patients with modern pacemakers cannot or should not be SWL-treated   without presence of a cardiologist.

To improve fragmentation and stone-free rates shock waves should be delivered with a frequency of 1-1.5 Hz. The advantage of ramping is discussed and questioned. Important is, however, that the patient during stepwise increment of the shock wave power becomes adapted to shock wave administration and pain.
Interestingly and surprisingly, despite four decades of experience with SWL, there is no strong recommendation on the most appropriate interval between repeated shock wave sessions. It seems reasonable, however, to consider the healing time of 10-14 days for renal contusions (reviewer’s comment).
That optimal pain control is necessary is emphasized.

The reviewer thinks that antibiotics, only because of stent insertion, is unnecessary provided the patient is without bacteriuria/urinary tract infection and the stent insertion is made under sterile conditions.
The role of mechanical percussion is said to be of importance for fragment passage [1, 2]. It is the reviewer’s opinion that much more should be done to include such procedures as a natural part of SWL of lower calyx stones.

References

1.	Zeng T, Tiselius HG, Huang J, Deng T, Zeng G, Wu W. Effect of mechanical percussion combined with patient position change on the elimination of upper urinary stones/fragments: a systematic review and meta-analysis.Urolithiasis. 2020 Apr;48(2):95-102. doi: 10.1007/s00240-019-01140-2. Epub 2019 May 6.PMID: 31062070
2.	2.  Wu W, Yang Z, Tang F, Xu C, Wang Y, Gu X, Chen X, Wang R, Yan J, Wang X,  Gao W, Hou C, Guo J, Zhang J, Gurioli A, Ye Z, Zeng G.  How to accelerate the upper urinary stone discharge after extracorporeal shockwave lithotripsy (ESWL) for

This article summarizes the essential points formulated by the EAU Guideline Panel for Urolithiasis 2022. The most important points related to SWL in the article are shown below: It is stated that stents do not improve stone-free rate but can reduce formation of steinstrasse. I agree with that point because stents can maintain a reasonably normal urine flow despite accumulation of fragments in the ureter. Thereby management of fragment accumulations with repeated SWL is facilitated making URS unnecessary. Treating patients with pace-makers nowadays apparently are more complicated than it used to be and it is obvious that patients with modern pacemakers cannot or should not be SWL-treated without presence of a cardiologist. To improve fragmentation and stone-free rates shock waves should be delivered with a frequency of 1-1.5 Hz. The advantage of ramping is discussed and questioned. Important is, however, that the patient during stepwise increment of the shock wave power becomes adapted to shock wave administration and pain. Interestingly and surprisingly, despite four decades of experience with SWL, there is no strong recommendation on the most appropriate interval between repeated shock wave sessions. It seems reasonable, however, to consider the healing time of 10-14 days for renal contusions (reviewer’s comment). That optimal pain control is necessary is emphasized. The reviewer thinks that antibiotics, only because of stent insertion, is unnecessary provided the patient is without bacteriuria/urinary tract infection and the stent insertion is made under sterile conditions. The role of mechanical percussion is said to be of importance for fragment passage [1, 2]. It is the reviewer’s opinion that much more should be done to include such procedures as a natural part of SWL of lower calyx stones. References 1. Zeng T, Tiselius HG, Huang J, Deng T, Zeng G, Wu W. Effect of mechanical percussion combined with patient position change on the elimination of upper urinary stones/fragments: a systematic review and meta-analysis.Urolithiasis. 2020 Apr;48(2):95-102. doi: 10.1007/s00240-019-01140-2. Epub 2019 May 6.PMID: 31062070 2. 2. Wu W, Yang Z, Tang F, Xu C, Wang Y, Gu X, Chen X, Wang R, Yan J, Wang X, Gao W, Hou C, Guo J, Zhang J, Gurioli A, Ye Z, Zeng G. How to accelerate the upper urinary stone discharge after extracorporeal shockwave lithotripsy (ESWL) for

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