Skolarikos A. et al., 2025: . European Association of Urology Guidelines on the Diagnosis and Treatment of Urolithiasis.

Andreas Skolarikos, Robert Geraghty, Bhaskar Somani, Thomas Tailly, Helene Jung, Andreas Neisius, Ales Petřík, Guido M Kamphuis, Niall Davis, Carla Bezuidenhout, Michael Lardas, Giovanni Gambaro, John A Sayer, Riccardo Lombardo, Lazaros Tzelves 
Eur Urol. 2025 Jul;88(1):64-75. doi: 10.1016/j.eururo.2025.03.011

Abstract

Background and objective: The European Association of Urology urolithiasis guidelines provide evidence-based recommendations for the diagnosis and treatment of urinary stone disease. Given the complexity and variability of stone formation, individualised patient management is emphasised.

Methods: The guidelines incorporate evidence from the latest research and focus on risk assessment, imaging techniques, pharmacological management, and surgical interventions. A research librarian conducted literature searches for urolithiasis in the Cochrane Library, Medline, and Embase databases via Dialog-Datastar. The strength of recommendations is also rated.

Key findings and limitations: Diagnosis relies on a combination of clinical history, biochemical evaluation, and imaging, with ultrasound as the first-line modality and low-dose computed tomography as the gold standard for precise stone assessment. Stone composition and burden influence treatment decisions with algorithms primarily based on stone size, location, and composition. Nonsteroidal anti-inflammatory drugs are recommended for first-line pain management, with opioids reserved as a secondary option. Medical expulsive therapy with α-blockers may be considered for selected patients with ureteral stones. Extracorporeal shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy remain the primary intervention modalities, with selection based on stone characteristics and patient factors. Advances in multiplanar imaging have improved assessment of the stone burden, although further research is needed to refine predictive models. Genetic testing is recommended for high-risk patients to guide personalised treatment.

Conclusions and clinical implications: The guidelines provide a framework for clinical decision-making while acknowledging the need for continued advances in urolithiasis.

Comment Hans-Göran Tiselius

This article is a publication of European Association of Urology guidelines on diagnosis and treatment of urolithiasis from the EAU guideline group 2025.
For SWL very little has changed between guidelines presented during recent years.
In terms of complications, it is surprising that macroscopic haematuria still is included here. Haematuria accompanies effective stone disintegration and is an expected finding. If there is no macroscopic haematuria the lithotripsy either is unsuccessful for unknown reasons or the lithotripter is too weak.
From the algorithm, I have extracted those data that support the use of SWL either as first (1) or second (2) treatment alternative.

The definition of unfavourable factors for SWL-treatment of lower pole 10-20 mm stones is not included in this article.

Hans-Göran Tiselius