Year : 2021 | Volume
: 33 | Issue : 2 | Page : 50--52
Guidelines and medical management of stone disease: Do we have a consensus?
Lazaros Tzelves, Panagiotis Mourmouris, Andreas Skolarikos
Department of Urology, National and Kapodistrian University of Athens, Sismanogleio General Hospital, Athens, Greece
Department of Urology, National and Kapodistrian University of Athens, Sismanogleio General Hospital, 1st Sismanogleiou Str, Marousi, Athens
Medical management of the stone disease is a topic of controversy even between worldwide guidelines. With this review, we attempt to clarify the disparities that exist in the literature and provide to the clinical urologist a tool for battling this common disease. The search was based on current Guidelines from national and international urological Associations including European and American guidelines and the guidelines of Societe d”Urologie. The use of a-blockers is highly indicated by most Guidelines as medical expulsion therapy, whereas nonsteroidal anti-inflammatory medication for pain relief. Fluid intake of 2 lit/day, controlled dietary calcium consumption and sodium restrictions are universal dietary modifications from urological Associations on the prevention of stone disease. Despite methodological heterogeneity and subjective rating of recommendations, an acceptable degree of consensus was noted on Guidelines regarding medical management of the stone disease.
|How to cite this article:|
Tzelves L, Mourmouris P, Skolarikos A. Guidelines and medical management of stone disease: Do we have a consensus?.Hellenic Urology 2021;33:50-52
|How to cite this URL:|
Tzelves L, Mourmouris P, Skolarikos A. Guidelines and medical management of stone disease: Do we have a consensus?. Hellenic Urology [serial online] 2021 [cited 2022 Oct 2 ];33:50-52
Available from: http://www.hellenicurologyjournal.com/text.asp?2021/33/2/50/346058
Urinary lithiasis tends to recur even after successful surgical treatment, with reported rates of recurrence of 50% within a decade after the first stone event, with 10% of them experience more than one recurrent episode. Considering their disease, a chronic condition, many patients often seek measures to prevent future stone episodes. Lifestyle changes, dietary modifications, and pharmaceutical interventions have been studied to aid toward that direction. International scientific committees publish guidelines with the goal of helping clinical decision evidence-based guidance. The variations of methodology often lead to discrepancies between existing guidelines and so the objective of our study is to find points of consensus or ambiguities between them and provide an overall quality assessment of these clinical tools.
Two authors (L. T., A. S.) performed an independent search of existing Guidelines from international/national societies. The search was confined to a membership list of Societe International d' Urologie (SIU), along with the list of international Associations in the American Urological Association (AUA) website. A search in PubMed/MEDLINE until June 30, 2020 using the following terms: “ Guideline OR guide OR recommendation OR algorithm” AND “urolithiasis OR kidney stone disease OR lithiasis OR calculi OR calculus OR nephrolithiasis” and associated MesH terms, was performed. Discrepancies were resolved on consensus between the two authors.
We evaluated each one of the included Guidelines with the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. The reviewer using AGREE II assesses each Guideline on six different domains, namely: scope and purpose, stakeholder involvement, the rigor of development, clarity of presentation, applicability, and editorial independence with a total of 23 questions.
Our search revealed a total of 82 urological Associations across six continents. Sixty-nine of these Associations either provided no recommendations or they provided links for relevant European Urology Association (EAU) or AUA Urolithiasis Guidelines. Recommendations from eight urological committees were eligible: EAU, AUA,,, SIU/International Consultation on Urological Diseases (ICUD), National Institute for Health and Care Excellence (NICE), Urological Association of Asia (UAA), Canadian Urological Association (CUA),, French Urological Association (AFU), and German Urological Association (DGU). An outdated review released by AFU was also excluded.
EAU publishes a yearly updated Guideline on Urolithiasis, which is based on the highest level of existing literature. AUA Guideline on medical management of stones was published in 2014 and reviewed-validated in 2019 by the Panel members. SIU/ICUD Guideline contains recommendations based onOxford Centre for Evidence-Based Medicine (OCEBM) definitions of level of evidence (LOE)/grade of recommendation (GOR) and information after reviewing EAU/AUA Guidelines. UAA developed the Guideline on urolithiasis after literature review between 1966 and 2017 with a combined search in EAU and AUA Guidelines. GOR was assessed after a literature search, while LOE was based on a system modified from OCEBM.
NICE produces evidence-based recommendations after literature review on a specific topic, performed by experts. Update is planned every 3 years, except an urgent circumstance requires a faster renewal.
There seems to be a consensus between guidelines (EAU, NICE, UAA, AFU, and DGU) for the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as 1st line treatment in renal colic, except in patients with contraindications (pregnancy, renal insufficiency, ischemic heart disease). The most commonly recommended drugs are diclofenac, metamizole, indomethacin, and ibuprofen, UAA also recommends NSAIDs/steroids for increased stone passage, while DGU for further pain episodes prevention. Alternatively, paracetamol is the drug of choice when NSAIDS cannot be used, while it is also suitable for pregnant/lactating women. Opiates are considered a 2nd line treatment option.
Almost all guidelines rate the recommendation of a-blockers as medical expulsion therapy with a high LOE, while the cut-off stone size is yet to be determined. EAU and UAA recommend the drug for stones >5 mm, while AUA and NICE for stones ≤10 mm. In addition, a-blocker is recommended after shock-wave lithotripsy (SWL) or Ho: YAG laser lithotripsy (EAU) to increase the stone-free rate and decrease analgesic needs, while its use is advised as beneficial for stent-related symptoms by EAU and AUA.
For medical management of recurrent lithiasis, both thiazide and potassium citrate in patients is a universal recommendation even if urine metabolic abnormalities are not detected (AUA, SIU/ICUD). Allopurinol is also strongly recommended by AUA and SIU/ICUD in patients with hyperuricosuria while in the opposite CUA advises against its use. In patients with cystine lithiasis, urine alkalization with alkaline citrates is the first recommended measure nevertheless the recommendation comes with a low LOE. If urine alkalization fails, most of the guidelines proposed in favor of the use of tiopronin.
As for the quality assessment EAU, AUA, and NICE Guidelines were the most highly rated. NICE Guideline was assessed with a higher score at stakeholder involvement (75%), whereas UAA, CUA, SIU/ICUD, and DGU Guidelines were rated with average scores 55%–75%.
Despite the heterogeneity, most of the recommendations on acute renal colic management were similar, with 1st line treatment proposed being NSAIDs/paracetamol and opiates the next option. Similarly, MET is recommended for distal ureteral stones, usually ≤10 mm, and also after SWL/laser lithotripsy and stent-related symptoms. Prevention of stone recurrence in high-risk patients is crucial since high-relapse rates are noticed.,,, All guidelines contained information on dietary modifications and medical interventions to decrease relapse rates. In general, dietary interventions proposed were similar, with differences noted in LOE/GOR ranking. This is the first study to review and compare urological guidelines on medical management of stone disease. A detailed search was performed, while two independent reviewers assessed all the recommendations/processes of development and ranked each one off the Guidelines with AGREE II instrument. A limitation of the study was the fact that some of the Guidelines overlap with others, most commonly with AUA and EAU recommendations and this could be a confounding factor.
This review highlights an acceptable degree of consensus on most aspects of medical management of the stone disease. Most differences were detected on GOR/LOE, which is partially explained by the average heterogeneity and the probable subjectivity of the author of each guideline.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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