EAU Guidelines on Urolithiasis - uroweb.org

1 C. T rk (Chair), A. Neisius, A. Pet k, C. Seitz, A. Skolarikos (Vice-chair), B. Somani, K. Thomas, G. Gambaro (Consultant nephrologist) Guidelines Associates: Davis, Donaldson, R. Lombardo, L. Tzelves European Association of Urology 2021 UrolithiasisEAU Guidelines onUROLITHIASIS - LIMITED UPDATE MARCH 20212 TABLE OF CONTENTS PAGE1. INTRODUCTION 6 Aims and scope 6 Panel composition 6 Available publications 6 Publication history and summary of changes 6 Publication history 6 Summary of changes 62. METHODS 7 Data identification 7 Review 7 Future goals 73. Guidelines 7 Prevalence, aetiology, risk of recurrence 7 Introduction 7 Stone composition 8 Risk groups for stone formation 8 Classification of stones 11 Stone size 11 Stone location 11 X-ray characteristics 11 Diagnostic evaluation 11 Diagnostic imaging 11 Evaluation of patients with acute flank pain/suspected ureteral stones 11 Radiological evaluation of patients with renal stones 12 Diagnostics - metabolism-related 12 Basic laboratory analysis - non-emergency Urolithiasis patients 12 Analysis of stone composition 12 Guidelines for laboratory examinations and stone analysis 13 Diagnosis in special groups and conditions 13 Diagnostic imaging during pregnancy 13 Diagnostic imaging in children 14 Summary of evidence and Guidelines for diagnostic imaging in children 14 Disease Management 15 Renal colic 15 Summary of evidence and Guidelines for the management of renal colic

2 15 Management of sepsis and/or anuria in obstructed kidney 16 Summary of evidence and Guidelines for the management of sepsis and anuria 16 Medical expulsive therapy 16 Summary of evidence and guideline for MET 17 Chemolysis 17 Summary of evidence and Guidelines for chemolysis 18 Extracorporeal shock wave lithotripsy (ESWL) 18 Summary of evidence and Guidelines for SWL 19 Ureteroscopy (retrograde and antegrade) 20 Summary of evidence and Guidelines for retrograde URS, RIRS and antegrade ureteroscopy 21 Percutaneous nephrolithotomy 22 Summary of evidence and Guidelines for endourology techniques for renal stone removal 23 General recommendations and precautions for stone removal 23 Antibiotic therapy Antithrombotic therapy and stone treatment 243 Urolithiasis - LIMITED UPDATE MARCH 2021 Summary of evidence and Guidelines for antithrombotic therapy and stone treatment 25 Obesity 26 Stone composition 26 Contraindications of procedures 26 Specific stone management of ureteral stones 26 Conservative treatment/observation 26 Pharmacological treatment.

3 Medical expulsive therapy 26 Indications for active removal of ureteral stones 27 Selection of procedure for active removal of ureteral stones 27 Summary of evidence and Guidelines for selection of procedure for active removal of ureteral stones 27 Specific stone management of renal stones 28 Conservative treatment (observation) 28 Pharmacological treatment of renal stones 28 Indications for active stone removal of renal stones 28 Selection of procedure for active removal of renal stones 29 Stones in renal pelvis or upper/middle calyces 29 Stones in the lower renal pole 29 Summary of evidence and Guidelines for the management of renal stones 29 Laparoscopy and open surgery 30 Summary of evidence and guideline for laparoscopy and open surgery 31 Steinstrasse 31 Summary of evidence and Guidelines for steinstrasse 31 Management of patients with residual stones 31 Summary of evidence and guideline for management of patients with residual stones 32 Management of specific patient groups 32 Management of urinary stones and related problems during pregnancy 32 Summary of evidence and guideline for the management of urinary stones and

4 Related problems during pregnancy 32 Management of stones in patients with urinary diversion 32 Summary of evidence and guideline for the management of stones in patients with urinary diversion 33 Management of stones in patients with neurogenic bladder 33 Summary of evidence and guideline for the management of stones in patients with neurogenic bladder 34 Management of stones in patients with transplanted kidneys 34 Summary of evidence and guideline for the management of stones in patients with transplanted kidneys 34 Special problems in stone removal 35 Management of stones in children 35 Clinical presentation 35 Conservative management 35 Medical expulsive therapy in children 36 Extracorporeal shock wave lithotripsy 36 Endourological procedures 36 Open and laparoscopic/robot-assisted stone surgery 37 Special considerations on recurrence prevention 37 Summary of evidence and Guidelines for the management of stones in children 374.

5 FOLLOW UP: METABOLIC EVALUATION AND RECURRENCE PREVENTION 38 General metabolic considerations for patient work-up 38 Evaluation of patient risk 38 Urine sampling 39 Timing of specific metabolic work-up 39 Urolithiasis - LIMITED UPDATE MARCH 20214 Reference ranges of laboratory values 39 Risk indices and additional diagnostic tools 39 General considerations for recurrence prevention 41 Fluid intake 41 Diet 41 Lifestyle 42 Summary of evidence and guideline for recurrence prevention 42 Stone-specific metabolic evaluation and pharmacological recurrence prevention 42 Introduction 42 Calcium oxalate stones 44 Diagnosis 44 Interpretation of results and aetiology 44 Specific treatment 46 Summary of evidence and Guidelines for pharmacological treatments for patients with specific abnormalities in urine composition (based on 24-hour)

6 Urine samples) 46 Calcium phosphate stones 46 Diagnosis 46 Interpretation of results and aetiology 46 Pharmacological therapy 47 Summary of evidence and Guidelines for the management of calcium phosphate stones 47 Disorders and diseases related to calcium stones 47 Hyperparathyroidism 47 Granulomatous diseases 48 Primary hyperoxaluria 48 Summary of evidence and guideline for the management of primary hyperoxaluria 48 Enteric hyperoxaluria 48 Renal tubular acidosis 49 Summary of evidence and Guidelines for the management of tubular acidosis 50 Nephrocalcinosis 50 Diagnosis 51 Uric acid and ammonium urate stones 51 Diagnosis 51 Interpretation of results 51 Specific treatment 51 Summary of

7 Evidence and Guidelines for the management of uric acid- and ammonium urate stones 52 Struvite and infection stones 53 Diagnosis 53 Interpretation 53 Specific treatment 53 Cystine stones 55 Diagnosis 55 Specific treatment 55 Pharmacological treatment of cystine stones 55 Summary of evidence and Guidelines for the management of cystine stones 56 2,8-Dihydroxyandenine stones and xanthine stones 57 2,8-Dihydroxyadenine stones 57 Xanthine stones 57 Fluid intake and diet 57 Drug-induced stones 57 Matrix Stones 57 Unknown stone composition 57 Recommendations for investigations for the assessment of patients with stones of unknown composition 585 Urolithiasis - LIMITED UPDATE MARCH 20215. REFERENCES 586. CONFLICT OF INTEREST 787. CITATION INFORMATION 78 Urolithiasis - LIMITED UPDATE MARCH 202161. Aims and scopeThe 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.

8 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 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 Panel compositionThe EAU Urolithiasis Guidelines Panel consists of an international group of clinicians with particular expertise in this area.

9 All experts involved in the production of this document have submitted potential conflict of interest statements, which can be viewed on the EAU, website Uroweb: Available publicationsA quick reference document (Pocket Guidelines ) is available, both in print and as an app for iOS and Android devices. These are abridged versions, which may require consultation together with the full text versions. A number of scientific publications are also available [1-3]. All documents can be accessed through the EAU website: Publication history and summary of Publication historyThe EAU Urolithiasis Guidelines were first published in 2000. This 2021 document presents a limited update of the 2020 Summary of changesThe literature for the entire document has been checked and, wherever relevant, updated (see Methods section ).For 2021, conclusions and recommendations have been rephrased and strength ratings reassessed across several sections. References and supporting text have also been refreshed.

10 Additional information has been added to the chapter on Prevalence, aetiology, risk of recurrence including Table Risk factors for chronic kidney disease and end stage kidney disease in stone formers and Table Risk factors for chronic kidney disease and renal stones . A consultant nephrologist has now been added to the panel and has reviewed the entire text. Updated recommendation strength ratings include the Guidelines for laboratory examinations and stone analysisRecommendations Strength ratingBloodSerum blood sample: creatinine; uric acid; (ionised) calcium; sodium; potassium; blood cell count; C-reactive Guidelines for the management of tubular acidosisRecommendations Strength ratingPrescribe alkaline citrates for distal renal tubular - LIMITED UPDATE MARCH 20212. Data identificationFor the 2020 Urolithiasis Guidelines , new and relevant evidence has been identified, collated and appraised through a structured assessment of the broad and comprehensive scoping exercise covering all areas of the guideline was performed.