[New guidelines for urinary stone treatment. Controversy or development?]

Abstract

The new guidelines of the European (EAU), American (AUA), German, and Austrian associations of urology are based on thorough and consistent research and analysis of the published literature. However, the methodology is very diverse. In the case of the EAU-AUA guidelines on ureteral stones, the evidence was generated by a laborious meta-analysis of the entire available published literature on the subject. These guidelines represent the 1A level of evidence. The traditional European guidelines evaluate each statement separately and assign a level of evidence to each. The following aspects are new: the even greater effort to formulate guidelines accompanied by the initiation of international cooperative projects, clarity of presentation and evaluation of the individual statements (including levels of evidence), information on medication-based treatment to facilitate spontaneous passage of ureteral stones as well as stone fragments after extracorporeal shock wave lithotripsy (ESWL), a shift in the value of ESWL and ureterorenoscopy for ureteral stones, retrograde intrarenal surgery for small kidney stones refractory to ESWL or in settings unsuitable for ESWL, the use of laparoscopy in those rare cases that represent an indication for open surgery, and the additional value given to metaphylaxis in diagnosis and therapy. All of the new guidelines take these developments into account, although they differ slightly in the importance they assign to the individual items. The modifications represent the developments secondary to electronic data processing and preparation on the one hand and the rapid development of medical instruments on the other. Although ESWL is still the most important procedure for treating urinary stones, advances in flexible endoscopes, intracorporeal lithotripsy, and extraction instruments have led to a shift in the range of indications. These developments are fully accommodated in the new guidelines.