Many major guidelines across the globe address the medical and surgical management of urolithiasis. We elected to compare and contrast the recommendations among the five most highly-cited guidelines on stone disease to offer insights on where evidence has created a consensus and where there remains ongoing controversy and hence a need for the pursuit of studies that will provide a higher level of evidence.
We reviewed the American Urological Association (AUA) 2019 medical and 2016 surgical guidelines, the 2016 Canadian Urological Association (CUA) guidelines, the 2020 European Association of Urology (EAU) guidelines, the 2019 National Institute of Health and Care Excellence (NICE), and the 2019 Urological Association of Asia (UAA). Tables correlating guideline statements by topic were created, and a comparative analysis was conducted to ascertain consensus and discordance.
Comparative analysis of recommendations from the AUA guidelines to the CUA, EAU, NICE guidelines, and UAA revealed a high consensus surrounding the medical management of stones. In terms of the surgical management of stones, there is high consensus regarding the treatment of ureteral stones including medical expulsive therapy using alpha blockers, not pre-stinting for uncomplicated ureteroscopy, and employment of either ureteroscopy or shockwave lithotripsy (SWL) as first line treatment. There is high consensus among the AUA, EAU, NICE, and UAA guidelines regarding renal stone treatment; the CUA does not have guidelines on the management of renal stones. Unlike the AUA and NICE, the CUA and EAU make specific recommendations regarding selection of patients for SWL procedures, including stone density, skin-to-stone distance, treatment rate, acoustic coupling, and post-SWL use of medical expulsive therapy.
There are many areas of consensus and only minor areas of conflict among the most up-to-date AUA, CUA, EAU, NICE, and UAA guidelines on the medical and surgical management of stone disease. Conflicts among guidelines and areas of low evidence, such as follow-up imaging strategies and stone surveillance, the use of an ureteral access sheath in ureteroscopy, and guidance on the use of miniaturized percutaneous nephrolithotomy, are opportunities for novel, impactful high grade clinical studies.
The Journal of urology. 2020 Dec 07 [Epub ahead of print]
Pengbo Jiang, Lillian Xie, Raphael Arada, Roshan M Patel, Jaime Landman, Ralph V Clayman
Department of Urology, University of California, Irvine.