Guideline of the Guidelines: Urolithiasis

Fahad Quhal; Christian Seitz


Curr Opin Urol. 2021;31(2):125-129. 

In This Article


A list of notable similarities and differences between the EAU and the AUA/ES guidelines on urolithiasis are summarized on Table 1.

Guidelines Reviewed

The guidelines included in this review are the EAU (European Association of Urology), the AUA (American Urological Association)/ES (Endourological Society), the UAA (Urological Association of Asia) and the NICE (National Institute for Health and Care Excellence) guidelines[5–8] (Table 2).

The EAU guidelines on urolithiasis were last updated in March 2020. The updates focused on literature reviews. The EAU guidelines utilize the modified version of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system,[4] wherein recommendations are graded as 'Strong' or 'Weak'.

The AUA guidelines were last updated in 2016. The guidelines are updated in conjunction with the Endourological Society and referred to as AUA/ES guidelines. The guidelines conduct a comprehensive systematic review and perform meta-analyses of published literature to generated guideline statements. On the basis of the level of evidence, the guidelines grade recommendations as strong, moderate or conditional recommendation.

The NICE guidelines were updated in January 2019. A systematic review of the literature is utilized in this guideline to evaluate evidence and generate recommendations. To grade recommendations, the committee analyses the benefits of an intervention against its harm and cost-effectiveness. NICE uses the term 'offer' to reflect a strong recommendation, usually where there is clear evidence of benefit, and the term 'consider' when the evidence of benefit is less certain.

The Urological Association of Asia clinical guideline for urinary stone disease was published in 2019. The guideline methodology starts with a literature review, as well as review of international guidelines such as EAU and AUA/ES. The guideline utilizes a classification system modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence, ranging from level-1 (highest evidence level) to level-55 (case study or expert opinion).[9]

Initial Evaluation

Most guidelines agree that ultrasound is well tolerated and inexpensive, and should be recommended as the first-line diagnostic imaging modality. The NICE guidelines recommend to offer low-dose noncontrast computed tomography (CT) as the first-line imaging modality. The NICE guidelines noted that the extra cost of CT is likely to be outweighed by avoiding additional investigations resulting from a less sensitive first test.

Contrast studies are recommended by the EAU and the AUA/ES in cases wherein the anatomy of the collecting system need to be assessed before intervention (EAU: strong, AUA/ES: conditional recommendation).

The EAU and UAA stated the low sensitivity of KUB x-ray; however, they acknowledged its benefit in follow-up of radiopaque stones.

Management Ureteric Stones Pain Relief

The EAU, UAA and NICE guidelines all agree that nonsteroidal anti-inflammatory drugs (NSAIDs) should be recommended as a first choice for renal colic. As a second option, the EAU guidelines recommends opioids (EAU: weak), and recommends decompression (percutaneous or ureteric stent) or ureteroscopy for pain refractory to analgesia (EAU: strong). The NICE guidelines recommend intravenous paracetamol as a second choice (if NSAID are contraindicated or insufficient), and provided a weak recommendation to consider opioids if NSAID or intravenous paracetamol are insufficient.

Management of Sepsis Secondary to Stone

All included guidelines recommend timely antibiotics and decompression (ureteric stent or percutaneous) in septic patients and to delay definitive stone management until sepsis resolves.

Medical Expulsion Therapy

Medical expulsion therapy (MET) has been the subject of several studies and debates; however, all guidelines agree on the benefit of MET in patients with distal ureteric stones. The EAU and the UAA strongly recommend α-blockers for distal ureter stone more than 5 mm. The AUA/ES and NICE guidelines also strongly recommend α-blockers in distal ureteric stone less than 10 mm. The EAU further recommends MET for stent-related symptoms (EAU: strong), and after ureteroscopy and laser stone fragmentation (EAU: strong).

All guidelines noted the limited evidence regarding the use of MET in the paediatric age group. However, the AUA/ES guidelines provided recommendation that observation with or without MET should be offered to children with 10 mm or less uncomplicated ureter stone (conditional recommendation).

Apart from MET, the UAA recommends external physical vibration lithecbole for distal ureter stones (grade: B).

Kidney Stones

Conservative Management. The EAU guidelines noted the lack of high-level evidence to provide indications for conservative management. However, if conservative management is selected, the guidelines recommends periodic follow-up (EAU: strong) and to provide active treatment in case of stone growth (EAU: weak). The AUA/ES guidelines recommend active surveillance for asymptomatic, nonobstructive calyceal stones (AUA/ES: conditional recommendation). The NICE guidelines recommend to consider watchful waiting for asymptomatic less than 5 mm stone.

Stones More Than 20 mm. All guidelines are in agreement that percutaneous nephrolithotomy (PNL) should be recommended as the first line of treatment for more than 20 mm kidney stones. When PNL is contraindicated, the EAU guidelines recommend retrograde intrarenal surgeries (RIRS) or extracorporeal shock wave lithotripsy (SWL) (EAU: strong) and to consider ureteral stent in these cases because of the high rate of follow up procedures.

Stones Less Than 20 mm. The AUA/ES guidelines recommends to offer SWL or RIRS for nonlower pole stone 20 mm or less, or lower pole stones 10 mm or less (AUA/ES: strong). The AUA/ES guidelines recommend against SWL for lower pole stones if more than 10 mm (AUA/ES: strong). On the contrary, the EAU recommends RIRS or PNL for lower pole stones even if less than 10 mm (EAU: strong). The EAU guidelines recommend SWL, RIRS or PNL for nonlower pole 10–20 mm stones (EAU: strong).

Procedure-specific Guidelines: Extracorporeal Shock Wave Lithotripsy. The EAU guidelines provided technical and patient-related factors that can label a stone favourable or unfavourable for SWL. The AUA/ES and NICE guidelines strongly recommend against routine pre-SWL stenting. The EAU guidelines did not provide recommendation regarding pre-SWL stenting; however, it highlighted the evidence that routine stenting does not improve the stone free rate of SWL.[10–12] Analgesia is also strongly recommended by the EAU guideline panel in order to reduce pain-related movement and excessive respiratory excursion.

Ureteroscopy. The EAU guidelines provided a detailed review of evidence on multiple different aspects of ureteroscopy. The EAU and AUA/ES guidelines did not provide recommendations regarding ureteral access sheath; however, the EAU guidelines stated that it can be used based on surgeon's preference. The AUA/ES guidelines also discussed the benefits and risks of ureteral access sheath in RIRS.

The EAU guidelines strongly recommend prestenting to improve the outcome of ureteroscopy. However, routine use is not necessary. Both the EAU guidelines and the AUA/ES guidelines strongly recommends against inserting ureteral stent after ureteroscopy in uncomplicated cases.

Percutaneous Nephrolithotomy. EAU and AUA/ES guidelines provide detailed review of evidence on technical aspects of PNL. The EAU guidelines noted high level evidence that both supine and prone PNL are well tolerated with no advantage of one over the other in term of operation time and stone free rates.

The EAU guidelines strongly recommend tubeless PNL in uncomplicated cases (EAU: strong), while the AUA recommends nephrostomy tube as an optional treatment after uncomplicated PNL (AUA/ES: conditional recommendation),

EAU, AUA/ES and UAA discussed the option of mini-PNL. The guidelines did not provide recommendations; however, they noted the evidence suggesting that mini-PNL is associated with lower complications with similar stone free rates.

Laparoscopy. The AUA/ES guidelines recommends against offering laparoscopic/robotic surgery as a first-line therapy except in rare cases of anatomic abnormalities, with large or complex stones, or those requiring concomitant reconstruction. EAU, AUA/ES and UAA noted the evidence regarding laparoscopic stone treatment is not high, and only recommended in cases where SWL, ureteroscopy and PNL fail or unlikely to be successful.

Special Groups and Conditions

Pregnancy. Urolithiasis during pregnancy is a challenging condition. The EAU, UAA and NICE guidelines all strongly recommend ultrasound as a first-line imaging modality for pregnant patient suspected to have urolithiasis. The EAU and UAA recommend MRI as a second line and low-dose CT scan as last line option. (EAU: strong, UAA: grade B)

With regards to the management of urolithiasis during pregnancy, the EAU, the AUA/ES and the UAA guidelines recommend to offer conservative management in uncomplicated cases. The EAU noted the high level of evidence to support ureteroscopy to avoid prolonged stenting or drainage. The AUS/ES guidelines recommend ureteroscopy or drainage with nephrostomy or ureteral stent with frequent change, for patients who fail conservative treatment (AUA/ES: strong).

Children. All guidelines strongly recommend ultrasound a first-line imaging modality in paediatric patients, and low-dose CT as a second option.

The AUS/ES and the UAA recommend conservative management as first-line treatment for 10 mm or less uncomplicated stones in children (AUA/ES: moderate, UAA: grade B), and consider SWL or ureteroscopy as an acceptable option in patient who fail conservative management. (AUA/ES: strong, UAA: grade B).

The EAU guidelines recommend SWL as first-line treatment for less than 10 mm ureter stones if localization is possible (EAU: strong), and recommends ureteroscopy as an alternative if SWL is not an option (strong). For renal stones, SWL is recommended for up to 20 mm stones in the EAU guidelines, and mini-PNL for more than 20 mm renal stones (EAU: strong). The AUA/ES guidelines further extend the recommendation of SWL as another option for more than 20 mm stones with mini-PNL also being an option (AUA/ES: moderate).

Obesity. The EAU guidelines discussed the lower success rate of SWL and PNL in this group of patients, and strongly recommend ureteroscopy as the first line treatment.