Unfavourablexxx域名

PlatinumPriority–GuidelinesEditorialbyXXXonpp.
x–yofthisissueEAUGuidelinesonInterventionalTreatmentforUrolithiasisChristianTu¨rka,AlesˇPetrˇkb,KemalSaricac,ChristianSeitzd,AndreasSkolarikose,MichaelStraubf,ThomasKnollg,*aDepartmentofUrology,RudolfstiftungHospital,Vienna,Austria;bDepartmentofUrology,RegionHospital,CˇeskeBudeˇjovice,CzechRepublic;cDepartmentofUrology,Dr.
LutfiKirdarKartalResearchandTrainingHospital,Istanbul,Turkey;dDepartmentofUrology,MedicalUniversityVienna,Austria;eSecondDepartmentofUrology,SismanoglioHospital,AthensMedicalSchool,Athens,Greece;fDepartmentofUrology,TechnicalUniversityMunich,Munich,Germany;gDepartmentofUrology,Sindelfingen-Bo¨blingenMedicalCentre,UniversityofTu¨bingen,Sindelfingen,Germany1.
IntroductionThelatestprintversionsoftheEuropeanAssociationofUrology(EAU)guidelinesforthediagnosisandtreatmentofurolithiasiswerepublishedin2001forrenalstones[1]andin2007forureteralstones[2],butonlineupdateshavebeenpublishedannually[3].
TheEAUguidelinesonimagingandconservativemanagementofurolithiasisandonpaediatricurolithiasiswillbepublishedseparately.
TheEAUguidelineonmetabolicevaluationandpreventionhasbeenpublishedEUROPEANUROLOGYXXX(2015)XXX–XXXavailableatwww.
sciencedirect.
comjournalhomepage:www.
europeanurology.
comArticleinfoArticlehistory:AcceptedJuly16,2015AssociateEditor:JamesCattoKeywords:UrinarycalculiUreteroscopyPercutaneousnephrolithotomyMedicalexpulsivetherapyStonesurgeryShockwavelithotripsyLaparoscopyStentingResidualfragmentsPregnancyAbstractContext:Managementofurinarystonesisamajorissueformosturologists.
Treatmentmodalitiesareminimallyinvasiveandincludeextracorporealshockwavelithotripsy(SWL),ureteroscopy(URS),andpercutaneousnephrolithotomy(PNL).
Technologicaladvancesandchangingtreatmentpatternshavehadanimpactoncurrenttreatmentrecommendations,whichhaveclearlyshiftedtowardsendourologicprocedures.
Theseguidelinesdescriberecentrecommendationsontreatmentindicationsandthechoiceofmodalityforureteralandrenalcalculi.
Objective:Toevaluatetheoptimalmeasuresfortreatmentofurinarystonedisease.
Evidenceacquisition:Severaldatabasesweresearchedtoidentifystudiesoninterven-tionaltreatmentofurolithiasis,withspecialattentiontothelevelofevidence.
Evidencesynthesis:Treatmentdecisionsaremadeindividuallyaccordingtostonesize,location,and(ifknown)composition,aswellaspatientpreferenceandlocalexpertise.
TreatmentrecommendationshaveshiftedtoendourologicproceduressuchasURSandPNL,andSWLhaslostitsplaceastherst-linemodalityformanyindicationsdespiteitsprovenefcacy.
Openandlaparoscopictechniquesarerestrictedtolimitedindications.
Bestclinicalpracticestandardshavebeenestablishedforalltreatments,makingalloptionsminimallyinvasivewithlowcomplicationrates.
Conclusion:Activetreatmentofurolithiasisiscurrentlyaminimallyinvasiveinterven-tion,withpreferenceforendourologictechniques.
Patientsummary:Foractiveremovalofstonesfromthekidneyorureter,technologicaladvanceshavemadeitpossibletouselessinvasivesurgicaltechniques.
Theseinter-ventionsaresafeandaregenerallyassociatedwithshorterrecoverytimesandlessdiscomfortforthepatient.
#2015EuropeanAssociationofUrology.
PublishedbyElsevierB.
V.
Allrightsreserved.
*Correspondingauthor.
DepartmentofUrology,KlinikumSindelngen-Bo¨blingen,UniversityofTu¨bingen,Arthur-Gruber-Strasse70,71065Sindelngen,Germany.
Tel.
+4970319812501;Fax:+497031815307.
E-mailaddress:t.
knoll@klinikverbund-suedwest.
de(T.
Knoll).
EURURO-6336;No.
ofPages8Pleasecitethisarticleinpressas:Tu¨rkC,etal.
EAUGuidelinesonInterventionalTreatmentforUrolithiasis.
EurUrol(2015),http://dx.
doi.
org/10.
1016/j.
eururo.
2015.
07.
041http://dx.
doi.
org/10.
1016/j.
eururo.
2015.
07.
0410302-2838/#2015EuropeanAssociationofUrology.
PublishedbyElsevierB.
V.
Allrightsreserved.
recently[4].
Technologicaldevelopmentsarecontinuouslyinfluencingthechoiceoftherapeuticoptions.
Thispapersummarisescurrentrecommendationsforthetreatmentofupperurinarytractstones.
2.
EvidenceacquisitionAprofessionalresearchlibrariancarriedoutliteraturesearchesforallsectionsoftheurolithiasisguidelinescoveringtheperioduptoAugust2014.
SearcheswerecarriedoutusingtheCochraneLibraryDatabaseofSystematicReviews,theCochraneLibraryofControlledClinicalTrials,andMedlineandEmbaseontheDialog–Datastarplatform.
Thesearchesusedthecontrolledterminologyoftherespectivedatabases.
BothMesHandEmtreewereanalysedforrelevantterms.
Inmanycases,useoffreetextensuredthesensitivityofthesearches.
Thefocusofthesearcheswasidentificationofalllevel1scientificpapers(systematicreviewsandmeta-analysesofrandom-isedcontrolledtrials[RCTs]).
Ifsufficientdatawereidentifiedtoanswertheclinicalquestion,thesearchwasnotexpandedtoincludelower-levelliterature.
Levelofevidence(LE)and/orgradeofrecommendation(GR)weredeterminedaccordingtotheOxfordCentreforEvidence-basedMedicine[5].
InsomecasestherewasnodirectlinkbetweenLEandGR,andrecommendationswereupgradedordowngradedfollowingexpertpaneldiscussion.
Thesecasesareclearlyidentifiableanddenotedintherecom-mendationswithanasterisk.
3.
Evidencesynthesis3.
1.
IndicationsforactivestoneremovalandprocedureselectionIndicationsforactivestoneremovalofrenalstonesareasfollows:StonegrowthSize>15mmStones20mm,andstagedproceduresareoftenrequired.
Stones>20mmshouldthereforebetreatedprimarilybyPNLbecauseSWLoftenrequiresmultipletreatments[8].
SWLachievesgoodSFRsforstones20mm,exceptforthoseatthelowerpole[9,10],forwhichendourologyisconsideredanalternative(Fig.
1).
NegativepredictorsofSWLsuccessaregiveninTable2.
ThevalueofsupportivemeasurestoimproveSWLoutcome,suchasinversion,vibration,andhydration,remainsamatterofdiscussion[11,12].
Openorlaparo-scopicapproachesarepossiblealternativesifothertreatmentmodalitiesfailorarenotavailable.
3.
1.
2.
SelectingaprocedureforactiveremovalofureteralstonesOverallSFRsafterURSorSWLforureteralstonesarecomparable.
PatientsshouldbeinformedthatURShasabetterchanceofachievingstone-freestatuswithasingleprocedure,buthashighercomplicationrates[13].
Table1–RecommendationsforactivetreatmentofrenalcalculiRecommendationGRSWLandendourology(PNLandURS)aretreatmentoptionsforrenalstones2cmshouldbetreatedbyPNLAFlexibleURSisapossiblesecond-linetreatmentforlargestones(>2cm)butSFRsarelowerandstagedproceduresmayberequiredBPNLorexibleURSisrecommendedforthelowerpole,evenforstones>1.
5cm,becauseSWLefcacyislimitedBGR=gradeofrecommendation;PNL=percutaneousnephrolithotomy;SFR=stone-freerate;SWL=extracorporealshockwavelithotripsy;URS=ureteroscopy.
Fig.
1–Treatmentalgorithmforrenalcalculi.
PNL=percutaneousnephrolithotomy;RIRS=retrogradeintrarenalsurgery;SWL=extracorporealshockwavelithotripsy.
EUROPEANUROLOGYXXX(2015)XXX–XXX2EURURO-6336;No.
ofPages8Pleasecitethisarticleinpressas:Tu¨rkC,etal.
EAUGuidelinesonInterventionalTreatmentforUrolithiasis.
EurUrol(2015),http://dx.
doi.
org/10.
1016/j.
eururo.
2015.
07.
0413.
2.
Generalrecommendationsforstoneremoval3.
2.
1.
AntibiotictherapyUrinarytractinfections(UTIs)shouldalwaysbetreatedifstoneremovalisplanned(Table3).
Inpatientswithaclinicallysignificantinfectionandobstruction,thekidneysshouldbedrainedforseveraldaysfirst.
3.
2.
2.
PerioperativeantibioticprophylaxisSingle-doseantibioticadministrationissufficientforURS[14].
AntibioticprophylaxissignificantlyreducestherateoffeverafterPNL,eveninpatientswithanegativebaselineurineculture[15].
AsforURS,single-doseapplicationseemstobesufficient(Table3).
NostandardantibioticprophylaxisbeforeSWLisrecommended,exceptincaseswithahigherriskofbacterialburden(eg,indwellingcatheter,nephros-tomytube,orinfectiousstones)[16].
3.
2.
3.
AnticoagulationtherapyPatientswithuncorrectedbleedingdiathesisundergoingstoneinterventionareathigherriskofhaemorrhage(Table4)[17].
Thereisnoevidencesupportingthesafetyoflow-doseacetylsalicylates.
3.
2.
4.
ObesityObesepatientshaveahigheranaesthesiariskandalowersuccessrateafterSWLandPNL(Table5)[18].
3.
2.
5.
StonecompositionStonescomposedofbrushite,calciumoxalatemonohy-drate,orcystineareparticularlyhard[20]andPNLandURSaremoreeffectivealternatives(Table6).
3.
2.
6.
PregnancyIfspontaneouspassagedoesnotoccurorifcomplicationsdevelop,placementofaureteralstentorapercutaneousnephrostomytubeisnecessary(LE3)[21].
However,becausesuchtemporarytherapiesareoftenassociatedwithpoortolerance,URShasbecomeareasonablealternativeinthesesituations(LE1a)(Table7)[22].
3.
2.
7.
ResidualstonesTherecurrenceriskishigherinpatientswithresidualfragmentsaftertreatmentofinfectionstonesthanforotherstones[23].
Fragments>5mmaremorelikelythansmalleronestorequireintervention[24].
TheindicationsforactiveTable2–Unfavourablefactorsforextracorporealshockwavelithotripsysuccess[59]Shockwave-resistantstones(calciumoxalatemonohydrate,brushite,orcystine)Steepinfundibular-pelvicangleLonglower-polecalyx(>10mm)Narrowinfundibulum(1000HU,SWLisnotrecommendedsincedisintegrationwillbelesslikely1AInuricacidstones,chemolysiscanbeconsidered2aBHU=Hounseldunits;GR=gradeofrecommendation;LE=levelofevidence;SWL=extracorporealshockwavelithotripsy.
Table7–RecommendationsfortreatmentofstonesinpregnancyRecommendationsLEGRConservativemanagementshouldberst-linetreatmentforallnoncomplicatedcasesofurolithiasisinpregnancy(exceptthosethathaveclinicalindicationsforintervention)ARegularfollow-upuntilnalstoneremovalisstronglyrecommendedowingtothehigherencrustationtendencyofstentsduringpregnancy3AGR=gradeofrecommendation;LE=levelofevidence.
EUROPEANUROLOGYXXX(2015)XXX–XXX3EURURO-6336;No.
ofPages8Pleasecitethisarticleinpressas:Tu¨rkC,etal.
EAUGuidelinesonInterventionalTreatmentforUrolithiasis.
EurUrol(2015),http://dx.
doi.
org/10.
1016/j.
eururo.
2015.
07.
041removalofresidualstonesandselectionoftheprocedurearebasedonthesamecriteriaasforprimarystonetreatmentandincludesrepeatSWL[25].
3.
3.
Modalitiesforactivestoneremoval(Fig.
2)3.
3.
1.
ExtracorporealSWLContraindicationstotheuseofSWLinclude:PregnancyBleedingdiathesesoranticoagulationUncontrolledUTISevereskeletalmalformationsandsevereobesity,whichpreventtargetingofthestoneArterialaneurysminthevicinityofthestoneAnatomicalobstructiondistaltothestone3.
3.
1.
1.
Bestclinicalpractice.
Loweringtheshockwavefrequen-cyfrom120to60–90shockwaves/minimprovestheSFR[27,28].
Thenumberofshockwavesthatcanbedeliveredateachsessiondependsonthetypeoflithotripterandshockwavepower.
Stepwisepowerrampingpreventsrenalinjury[29].
RecommendationstoimproveacousticcouplingandmanagepaincontrolarealsoincludedinTable8.
3.
3.
1.
2.
MedicalexpulsivetherapyafterextracorporealSWL.
Medi-calexpulsivetherapyafterSWLforureteralorrenalstonescanexpediteexpulsion,increaseSFR,andreduceadditionalanalgesicrequirements(Table9)[31,32].
3.
3.
1.
3.
ComplicationsofextracorporealSWL.
ComparedtoPNLandURS,therearefeweroverallcomplicationswithSWL(Table10)[33].
3.
3.
2.
PercutaneousnephrolithotomyForPNL,endoscopesofdifferentsizesareavailable.
Theefficacyofminiaturisedsystemsseemstobehigh,butnobenefitcomparedtostandardPNLforselectedpatientshasyetbeendemonstrated[34].
3.
3.
2.
1.
Contraindications.
Anticoagulanttherapymustbedis-continuedbeforePNL[35].
Otherimportantcontraindica-tionsincludeuntreatedUTI,tumourinthepresumptiveaccesstractarea,potentialmalignantkidneytumour,andpregnancy.
3.
3.
2.
2.
Positioningofthepatient.
Proneandsupinepositionsareequallysafe.
MoststudiescannotdemonstrateanadvantageofsupinePNLintermsofoperatingtime[36].
Insomeseries,theSFRislowerforthesupinethanthepronepositiondespitealongeroperatingtime[36].
Thepronepositionoffersmoreoptionsforpunctureandisthereforepreferredforupper-poleormultipleaccess[37].
3.
3.
2.
3.
Access.
ColoninterpositioninthePNLaccesstractcanleadtocoloninjuries.
Preoperativecomputedtomographyorintraoperativeultrasoundallowsidentificationofthetissuebetweentheskinandkidneyandlowerstheincidenceofbowelinjury[38].
3.
3.
2.
4.
Dilation.
Tractdilationcanbeachievedusingametallictelescopeorasingleorballoondilator.
DifferencesFig.
2–Treatmentalgorithmforureteralcalculi.
SWL=extracorporealshockwavelithotripsy;URS=ureteroscopy.
Table10–RecommendationonroutinestentinginSWLRecommendationLEGRRoutinestentingisnotrecommendedaspartofSWLtreatmentofureteralstones[26]1bALE=levelofevidence;GR=gradeofrecommendation;SWL=extracorporealshockwavelithotripsy.
Table8–RecommendationsforbestclinicalpracticeinshockwavelithotripsyRecommendationsLEGRTheoptimalshockwavefrequencyis1.
0–1.
5Hz1aAEnsurecorrectuseofthecouplinggelbecausethisiscrucialforeffectiveshockwavetransport2aBUseproperanalgesiabecauseitimprovestreatmentresultsbylimitinginducedmovementsandexcessiverespiratoryexcursions[30]4CMaintaincarefuluoroscopicand/orultrasonographicmonitoringduringtheprocedure4A*LE=levelofevidence;GR=gradeofrecommendation.
*Upgradedbasedonpanelconsensus.
Table9–Recommendationsforfollow-upafteractivestoneremovalRecommendationsLEGRPatientswithresidualfragmentsorstonesshouldbefollowedupregularlytomonitordiseasecourse4CAfterSWLandURS,andinthepresenceofresidualfragments,METisrecommendedusingana-blockertoimprovefragmentclearance1aALE=levelofevidence;GR=gradeofrecommendation;SWL=extracorporealshockwavelithotripsy;URS=ureteroscopy;MET=medicalexpulsivetherapy.
EUROPEANUROLOGYXXX(2015)XXX–XXX4EURURO-6336;No.
ofPages8Pleasecitethisarticleinpressas:Tu¨rkC,etal.
EAUGuidelinesonInterventionalTreatmentforUrolithiasis.
EurUrol(2015),http://dx.
doi.
org/10.
1016/j.
eururo.
2015.
07.
041inoutcomesarelessrelatedtothetechnologyusedthantotheexperienceofthesurgeon[40].
3.
3.
2.
5.
Intracorporeallithotripsy.
Ultrasonicandpneumaticsystemsaremostcommonlyusedforrigidnephroscopy(GRA*),whilelasersareusuallyusedinminiaturisedandflexibleinstruments(LE2a)[34].
Electrohydrauliclitho-tripsyisnotconsideredtobeafirst-linetechniqueowingtopossiblecollateraldamage[41].
3.
3.
2.
6.
Nephrostomyandstents.
Thedecisionaboutpercutane-ousnephrostomy(PCN)placementdependson:residualstones,likelihoodofasecond-lookprocedure,intraoperativebleeding,perforation,ureteralobstruction,potentialbacte-riuriaduetoinfectedstones,solitarykidney,andbleedingdiathesis(Table11).
Small-borePCNseemtocauselesspostoperativepain[42].
3.
3.
2.
7.
Complications.
Themostcommonpostoperativecom-plicationsassociatedwithPNLarefever,bleeding,urinaryleakage,andproblemsduetoresidualstones(Table12).
Perioperativefevercanoccur,evenwithasterilepreopera-tiveurinarycultureandperioperativeantibioticprophy-laxis,becausethekidneystonesthemselvesmaybeasourceofinfection[43].
BleedingafterPNLmaybetreatedbybriefclampingofthePCN.
Superselectiveembolicocclusionofanarterialbranchmaybecomenecessaryincasesofseverebleeding.
3.
3.
3.
UreteroscopyTechnicalimprovementsandtheintroductionofawiderangeofdisposableshaveledtoincreaseduseofURS.
Majortechnologicalprogresshasbeenachievedforflexibleureteroscopy,includingimprovementsin(digital)imagingquality,resultinginshorteroperatingtimes[44–46].
Thecurrentstandardforrigiduretero(reno)scopesaretipdiametersof<8F.
RigidorflexibleURScanbeusedforthewholeureter,dependingonindividualanatomyandsurgeonpreference[2].
3.
3.
3.
1.
Contraindications.
ApartfromgeneralproblemssuchasgeneralanaesthesiaoruntreatedUTIs,URScanbeperformedinallpatientswithoutanyspecificcontra-indications(Table13).
3.
3.
3.
2.
Bestclinicalpractice.
Forsafetyreasons,fluoroscopicequipmentmustbeavailableintheoperatingtheatre.
Werecommendplacementofasafetywire(Table14)[47].
Dilatorsareavailableifnecessary[48].
IfinsertionofaflexibleURSisdifficult,apriorrigidURScanbehelpfulforopticaldilation.
Ifureteralaccessisnotpossible,insertionofaJJstentseveraldaysbeforethesecondattemptoffersanalternativetodilation[49].
3.
3.
3.
3.
Ureteralaccesssheaths(UASs).
UASsofdifferentcalibrecanbeinsertedviaaguidewire,withthetipplacedintheproximalureter.
UASsalloweasymultipleaccesstotheupperurinarytract.
UASusedecreasesintrarenalpressure,improvesvisionbyestablishingacontinuousoutflow,andpotentiallyreducesoperatingtime[50].
UASinsertionmayleadtoureteraldamage;theriskislowestinprestentedsystems[51].
3.
3.
3.
4.
Stoneextraction.
TheaimofURSiscompletestoneremoval.
Dustingstrategiesshouldbelimitedtothetreatmentoflargerenalstones.
Stonescanbeextractedwithendoscopicforcepsorbaskets.
OnlybasketsmadeofnitinolcanbeusedforflexibleURS[52].
Blindbasketingshouldnotbeperformed(LE4,GR4*).
3.
3.
3.
5.
Intracorporeallithotripsy.
ThemosteffectivelithotripsysystemistheHo:YAGlaser(Table15)[53].
PneumaticandultrasoundsystemscanbeusedwithhighdisintegrationefficacyinrigidURS[54].
3.
3.
3.
6.
Stenting.
RoutinestentingisnotnecessarybeforeURS.
However,prestentingfacilitatesURSmanagementofTable11–RecommendationfornephrostomyorstentplacementinPNLRecommendationLEGRInuncomplicatedcases,tubeless(withoutPCN)ortotallytubeless(withoutPCNandureteralstent)PNLproceduresprovideasafealternative.
1bALE=levelofevidence;GR=gradeofrecommendation;PCN=percutaneousnephrostomy;PNL=percutaneousnephrolithotomy.
Table13–RecommendationforpercutaneousremovalofureteralstonesRecommendationGRPercutaneousantegraderemovalofureteralstonesisanalternativewhenSWLandURSarenotindicatedorhavefailed[39]AGR=gradeofrecommendation;SWL=extracorporealshockwavelithotripsy;URS=ureteroscopy.
Table12–Complicationsfollowingpercutaneousnephrolithotomy[60]ComplicationFrequency,%(range)(n=11929)Transfusion7(0–20)Embolisation0.
4(0–1.
5)Urinoma0.
2(0–1)Fever10.
8(0–32.
1)Sepsis0.
5(0.
3–1.
1)Thoraciccomplications1.
5(0–11.
6)Organinjury(0.
4(0–1.
7)Death0.
05(0–0.
3)Table14–RecommendationforbestclinicalpracticeinURSRecommendationGRPlacementofasafetywireisrecommended.
A*GR=gradeofrecommendation.
EUROPEANUROLOGYXXX(2015)XXX–XXX5EURURO-6336;No.
ofPages8Pleasecitethisarticleinpressas:Tu¨rkC,etal.
EAUGuidelinesonInterventionalTreatmentforUrolithiasis.
EurUrol(2015),http://dx.
doi.
org/10.
1016/j.
eururo.
2015.
07.
041stones,improvestheSFR,andreducescomplications[55].
RCTshavefoundthatroutinestentingafteruncompli-catedURSisnotnecessary;stentingmightbeassociatedwithhigherpostoperativemorbidity(LE1a)[56].
However,stentsshouldbeinsertedinpatientswhoareathigherriskofcomplications(eg,ureteraltrauma,residualfragments,orperforation).
Theidealstentingdurationisnotknown,butmosturologistsfavour1–2wkafterURS.
a-Blockersseemtoimproveureteralstenttolerability(LE1a)[57].
3.
3.
3.
7.
Complications.
TheoverallcomplicationrateafterURSis9–25%[2,13].
Mostcomplicationsareminoranddonotrequireintervention.
Ureteralavulsionandstricturesarerare(<1%).
3.
3.
4.
OpenandlaparoscopicsurgeryforremovalofureteralandrenalstonesCurrently,indicationsforopenorlaparoscopicstonesurgeryarerare(Table16)[58].
However,openorlaparoscopicsurgerymaybeavalidtreatmentoptionifpercutaneousapproachesarenotlikelytobesuccessful,orifendourologicapproacheshavebeenperformedunsuc-cessfully,especiallyincaseswithacentrallylocatedrenalstonemass.
4.
ConclusionsTreatmentdecisionsaremadeindividuallyonthebasisofstonesize,location,and(ifknown)composition,patientpreference,andlocalexpertise.
However,treatmentrecom-mendationshaveshiftedtoURSandPNLendourologicprocedures,andextracorporealSWLhaslostitsplaceasthefirst-linemodalityformostrenalandureteralstones,eventhoughitisstilleffective.
Openandlaparoscopictechniquesarerestrictedtolimitedindications.
Bestclinicalpracticestandardshavebeenestablishedforalltreatments,andalloptionsareminimallyinvasivewithlowcomplicationrates.
Authorcontributions:ThomasKnollhadfullaccesstoallthedatainthestudyandtakesresponsibilityfortheintegrityofthedataandtheaccuracyofthedataanalysis.
Studyconceptanddesign:Knoll,Tu¨rk,Petrˇk,Sarica,Seitz,Skolarikos,Straub.
Acquisitionofdata:Knoll,Tu¨rk,Petrˇk,Sarica,Seitz,Skolarikos,Straub.
Analysisandinterpretationofdata:Tu¨rk,Knoll,Petrik,Sarica,Seitz,Skolarikos,Straub.
Draftingofthemanuscript:Knoll.
Criticalrevisionofthemanuscriptforimportantintellectualcontent:Tu¨rk,Knoll,Petrik,Sarica,Seitz,Skolarikos,Straub.
Statisticalanalysis:None.
Obtainingfunding:None.
Administrative,technical,ormaterialsupport:None.
Supervision:Knoll.
Other:None.
Financialdisclosures:ThomasKnollcertiesthatallconictsofinterest,includingspecicnancialinterestsandrelationshipsandafliationsrelevanttothesubjectmatterormaterialsdiscussedinthemanuscript(eg,employment/afliation,grantsorfunding,consultancies,honoraria,stockownershiporoptions,experttestimony,royalties,orpatentsled,received,orpending),arethefollowing:AlesˇPetrikhasreceivedspeakerhonorariafromGSKandfellowshipandtravelgrantsfromAstellasandOlympus.
ChristianSeitzhasreceivedconsultantfeesfromAstellasandspeakerhonorariafromRowaWagner.
MichaelStraubhasreceivedconsultantfeesfromRichardWolfEndoskopeandSanochemiaPharmazeutika.
ThomasKnollhasreceivedconsultantfeesfromSchoelly,BostonScientic,Olympus,andStorzMedical,andspeakerhonorariafromKarlStorz,RichardWolf,Olympus,BostonScientic,andIbsen;andhasparticipatedintrialsbyCookandColoplast.
ChristianTu¨rk,AndreasSkolarikosandKemalSaricahavenothingtodisclose.
Funding/Supportandroleofthesponsor:None.
Acknowledgments:TheEAUGuidelinesPanelonUrolithiasiswouldliketothanktheEAUGuidelinesOfceundertheChairmanshipofProfessorJamesN'Dowforsettingtheenvironmentandprovidingguidance.
WeexpressourdeepestgratitudetoMs.
KarinPlassandthewholeteamforinvaluablesupport.
References[1]TiseliusHG,AckermannD,AlkenP,BuckC,ConortP,GallucciM.
Guidelinesonurolithiasis.
EurUrol2001;40:362.
[2]PremingerGM,TiseliusHG,AssimosDG,etal.
2007guidelineforthemanagementofureteralcalculi.
EurUrol2007;52:1610–31.
[3]Tu¨rkCK,KnollT,PetrikA,etal.
Guidelinesonurolithiasis.
EuropeanAssociationofUrology;2015.
http://uroweb.
org/wp-content/uploads/22-Urolithiasis_LR_full.
pdf[4]SkolarikosA,StraubM,KnollT,etal.
Metabolicevaluationandrecurrencepreventionforurinarystonepatients:EAUguidelines.
EurUrol2015;67:750–63.
[5]HowickJ.
Levelsofevidence.
Oxford,UK:CentreforEvidence-basedMedicine;2009.
http://www.
cebm.
net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/[6]ArgyropoulosAN,TolleyDA.
Evaluationofoutcomefollowinglithotripsy.
CurrOpinUrol2010;20:154–8.
[7]SrisubatA,PotisatS,LojanapiwatB,SetthawongV,LaopaiboonM.
Extracorporealshockwavelithotripsy(ESWL)versuspercutaneousnephrolithotomy(PCNL)orretrogradeintrarenalsurgery(RIRS)forkidneystones.
CochraneDatabaseSystRev2009:CD007044.
[8]PearleMS,NadlerR,BercowskyE,etal.
Prospectiverandomizedtrialcomparingshockwavelithotripsyandureteroscopyforman-agementofdistalureteralcalculi.
JUrol2001;166:1255.
Table16–RecommendationsforopenandlaparoscopicstoneremovalRecommendationLEGRLaparoscopicoropensurgicalstoneremovalmaybeconsideredinrarecasesinwhichSWL,URS,andPNLfailorareunlikelytobesuccessful3CWhenexpertiseisavailable,laparoscopicsurgeryshouldbethepreferredoptionbeforeproceedingtoopensurgery.
Exceptionsareacomplexrenalstoneburdenand/orstonelocation3CForureterolithotomy,laparoscopyisrecommendedforlargeimpactedstoneswhenendoscopiclithotripsyorSWLhasfailed2BTable15–RecommendationforintracorporeallithotripsyRecommendationLEGRHo:YAGlaserlithotripsyisthepreferredmethodfor(exible)URS.
3BLE=levelofevidence;GR=gradeofrecommendation;URS=ureteroscopy.
EUROPEANUROLOGYXXX(2015)XXX–XXX6EURURO-6336;No.
ofPages8Pleasecitethisarticleinpressas:Tu¨rkC,etal.
EAUGuidelinesonInterventionalTreatmentforUrolithiasis.
EurUrol(2015),http://dx.
doi.
org/10.
1016/j.
eururo.
2015.
07.
041[9]SahinkanatT,EkerbicerH,OnalB,etal.
Evaluationoftheeffectsofrelationshipsbetweenmainspatiallowerpolecalycealanatomicfactorsonthesuccessofshock-wavelithotripsyinpatientswithlowerpolekidneystones.
Urology2008;71:801–5.
[10]PremingerGM.
Managementoflowerpolerenalcalculi:shockwavelithotripsyversuspercutaneousnephrolithotomyversusex-ibleureteroscopy.
UrolRes2006;34:108–11.
[11]KosarA,OzturkA,SerelTA,AkkusS,UnalOS.
Effectofvibrationmassagetherapyafterextracorporealshockwavelithotripsyinpatientswithlowercalicealstones.
JEndourol1999;13:705–7.
[12]AlbanisS,AtherHM,PapatsorisAG,etal.
Inversion,hydrationanddiuresisduringextracorporealshockwavelithotripsy:doesitimprovethestone-freerateforlowerpolestoneclearanceUrolInt2009;83:211–6.
[13]PerezCastroE,OstherPJ,JingaV,etal.
Differencesinureteroscopicstonetreatmentandoutcomesfordistal,mid-,proximal,ormultipleureterallocations:theClinicalResearchOfceoftheEndourologicalSocietyureteroscopyglobalstudy.
EurUrol2014;66:102–9.
[14]HsiehCH,YangSSD,LinCD,ChangSJ.
AreprophylacticantibioticsnecessaryinpatientswithpreoperativesterileurineundergoingureterorenoscopiclithotripsyBJUInt2014;113:275–80.
[15]GravasS,MontanariE,GeavleteP,etal.
Postoperativeinfectionratesinlowriskpatientsundergoingpercutaneousnephrolithot-omywithandwithoutantibioticprophylaxis:amatchedcasecontrolstudy.
JUrol2012;188:843–7.
[16]GrabeM,BartolettiR,Bjerklund-JohansenT-E,etal.
EAUguidelinesonurologicalinfections.
EuropeanAssociationofUrology;2014.
http://uroweb.
org/wp-content/uploads/19-Urological-infections_LR2.
pdf[17]AboumarzoukOM,SomaniBK,MongaM.
Flexibleureteroscopyandholmium:YAGlaserlithotripsyforstonediseaseinpatientswithbleedingdiathesis:asystematicreviewoftheliterature.
IntBrazilJUrol2012;38:298–305.
[18]FullerA,RazviH,DenstedtJD,etal.
TheCROESpercutaneousnephrolithotomyglobalstudy:theinuenceofbodymassindexonoutcome.
JUrol2012;188:138–44.
[19]AboumarzoukOM,SomaniB,MongaM.
Safetyandefcacyofureteroscopiclithotripsyforstonediseaseinobesepatients:asystematicreviewoftheliterature.
BJUInt2012;110:E374–80.
[20]El-NahasAR,El-AssmyAM,MansourO,SheirKZ.
Aprospectivemultivariateanalysisoffactorspredictingstonedisintegrationbyextracorporealshockwavelithotripsy:thevalueofhigh-resolu-tionnoncontrastcomputedtomography.
EurUrol2007;51:1688–94.
[21]TsaiYL,SeowKM,YiehCH,etal.
Comparativestudyofconservativeandsurgicalmanagementforsymptomaticmoderateandseverehydronephrosisinpregnancy:aprospectiverandomizedstudy.
ActaObstetGynecolScand2007;86:1047–50.
[22]SeminsMJ,MatlagaBR.
Ureteroscopyduringpregnancy.
IndianJUrol2009;25:291–5.
[23]BeckEM,RiehleJrRA.
Thefateofresidualfragmentsafterextra-corporealshockwavelithotripsymonotherapyofinfectionstones.
JUrol1991;145:6.
[24]CandauC,SaussineC,LangH,RoyC,FaureF,JacqminD.
NaturalhistoryofresidualrenalstonefragmentsafterESWL.
EurUrol2000;37:18.
[25]KringsF,TuerkC,SteinkoglerI,MarbergerM.
Extracorporealshockwavelithotripsyretreatment(''stir-up'')promotesdischargeofpersistentcalicealstonefragmentsafterprimaryextracorporealshockwavelithotripsy.
JUrol1992;148:1040.
[26]MusaAAK.
Useofdouble-Jstentspriortoextracorporealshockwavelithotripsyisnotbenecial:resultsofaprospectiverandom-izedstudy.
IntUrolNephrol2008;40:19–22.
[27]PaceKT,GhiculeteD,HarjuM,HoneyRJ.
Shockwavelithotripsyat60or120shocksperminute:arandomized,double-blindtrial.
JUrol2005;174:595–9.
[28]SeminsMJ,TrockBJ,MatlagaBR.
Theeffectofshockwaverateontheoutcomeofshockwavelithotripsy:ameta-analysis.
JUrol2008;179:194–7.
[29]ConnorsBA,EvanAP,BlomgrenPM,etal.
Extracorporealshockwavelithotripsyat60shockwaves/minreducesrenalinjuryinaporcinemodel.
BJUInt2009;104:1004–8.
[30]EichelL,BatzoldP,ErturkE.
Operatorexperienceandadequateanesthesiaimprovetreatmentoutcomewiththird-generationlithotripters.
JEndourol2001;15:671–3.
[31]ZhengS,LiuLR,YuanHC,WeiQ.
Tamsulosinasadjunctivetreat-mentaftershockwavelithotripsyinpatientswithupperurinarytractstones:asystematicreviewandmeta-analysis.
ScandJUrolNephrol2010;44:425–32.
[32]SinghS,PawarD,GriwanM.
Tamsulosinasanexpulsivetherapyforloweruretericcalculusafterextracorporealshockwavelithotripsy:arandomizedcontrolledstudy.
NephroUrolMonthly2011;3:62–8.
[33]PearleMS,NadlerR,BercowskyE,etal.
Prospectiverandomizedtrialcomparingshockwavelithotripsyandureteroscopyforman-agementofdistalureteralcalculi.
JUrol2001;166:1255–60.
[34]KnollT,JessenJP,HoneckP,Wendt-NordahlG.
Flexibleureteror-enoscopyversusminiaturizedPNLforsolitaryrenalcalculiof10–30mmsize.
WorldJUrol2011;29:755–9.
[35]JohnsonE,BechisS,DeshmukhS,Barboglio-RomoP,EisnerB,PaisJrV.
Impactofperioperativeanticoagulationonincidenceofbleed-ingcomplicationsinpatientsundergoingpercutaneousnephro-lithotomy.
JUrol2013;189(4Suppl):e632.
[36]AstrozaG,LipkinM,NeisiusA,etal.
Effectofsupinevspronepositiononoutcomesofpercutaneousnephrolithotomyinstag-horncalculi:resultsfromtheClinicalResearchOfceoftheEndour-ologySocietyStudy.
Urology2013;82:1240–4.
[37]WangY,WangY,YaoY,etal.
Proneversusmodiedsupinepositioninpercutaneousnephrolithotomy:aprospectiverandomizedstudy.
IntJMedSci2013;10:1518–23.
[38]PatelU,WalkdenRM,GhaniKR,AnsonK.
Three-dimensionalCTpyelographyforplanningofpercutaneousnephrostolithotomy:accuracyofstonemeasurement,stonedepictionandpelvicalycealreconstruction.
EurRadiol2009;19:1280–8.
[39]TopalogluH,KarakoyunluN,SariS,OzokHU,SagnakL,ErsoyH.
Acomparisonofantegradepercutaneousandlaparoscopicapproachesinthetreatmentofproximalureteralstones.
BiomedResInt2014;2014:691946.
[40]WezelF,MamoulakisC,RiojaJ,MichelMS,delaRosetteJ,AlkenP.
Twocontemporaryseriesofpercutaneoustractdilationforpercu-taneousnephrolithotomy.
JEndourol2009;23:1655–61.
[41]HofbauerJ,Ho¨barthK,MarbergerM.
Electrohydraulicversuspneu-maticdisintegrationinthetreatmentofureteralstones:arandom-ized,prospectivetrial.
JUrol1995;153:623–5.
[42]CormioL,GonzalezGI,TolleyD,etal.
Exitstrategiesfollowingpercutaneousnephrolithotomy(PCNL):acomparisonofsurgicaloutcomesintheClinicalResearchOfceoftheEndourologicalSociety(CROES)PCNLGlobalStudy.
WorldJUrol2013;31:1239–44.
[43]ZanettiG,PaparellaS,TrinchieriA,PreziosoD,RoccoF,NaberKG.
Infectionsandurolithiasis:currentclinicalevidenceinprophylaxisandantibiotictherapy.
ArchItalUrolAndrol2008;80:5–12.
[44]Wendt-NordahlG,MutT,KrombachP,MichelMS,KnollT.
DonewgenerationexibleureterorenoscopesofferahighertreatmentsuccessthantheirpredecessorsUrolRes2011;39:185–8.
[45]BinbayM,YurukE,AkmanT,etal.
Isthereadifferenceinoutcomesbetweendigitalandberopticexibleureterorenoscopyproce-duresJEndourol2010;24:1929–34.
EUROPEANUROLOGYXXX(2015)XXX–XXX7EURURO-6336;No.
ofPages8Pleasecitethisarticleinpressas:Tu¨rkC,etal.
EAUGuidelinesonInterventionalTreatmentforUrolithiasis.
EurUrol(2015),http://dx.
doi.
org/10.
1016/j.
eururo.
2015.
07.
041[46]MitchellS,HavranekE,PatelA.
Firstdigitalexibleureteroreno-scope:initialexperience.
JEndourol2008;22:47–50.
[47]DicksteinRJ,KreshoverJE,BabayanRK,WangDS.
IsasafetywirenecessaryduringroutineexibleureteroscopyJEndourol2010;24:1589–92.
[48]BinX,FriedlanderJI,ChuangK-W,etal.
Predictivefactorsforintraoperativeballoondilationinsemirigidureteroscopiclithotrip-sy.
JEndourol2012;26:988–91.
[49]HubertKC,PalmerJS.
Passivedilationbyureteralstentingbeforeureteroscopy:eliminatingtheneedforactivedilation.
JUrol2005;174:1079–80.
[50]L'EsperanceJO,EkeruoWO,ScalesJrCD,etal.
Effectofureteralaccesssheathonstone-freeratesinpatientsundergoingureteroscopicmanagementofrenalcalculi.
Urology2005;66:252–5.
[51]TraxerO,ThomasA.
Prospectiveevaluationandclassicationofureteralwallinjuriesresultingfrominsertionofaureteralaccesssheathduringretrogradeintrarenalsurgery.
JUrol2013;189:580–4.
[52]BachC,NesarS,KumarP,etal.
Thenewdigitalexibleuretero-scopes:''sizedoesmatter''—increaseduretericaccesssheathuse!
UrolInt2012;89:408–11.
[53]BagleyDH,KuoRL,ZeltserIS.
Anupdateonureteroscopicinstru-mentationforthetreatmentofurolithiasis.
CurrOpinUrol2004;14:99.
[54]GargS,MandalAK,SinghSK,etal.
Ureteroscopiclaserlithotripsyversusballisticlithotripsyfortreatmentofuretericstones:apro-spectivecomparativestudy.
UrolInt2009;82:341–5.
[55]RubensteinRA,ZhaoLC,LoebS,ShoreDM,NadlerRB.
Prestentingimprovesureteroscopicstone-freerates.
JEndourol2007;21:1277–80.
[56]NabiG,CookJ,N'DowJ,McClintonS.
Outcomesofstentingafteruncomplicatedureteroscopy:systematicreviewandmeta-analy-sis.
BMJ2007;334:572.
[57]LambAD,VowlerSL,JohnstonR,DunnN,WisemanOJ.
Meta-analysisshowingthebenecialeffectofalpha-blockersonuretericstentdiscomfort.
BJUInt2011;108:1894–902.
[58]AlivizatosG,SkolarikosA.
IstherestillaroleforopensurgeryinthemanagementofrenalstonesCurrOpinUrol2006;16:106–11.
[59]ManikandanR,GallZ,GunendranT,NeilsonD,AdeyojuA.
DoanatomicfactorsposeasignicantriskintheformationoflowerpolestonesUrology2007;69:620–4.
[60]SeitzC,DesaiM,HackerA,etal.
Incidence,prevention,andman-agementofcomplicationsfollowingpercutaneousnephrolithola-paxy.
EurUrol2012;61:146–58.
EUROPEANUROLOGYXXX(2015)XXX–XXX8EURURO-6336;No.
ofPages8Pleasecitethisarticleinpressas:Tu¨rkC,etal.
EAUGuidelinesonInterventionalTreatmentforUrolithiasis.
EurUrol(2015),http://dx.
doi.
org/10.
1016/j.
eururo.
2015.
07.
041