Qualitative Review of Clinical Guidelines for Medical and Surgical Management of Urolithiasis: Consensus and Controversy 2020

You have accessJournal of UrologyReview Article1 Apr 2021Qualitative Review Clinical Guidelines for Medical and Surgical Management Urolithiasis: Consensus Controversy 2020 Pengbo Jiang, Lillian Xie, Raphael Arada, Roshan M. Patel, Jaime Landman, Ralph V. Clayman JiangPengbo Jiang Correspondence: Department Urology, University California, Irvine, 333 City Boulevard West, Suite 2100, Orange, California 92868 telephone: 714-456-6047; FAX: 888-378-4358; E-mail Address: [email protected] Irvine More articles by this author , XieLillian Xie AradaRaphael Arada PatelRoshan Patel LandmanJaime Landman ClaymanRalph View All Author Informationhttps://doi.org/10.1097/JU.0000000000001478AboutAbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Abstract Purpose: Many major guidelines across the globe address medical surgical management urolithiasis. We elected compare contrast recommendations among 5 most highly cited on stone disease offer insights where evidence has created a consensus there remains ongoing controversy hence need pursuit studies that will provide higher level evidence. Materials Methods: reviewed American Urological Association 2019 2016 guidelines, Canadian European Urology National Institute Health Care Excellence Asia guidelines. Tables correlating guideline statements topic were created, comparative analysis was conducted ascertain discordance. Results: Comparative from Association, revealed high surrounding stones. In terms stones, is regarding treatment ureteral stones including expulsive therapy using alpha blockers, not prestenting uncomplicated ureteroscopy employment either or shockwave lithotripsy as first line treatment. There renal The does Unlike Excellence, make specific selection patients procedures, density, skin-to-stone distance, rate, acoustic coupling postshockwave use therapy. Conclusions: are many areas only minor conflict up-to-date disease. Conflicts low evidence, such followup imaging strategies surveillance, access sheath in guidance miniaturized percutaneous nephrolithotomy, opportunities novel, impactful grade clinical studies. Abbreviations Acronyms AUA CP principle CT computerized tomography CUA EAU EO expert opinion NICE PCNL nephrolithotomy RCT randomized control trial SWL UAA UAS URS urolithiasis complex. Though certain aspects universal result quality research evidence-based practice, still exists divergence care due lack preponderance opinion. Worldwide, urologists compiled how properly manage with both medically surgically. However, methodologies upon which classified differ guideline. For example, includes well-conducted trials “strong observational studies,” cohort case-control studies, its highest (ie Grade A). contradistinction, Urology,1 Association2,3 Asia4 assign meta-analyses RCTs well-designed individual RCTs. Well-designed graded second tier levels at best. Even when converge, strength recommendation may based what experts respective associations designate absence diverge greatly they become dependent opinions “eminence-based medicine”).5 predominate fields would yield Accordingly, we review conflicts disease: AUA,6–8 EAU,1 CUA2,3 Excellence9 Asia.4 Methods A web search performed keywords: “kidney stone”, “urolithiasis”, “guidelines”. Each national international urology society webpage reviewed. addition, PubMed® terms: included if English language published after 2015. supportive grades independently assessed (LX, RA). Guideline then correlated (PJ). defined complete agreement all given topic. Results websites inclusion exclusion criteria guidelines: update 2014 guidelines,6–8 guidelines,2,3 guidelines,9 guidelines.4 results further divided into management; however, do stones.2,3 comprehensive.1,4 highlight key points moderate thus omit multiple topics.9 Grades Evidence grading several striking differences, resulted myriad (Appendix 1). between Level 1, reserved RCTs.1–3 also imply 1 must come “multiple large-scale RCTs.”4 states “good RCT” could, itself, whereas deems “Level 1b” 2 evidence.1–4 “Grade A” “exceptionally strong studies.” Its lowest C” “observational conflicting information design problems (eg, small sample size).”6–8 eschew these studies; their lowest, nonexpert 3 “good-quality retrospective studies” “well-designed nonexperimental studies…and case reports” 1).1–3 Appendix 1. Methodology determination Description evidence; certainty: (RCTs); exceptionally B some weaknesses; generally C (such very size) meta-analysis good low-quality good-quality prospective series 4 “first principles” bench research, 1a Meta-analysis 1b least one 2a controlled study without randomization 2b other type quasi-experimental correlations reports committee experience respected authorities Very Low Nonrandomized OR Randomized more than serious (1) risk bias, (2) inconsistency, (3) indirectness, (4) imprecision, downgraded because reasons listed below* no ONE concern (either imprecision), Moderate High imprecision obtained single nonrandomized can be of: bias (1 increment), (2 increments), heterogeneity unclear subgroup confidence interval crossing MID MIDs increments). Per AUA, any engender “Strong” recommendation, while engenders “Weak” “Conditional” recommendations.6–8 Likewise, per EAU, (Level 1-4) 3-4 2).1 Similarly, UAA, Levels C1” 2). Unique readiness recommend against practices, C2” “not recommend” D “recommended do” 2).4 2. correlation Recommendation A–C Strong conditional No Expert Opinion (EO) Principle (CP) 1–4 3–4 Weak provided 2–4 2–5 C1: consider C2: recommended 4–5 D: Guidelines, employed completely different set assessment system. They predominantly considered RCTs, few establishment systematic principles Furthermore, descriptive high, moderate, low) rather numbered.9 CUA, discordance (fig. initial evaluation, obtaining detailed dietary history, serum chemistries, urinalysis +/- urine culture (AUA: CP; CUA: C; EAU: Strong; NICE: omitted; UAA: B). Additional metabolic testing (omitted NICE) regards utilization 24-hour collections. differed patient populations should undergo evaluation. recurrent formers optional workup interested first-time formers. recommends 2, collections; collections B; specified; If captured, infrared spectroscopy x-ray diffraction Evidence).1,3,4,8,9 Figure tree diagram Lifestyle modifications play significant role fluid intake achieve output greater 2.5 liters day Low; general prevention, diets fruits vegetables EO; B).1,3,4,8,9 calcium formers, 1,000 1,200 mg daily C1). While distinction compositions, discussions stated oxalate albeit separation monohydrate dihydrate composition. restriction sodium prevention; each varies upper limit. less 2,300 daily, 3,000 5,000 6,000 (NICE: Moderate).1,3,4,8,9 hypercalciuria thiazide diuretic A–B; None thiazide. Potassium citrate adjunctive thiazides who hypocitraturia prescribed alkali addition citrate, specifically bicarbonate viable (EAU: Strong); additional discussion hypothetical possible an increase urinary calcium.1,3,4,8,9 Only provides pharmacological phosphate formers: hypercalciuric Strong) acidify (L-Methionine) pH Weak).1 hyperuricosuria, allopurinol specified). Febuxostat agent Strong). regard, it noted U.S. Food Drug Administration issued safety alert data increased cardiac death compared allopurinol. Finally, empiric and/or discernible abnormalities B).1,2,8 uric acid limiting animal protein omitted). Urine alkalization alkaline citrates almost universally routine EO), supports presence hyperuricosuria Strong).1,2,8 cystine 3L (CUA: discuss 7-7.5 refractory alkalization, thiol binding agents initiated management.1,2,4,8 After initiation therapy, assess response collection within 6 months 8 12 weeks Periodic blood tests monitor adverse effects A; include periodic growth new formation. made timing modality A).1,2,4,8,9 nearly addresses but omits Preoperative vary suggest noncontrast helpful determine optimal intervention prior performing enhanced surgeon’s judgment collecting system anatomy needs functional (with DTPA [diethylenetriaminepentaacetic acid] MAG-3 [mercaptuacetyltriglycine]) suspicion function loss C).1,2,4,6,7 emphasize importance rule out tract infection setting acute obstruction infection, prompt drainage stent nephrostomy tube proceeding definitive later date Patients undergoing appropriate antibiotic prophylaxis Strong).1,2,4,6,7 blockers distal mm 10 A).1,2,4,6,7,9 fails pass candidate equal >10 mm, SWL, B, stratified stone’s location ureter. difference recommendations. contrast, regard location, mid note lower clearance rates mm. counsel informed stone-free complication rate B).1,2,4,6,7,9 Other factors influencing suspected composition, density distance. preferred over EO). known cystine, brushite likely better treated URS. state >1,000 HU cm served Also, obese comment variables. holmium laser holmium:YAG effective flexible (Strong), pneumatic ultrasound systems used disintegration efficacy rigid electrohydraulic lithotripter Strong).1,2,4,6,7,9 heterogeneous. divide size. delineate size only. indications ultra, micro, miniPCNL. <10 20 >20 Low). regardless ultraPCNL microPCNL. pole acceptable cases favorable conditions (eg broad infundibulopelvic angle, short infundibulum, wide composition; ultraPCNL, microPCNL miniPCNL.1,4,6,7,9 placement stents intervention; stenting facilitates ureteroscopic outcomes. Omitted).1,2,6,7,9 ureteroscopy, Omitted). impede fragment passage rates. decrease steinstrasse hand, mentions internal before improve nor number auxiliary treatments, reduce formation steinstrasse. PCNL, tubeless (without tube) totally stent; AUA: did approach other.1,2,4,6,7,9 NICE, coupling, postSWL expulsion parameters 3). Both proper technical considerations efficiency Strong).1,2,4 3. lithotripsy. highlighted particular, wire “most endoscopic procedures” clinicians normal saline irrigation sheaths ureteroscopy. “highly useful tool armamentarium urologist during ureteroscopy.” needed “to safety, define cost-effectiveness, impact reduction intrarenal pressures” C). benefits disadvantages use. UAS.1,2,4,6,7 except pregnant patients. diversions. pediatric urolithiasis.1,2,4,6,7,9 Discussion Urolithiasis affects 11 individuals United States.10 At half had another.11 As such, spans beyond stone, calling measures prevent recurrence established peer-reviewed medicine. designed facilitate often organizations default local eminence-based experience. Fortunately, our found consensus. This concordance reflects contemporary incorporating same recently data. Areas surprisingly generated topics paucity future research. To wit, utilizing (plain film, CT) timing. similarly omitted poorly discussed led widespread disparity reported therapeutic success since modalities fine-cut scans degree false negatives, thereby inflating “stone-free” rate. none suggested status defined, adding range postoperative success. assessing patients’ burden. Noncontrast held gold standard sensitivity specificity ultrasound.12,13 understandable radiation exposure.13 Recent demonstrate dose now ultralow mitigate concerns, although cohorts remain relatively small.14–16 Another area makes conjunction (>4.0 mmol/day) hyperuricemia (>380 μmol). Upon closer analysis, explain discrepancy. references Marchini et al’s matched examining composition distribution gout nongout patients.17 changes gout, similar reducing fewer pure recognizes UAS. made. briefly potential advantages literature UAS, growing body benefits. Breda al UAS: facilitation repeated retrograde access, pressure, harm ureter ureteroscope improved extraction.18 Traxer al, 2015, UAS.19 group Society Anesthesiologists® scores larger damage bleeding, reduced infectious complications.19 Absence attention reflect fact always trail current literature. Currently, distinguish traditional vs miniPCNL, ultraminiPCNL. smaller sizes, explicitly acknowledges,1 recommended. miniPCNL conventional tracts, addressed Further warranted panels stronger Lastly, cyber connectivity contributed immensely globalization circulation information. Today, urological societies working groups. propose various groups together develop Pradere collaborative effort confusion management.20 sure, regional discrepancies incidence. common Caucasian males.21 Although prevalence lower, complaints Asian countries.22 Any afflicted benefit vetted world’s updated biennial basis. Conclusions (2019 – medical/2016 surgical), (2016), (2020), (2019), (2019) stem These important amount necessary create frequent update, time ripe structured global effort. References : interventional Eur Urol 2016; 69: 475. Google Scholar Guideline: calculi. Can Assoc J 2015; 9: E837. evaluation kidney - update. 10: E347. 4. Int 2019; 26: 688. 5. Swarm-based Med Internet Res 2013; 15: e207. 6. Stones: Association/Endourological Guideline, PART II. 196: 1161. Link, 7. I. 1153. 8. stones: 2014; 192: 316. 9. Renal Ureteric Assessment Management: ureteric management. BJU 123: 220. 10. Prevalence States. 2012; 62: 160. 11. stone. Ann Intern 1989; 111: 1006. 12. Diagnosis flank pain: value unenhanced helical CT. AJR Am Roentgenol 1996; 166: 97. 13. Imaging techniques methods exposure. Clin North 40: 47. 14. Feasibility ultra-low model-based iterative reconstruction: pilot study. 39: 99. 15. Ultra-low-dose limited volumetric surveillance: Abdom Radiol (NY) 44: 227. 16. Low-dose versus standard-dose protocol clinically colic. 2007; 188: 927. 17. Gout, risk: 189: 1334. 18. Benefits risks access. Curr Opin 70. 19. Differences outcomes support sheath: Research Office Endourological Ureteroscopy Global Study. World 33: 2137. 20. Evaluation 2018; 199: 1267. 21. Temporal trends incidence Kidney 83: 146. 22. Epidemiology Asia. 5: 205. © 2021 Education Research, Inc.FiguresReferencesRelatedDetails Volume 205Issue 4April 2021Page: 999-1008 Advertisement Copyright & Permissions© Inc.Keywordsevidence-based practicekidney calculiurolithiasisureteral calculiconsensusMetricsAuthor Information Expand Loading ...