by Robert Fay

The American Urological Association (AUA) and the European Association of Urology (EAU) released updated guidelines for the management of ureteral calculi. The document is an update to the 1997 AUA ureteral calculi management guidelines as well as an update of a section of the EAU's 2006 guidelines on urolithiasis.

Although the previous guidelines provided useful recommendations on the management of ureteral calculi, Glen M. Preminger, MD, FACS, Professor of Urologic Surgery and Director of the Comprehensive Kidney Stone Center at Duke University Medical Center and co-chairman of the joint guidelines panel explained that the update was necessary to reflect that "significant changes in shockwave lithotripsy (SWL) technology, endoscope design, intracorporeal lithotripsy techniques and laparoscopic expertise have mushroomed during the past 5 to 10 years."

The document incorporates a large amount of research developed during the last 10 years, including the use of SWL, ureteroscopy (URS), and medical expulsive therapies (MET), medications such as alpha blockers and nifedipine, which help patients spontaneously pass stones. In addition, the update changes the indications for URS. Formerly recommended as the choice for surgical treatment of middle and distal ureteral stones, URS is now preferred for stones in all locations and is now considered appropriate for stones of any size in the proximal ureter. The update also supports ureteroscopic stone management in the middle ureter, which has been a challenging location for treating stones surgically.

The document also touches on the direction of future research, identifying deficiencies, such as too few randomized controlled trials (RCTs) for data extraction as well as inconsistencies, beginning with the definition of stone sizes and ending with variable definitions of a stone-free state. These limitations, say the authors, "hinder the development of evidence-based recommendations." Research recommendations include:

• RCTs that compare interventional techniques, pharmacological studies of stone-expulsion therapies as double-blinded RCTs;
• Reporting stone-free data without including residual fragments;
• Using consistent nomenclature to report stone size, stone location, stone-free rates, time point when stone-free rate is determined, or method of imaging to determine stone-free rate; and
• Reporting data stratified by patient/stone characteristics, such as patient age, stone size, stone location, stone composition, gender, body mass index, and treatment modality.

Preminger, also a member of the Urology Domain Medical Advisory Board, says the new guidelines set a precedent because they are "the first set of international guidelines jointly offered by the EAU and the AUA. The panel believes that future collaboration between the EAU and the AUA will serve to establish a set of internationally approved guidelines, offering physician and patient guidance throughout the world."

The first chapter of the guideline has been published in the Journal of Urology and European Urology. The entire guideline can be accessed online at the AUA website or at the EAU website.

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Source: Preminger GM, Tiselius HG, Assimos DG, et al. 2007. 2007 guideline for the management of ureteral calculi. Journal of Urology 178:2418-2434.

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