2015 EAU 泌尿系结石治疗的热点与争议

Platinum Priority –Editorial

Referring to the articles published on pp.x–y of this issue

Contemporary Management of Stone Disease:The New EAU Urolithiasis Guidelines for 2015

Matthew Bultitude a ,*,Daron Smith b ,Kay Thomas a

a

Stone Unit,Guy’s and St.Thomas’NHS Foundation Trust,London,UK;b Stone /EndoUrology Unit,University College Hospital,London,UK

In this month’s issue of European Urology ,two major components of the European Association of Urology guidelines are summarised regarding the diagnosis and management and the interventional treatment of urolith-iasis [1,2].The low level of evidence for many of the reference statements demonstrates the paucity of high-quality randomised trials available in stone disease,making this expert consensus all the more important for guiding current practice.

The diagnostic guidelines are clear.Although ultraso-nography is the primary diagnostic tool,it remains user dependent,with a range of sensitivities from 19%to 93%.Noncontrast computed tomography scan (NCCT)is the standard for investigation of acute flank pain,with dose-reduction techniques offering high sensitivity (97%)and specificity (95%).Radiation exposure reference ranges are given,demonstrating that low-dose NCCT achieves similar doses to kidney,ureter,and bladder x-ray (0.97–1.9vs 0.5–1.0mSv).Computed tomography (CT)scanning also allows assessment of Hounsfield units (HU),which may be helpful in planning treatment;the guidelines suggest that >1000HU are less likely to be fragmented with shockwave lithotripsy (SWL).An aspect not addressed is the potential for dual-energy CT to assess stone composition.This type of technology may be helpful in the future not only for directing surgical therapy but also for identifying stones suitable for medical dissolution with alkalinising agents.Diagnostic imaging in pregnancy is a challenging situation,and ultrasound remains the imaging method of choice,with magnetic resonance imaging as a second-line option,but these updated guidelines now include low-dose CT scanning as the final option in selected cases.

Nonsteroidal anti-inflammatory drugs are clearly super-ior to opiate medication for the acute stone episode [3],and prescription of these drugs should be first line if no contraindication exists.Readers,however,should be aware of evolving literature regarding cardiovascular side effects,as regulatory authorities have recommended that systemic diclofenac should be contraindicated in patients with ischaemic heart disease,peripheral arterial disease,cere-brovascular disease,and congestive heart failure due to the risk of thrombotic events [4].Naproxen and ibuprofen may have lower risk.

Medical expulsive therapy (MET)has become widely adopted since publication of the meta-analysis of trials in 2006[5],and this is reflected in these guidelines,which advocate MET to facilitate spontaneous passage and to reduce painful episodes.A recent large multicentre randomised trial of 1167patients [6],however,may change future guidance on MET.This trial showed no benefit from MET with tamsulosin or nifedipine versus placebo for stone passage,analgesic use,or time to stone passage.Although this is a single trial,it had more patients than the meta-analysis data,and significant weight needs to be given to this paper when deciding whether to continue to offer MET for ureteric stones.

An issue discussed in both guidelines [1,2]is the management of asymptomatic calyceal stones.The evi-dence base remains poor,with the risk of symptomatic episode or need for intervention quoted as 10–25%per year.Although observation of tiny stones seems sensible for most,many would not observe stones of up to 15mm in size,as suggested in the guideline;clearly,treatment needs to be tailored to the individual patient.Active treatment of

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DOIs of original articles:/10.1016/j.eururo.2015.07.041,/10.1016/j.eururo.2015.07.040.

*Corresponding author.Stone Unit,2nd Floor,Tower Wing,Guy’s Hospital,Guy’s and St.Thomas’NHS Foundation Trust,Great Maze Pond,London SE19RT,UK.Tel.+442071889099.

E-mail address:matthew.bultitude@ (M.

Bultitude).

/10.1016/j.eururo.2015.08.010

0302-2838/#2015European Association of Urology.Published by Elsevier B.V.All rights reserved.