2015 EAU 泌尿系结石治疗的热点与争议

Platinum Priority –EditorialReferring to the articles published on pp.x–y of this issueContemporary Management of Stone Disease:The New EAU Urolithiasis Guidelines for 2015Matthew Bultitude a ,*,Daron Smith b ,Kay Thomas aaStone Unit,Guy’s and St.Thomas’NHS Foundation Trust,London,UK;b Stone /EndoUrology Unit,University College Hospital,London,UKIn 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 ofE U R O P E A N U R O L O G Y X X X (2015)X X X –X X Xa v a i l ab l e a t ww w.sc i e n c ed i re c t.c o mj o u r n a l h o m e p a g e :w w w.e u r o p e a n u r o l o g y.c omDOIs 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.2015.08.0100302-2838/#2015European Association of Urology.Published by Elsevier B.V.All rights reserved.smaller stones for patients with solitary kidneys or frequent travellers may be appropriate,whereas observation of quite large stones is certainly possible in the elderly or comorbid and in those who have easy access to medical treatment.Management of these stones in the presence of comorbid-ities poses challenges,as patients may be less able to tolerate intervention in the future if they experience stone growth,symptoms,or obstruction.Although the only randomised trial in this area (SWL vs observation)showed no benefit [7],21%of the observation group required ‘‘additional treatment’’at a median of only 2.2yr.More studies are required to further direct the management of these patients,including the optimal frequency and duration of follow-up.In an era of concern regarding antibiotic resistance,it is good to see clear guidance on the use of prophylactic antibiotics in stone surgery.This update states that single-dose administration is sufficient for ureteroscopy (URS)and percutaneous nephrolithotomy (PNL)procedures.Although there is evidence for longer courses [8],the guidelines are pragmatic to minimise overuse of antibiotics and can be tailored for specific patients with recurrent infections.There is no benefit to routine antibiotic prophylaxis in SWL unless there is a potential infective source such as infection stone or nephrostomy tube.Decision making in choosing active treatment is aided by a treatment algorithm to help stratify choices among SWL,URS,and PNL.It is interesting that miniaturisation of instruments has led to PNL taking on smaller and smaller stones.At the same time,durability and digitalisation of flexible ureteroscopes has led to surgeons tackling larger and larger stones,with published series demonstrating efficacy in stones 2–3cm.Forming a treatment algorithm is now almost impossible,but what is clear is that rates of SWL have been declining worldwide,and the emphasis of this guideline reflects this shift,although SWL remains a vital component of a stone surgeon’s armamentarium with appropriate patient selection.Ureteral access sheaths (UAS)have clear benefits,as outlined;however,care has to be taken to prevent ureteral injury,as detailed by Traxer and Thomas [9].The decision of whether to use UAS may depend on the choice of whether to dust the stone or fragment and remove it.The guideline makes a bold statement that dusting should be limited to large renal stones.Little evidence exists to promote either strategy,and it could be argued that larger stones are best being removed because of the sheer stone volume,whereas dusting small stones is acceptable.What is clear is that if there is no prior stone analysis,then one should be obtained for every patient to guide future decision making.The use of stents and nephrostomy tubes after URS and PNL,respectively,remains controversial.Despite the guidance suggesting that tubeless or totally tubeless procedures are safe after uncomplicated PNL,many surgeons will remain cautious and tend to favour placement to maximise postoperative access and options (including second-look PNL).Following URS,the evidence suggests that stenting is not required after uncomplicated proce-dures;however,this depends on a number of factors,and strategies to minimise indwelling time,such as leaving the tether attached to allow easy early removal (‘‘stent on a string’’),are useful in cases of uncertainty.In conclusion,these publications provide a timely well-referenced guide for the treating clinician;however,these are only guidelines,and many aspects will differ in clinical practice.A lot of the emphasis in treating stones must be given to individual patient factors as well as local and timely availability of services.Conflicts of interest:Matthew Bultitude has worked as a consultant forBoston Scientific.Daron Smith has received an honorarium from Lilly forlectures.Kay Thomas has nothing to disclose.References[1]Tu¨rk C,Petr ˇı´k A,Sarica K,et al.EAU guidelines on diagnosis and conservative management of urolithiasis.Eur Urol.In press.http:///10.1016/j.eururo.2015.07.040[2]Tu¨rk C,Petr ˇı´k A,Sarica K,et al.EAU guidelines on interventional treatment for urolithiasis.Eur Urol.In press./10.1016/j.eururo.2015.07.041[3]Holdgate A,Pollock T.Nonsteroidal anti-inflammatory drugs(NSAIDs)versus opioids for acute renal colic.Cochrane DatabaseSyst Rev 2005:CD004137.[4]Coxib and Traditional NSAID Trialists’(CNT)Collaboration.Vascularand upper gastrointestinal effects of non-steroidal anti-inflammato-ry drugs:meta-analyses of individual participant data from random-ised ncet 2013;382:769–79.[5]Hollingsworth JM,Rogers MAM,Kaufman SR,et al.Medical therapyto facilitate urinary stone passage:a ncet2006;368:1171–9.[6]Pickard R,Starr K,MacLennan G,et al.Medical expulsive therapy inadults with ureteric colic:a multicentre,randomised,placebo-con-trolled ncet 2015;386:341–9.[7]Keeley Jr FX,Tilling K,Elves A,et al.Preliminary results of arandomized controlled trial of prophylactic shock wave lithotripsyfor small asymptomatic renal calyceal stones.BJU Int 2001;87:1–8.[8]Mariappan P,Smith G,Moussa SA,Tolley D.One week of ciprofloxa-cin before percutaneous nephrolithotomy significantly reduces up-per tract infection and urosepsis:a prospective controlled study.BJUInt 2006;98:1075–9.[9]Traxer O,Thomas A.Prospective evaluation and classification ofureteral wall injuries resulting from insertion of a ureteral accesssheath during retrograde intrarenal surgery.J Urol 2013;189:580–4.E U R O P E A N U R O L O G Y X X X (2015)X X X –X X X2。