Urolithiasis is a common disease of urology, the prevalence rate is as high as 5-10%, in China urolithiasis patients accounted for nearly a quarter of the urology hospitalized patients, seriously affecting people’s health. In recent years, China’s urology has developed rapidly, and various treatment methods for stones have basically been brought into line with international standards, but the choice of treatment methods has not yet been standardized, leading to the problem of some hospitals choosing treatment methods as they wish or choosing treatment methods according to their medical conditions. In order to standardize the treatment of stones, we have compiled and organized the guidelines for the diagnosis and treatment of urolithiasis published by the 2005 European Annual Congress of Urology, hoping that the standardization of the treatment of urolithiasis in China will be helpful. 1, Introduction Urolithiasis has always occupied an important position in clinical practice. A person’s lifetime risk of developing stones ranges from 5-10%. The incidence is higher in men than in women, with a ratio of about 3:1, and the peak age of onset is 40-50 years. Any type of stone may recur, and recurrent stones are common in clinical practice and are the focus of treatment and prevention. 2. Classification of stone patients Based on the chemical composition of stones and the severity of the disease, we can classify stone patients into different types (see Table 1). Table 1: Classification of stone patients Description Abbreviation Infectious stones INF Non-calcium stones Uric acid/sodium urate/ammonium urate UR Cystine stones CY Patients with primary stones, no residual stones S 0 Patients with primary stones, with residual stones S res Calcium stones Patients with recurrent stones, with mild disease, no residual stones S m-0 Patients with recurrent stones, with mild disease, with residual stones S m-res Patients with recurrent stones, with Severe condition, with or without residual stones R s Patients with stones with special risk factors, disregarding other defined categories Risk 3. Risk factors for stone formation Due to the presence of a number of special risk factors, some patients require special attention (see Table 2). Table 2: Special risk factors for stone formation Early age of stone occurrence (<25 years) Stones contain calcium phosphate dihydrate Only one kidney is functional Diseases associated with stone formation: hyperparathyroidism, renal tubular acidosis, ileojejunal bypass, Crohn's disease, intestinal resection, malabsorption, sarcoidosis, hyperthyroidism Pharmacological treatments associated with stone formation: Calcium and vitamin D supplementation, high dose of vitamin C (4 g/day), sulfonamides. ), administration of sulfonamides, aminopterin, indinavir Anatomical abnormalities associated with stone formation: dilated renal tubules (MSK), stenosis of the renal pelvic ureteral junction (UPJ), calyceal diverticulum/calyceal cysts, ureteral stenosis, vesicoureteral reflux, horseshoe kidneys, ureteral cysts 4. DIAGNOSIS 4.1 Imaging Diagnosis In patients with renal stones, renal colic, when it occurs, is usually manifested by a characteristic low back pain, Vomiting as well as low-grade fever, and may have a history of previous stone disease. Clinical diagnosis depends on appropriate imaging methods. In patients with fever or isolated kidneys, or when the diagnosis of urolithiasis is uncertain, imaging is essential. Routine investigations include plain abdominal film (KUB) + ultrasonography, excretory urography (IVU) or unenhanced spiral CT. Contraindications to IVU include: ● Allergy to contrast agents ● Serum creatinine levels >200 μmol/L ● Mephenhydramine use ● Myelogenous leukemia Special investigations that may be performed at this time include: ● Retrograde or percutaneous cis-physelogram ● Radionuclide scanning 4.2 Laboratory Table 3: Analysis of patients with uncomplicated stones Stone analysis Blood analysis Urine analysis Stones analysis (at least one stone) in each patient Calcium Albumina Creatinine Urateb Fasting, morning urine sample Strip test: PH Leukocytes/bacteriac Cystine testd a Calcium + albumin or free calcium concentration test b Optional analysis c Urine culture if bacteriuria is present d If cystine cannot be ruled out by other means, urine culture should be performed. Urine cystine test if cystinuria cannot be excluded by other means Table 4: Analysis of patients with complex stones Stone analysis Blood analysis Urine analysis Stones analysis in each patient (at least one stone) Calcium Albumina Creatinine Urateb Potassium Fasting, urine sample in the morning Strip test: PH Leukocytes/bacteriac Cystine testd Collection of 24 disappeared urinec Sending of: urinary calcium, urinary oxalate, urinary citrate, urinary citrate, urinary citrate, urinary citrate, urinary citrate, urinary citrate, urinary citrate, urinary citrate, urinary citrate, urinary citrate, urinary citrate, urinary citrate, urinary cystine citrate, urinary uric acidd, urinary creatinine, urine volume, urinary magnesiumb,e, urinary phosphorusb,e,f, urinary ureab,f, urinary sodiumb,f, urinary chlorineb,f, urinary potassium assayb,f a Calcium + albumin or free calcium ion concentration assay b Alternative analyses available c 24-hour urine may be substituted with urine from a particular period of time during the day d Urine specimens that have not been acidified and processed e Urinary magnesium and urine phosphorus assays are used for evaluation of the ionic activity of calcium oxalate and calcium phosphate products f Urinary uric acid, urinary phosphorus, urinary sodium, and urinary potassium assays in response to dietary factors Table 5: Analyses for timely patient metabolic assessment related to stone classification Classification Blood analysis Urine analysis Preventive follow-up Infectious stones Blood creatinine Urine culture, PH Required Uric acid stones Blood uric acid, blood creatinine Urinary uric acid, PH Required Cystine stones Blood creatinine Cystine, PH Required So Required ( See Table 3) Partial urinalysis (see Table 3) Not required Sres Required (see Table 4) Required (see Table 4) Required Rm-o Required (see Table 3) Partial urinalysis (see Table 3) Not required Rm-res Required (see Table 4) Required (see Table 4) Required Rs Required (see Table 4) Required (see Table 4) Required Risk Required (see Table 4) Required (see Table 4) Required 5. TREATMENT 5.1 Pain relief ● The following drugs should be applied to relieve pain by different routes of administration; diclofenac sodium (fotarabine), indomethacin (anti-inflammatory pain), dihydromorphinone hydrochloride + atropine sulphate (dihydromorphinone atropine hydrochloride), anandamide, pentazocine and tramadol. ● Treatment should start with NSAIDs and be switched to other medications if pain persists. ● Hydromorphone and other opioids should not be used alone if atropine is not given at the same time. ● Diclofenac sodium affects glomerular filtration rate in patients with renal dysfunction, but not in those with normal renal function. ● When spontaneous stone expulsion is expected to be possible, 50 mg diclofenac sodium tablets or suppositories used twice daily for 3-10 days are effective in reducing ureteral edema as well as decreasing the rate of painful recurrence. ● Stone expulsion should be confirmed and renal function assessed by appropriate methods. Recoveries are promptly analyzed. ● When pain is not relieved by medication, a stent or percutaneous nephrostomy should be placed as well as lithotripsy performed to achieve drainage of urine. 5.2 Lithotripsy 5.2.1 Preoperative assessment: ● Presence of urinary tract infection: all patients prepared for lithotripsy must be screened for bacteriuria. When the bacteriuria test is positive, or the urine culture suggests bacterial growth, or when bacterial infection is suspected, antibiotic treatment should be used before stone extraction. Coagulopathy: Coagulopathy is a contraindication to extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotripsy (PNL), ureteroscopy (URS), and open surgery. ● Presence of pregnancy: pregnant women are contraindications for ESWL, PNL, and URS. 5.2.2 Choice of treatment The size, location, and nature of the stone affect the strategy for stone extraction. ● Stones less than 4 mm in diameter are self-extracted in 80% of cases. ● Stones larger than 7 mm in diameter have little chance of self-discharge and usually require stone extraction or lithotripsy. For stones in the proximal, middle, and distal ureter, the overall expulsion rates are 25%, 45%, and 70%, respectively. stones larger than 6-7 mm in diameter usually require lithotripsy. Clear indications for stone extraction or lithotripsy include pain unrelieved by medication, persistent obstruction with impaired renal function, risk of urinary tract infection, hydronephrosis, or pyuria, bilateral obstruction, or obstruction in a solitary functioning kidney. 5.2.3 Principles of treatment of ureteral stones For stones in different parts of the ureter, as well as for stones of different compositions, the most appropriate methods of stone extraction are given in Table 6. Four steps, 1, 2, 3, and 4, were developed based on the unanimity reached. step 1 was preferred, and the serial numbers were listed in order of preference; if the serial numbers were the same, it meant that both methods were equally important, and either method could be chosen. In situ ESWL treatment often needs to be repeated. Repeat treatment rates are highest for large, dense stones. Posterior laparoscopic surgery is a minimally invasive option compared to open surgery. 5.2.4 Basic principles of renal stone extraction The success rate of ESWL is related to the size of the stone. Larger stones require more treatment sessions. For larger kidney stones, PNL and ESWL, there is an ongoing debate as to which is the best method. The corresponding recommended treatments based on stone size and composition are shown in Table 7.Residual stone fragments (so-called clinically insignificant residual stones) are common after ESWL for kidney stones. For stones larger than 20 mm in diameter, it is recommended to place a double J-tube stent prior to ESWL to prevent stone accumulation and obstruction of the ureter, i.e., to prevent the formation of “stone streets”. For large ESWL-resistant stones, percutaneous nephrolithotripsy is the best option. Sometimes small stones in the calyx can cause severe pain or discomfort. Proximal ureter Middle ureter Distal ureter Impermeable stones (1) ESWL in situ (1) ESWL in situ, prone position (1) ESWL in situ (2) ESWL after “push up” (1) URS+lithotripsy (1) URS+lithotripsy (3) URS+lithotripsy (2) UC/IV contrast+ESWL (2) UC+ESWL (4) Percutaneous paracatheteroscopy (2) ESWL after “push-up” (3) Percutaneous transluminal ureteroscopy Infected stone, stone with infection (1) AB + ESWL in situ (1) AB + ESWL in situ + prone (1) AB + ESWL in situ (2) AB + “push-up” posterior (1) AB + URS + Lithotripsy ESWL (1) AB + URS + Lithotripsy ESWL (2) UC/Venography + ESWL (2) UC + ESWL (3) UC + URS + Lithotripsy Lithotripsy ESWL (1) AB + URS + lithotripsy (2) AB + PN + ESWL in situ (3) AB + URS + lithotripsy (2) AB + UC/IV contrast (2) AB + UC + ESWL (4) AB + percutaneous by-pass ureteroscopy + ESWL (2) AB + “push up” + ESWL (3) AB + percutaneous by-pass ureteroscopy Uric acid stones Stone (1) Stent + oral litholytic (1) ESWL in situ, prone position (1) ESWL in situ, IV contrast (2) ESWL in situ + oral (1) URS + lithotripsy (1) URS + lithotripsy Lithotripsy (2) UC/IV contrast + ESWL (2) UC + contrast + ESWL (3) URS + lithotripsy (2) “Push up” + ESWL (3) PN+ contrast + ESWL (4) Percutaneous by-pass ureteroscopy (2) Stent + oral lithotrips (3) Percutaneous by-pass ureteroscopy Cystine stones (1) In situ ESWL (1) In situ ESWL (1) In situ ESWL (2) ESWL after “push up” (1) URS + lithotrips (3) URS + lithotrips (2) UC/IV contrast + ESWL (2) URS + lithotrips (4) Percutaneous by-pass URS (2) ESWL after “push up” (2) UC + ESWL (3) Percutaneous by-pass ureteroscopy ESWL including piezoelectric lithotripsy URS = Ureteroscopy UC = Ureteral catheter AB = Antibiotics PN = Percutaneous nephrostomy 5.3 Calcium stone prophylaxis ● Prophylaxis for the patient with calcium stones should begin with conservative treatment. Consider pharmacologic therapy when conservative treatment fails. ● Conservative treatment: drink plenty of fluids so that the 24-hour urine output exceeds 2000 ml, and the necessary degree of urine dilution achieved should be guided by the supersaturation level of the urine. ● Balanced diet, avoiding partiality, eating appropriate fiber-containing foods, limiting oxalate-rich foods, and adjusting dietary structure according to biochemical abnormalities in each patient. 5.4 Pharmacological treatment of calcium stones Table 8 summarizes the recommended regimen for pharmacological treatment of calcium stones. Table 7: Basic principles of stone removal for renal stones Renal stones ≤ 20 mm Renal stones ≥ 20 mm Complete or partial staghorn-shaped stones Impermeable stones (1) ESWL (1) PNL (1) PNL (1) PNL (2) PNL (2) PNL (2) PNL+ESWL (3) PNL+ESWL (3) PNL+ESWL (3) PNL+PNL (4) Open surgery Infected stones, stones with infections (1) AB+ESWL (1) AB+PNL (1) PNL (2) AB+PNL (2) AB+ESWL placed (2) PNL+ESWL or no stent (3) PNL/ESWL + oral lithotripsy (3) AB+PNL+ESWL (4) ESWL+PNL (5) AB+ESWL+lithotripsy Uric acid stones (1) Oral lithotripsy (1) Oral lithotripsy (1) PNL (2) Stent+ESWL (2) Stent+ESWL (2) Stent+ESWL + (2) PNL+ESWL Oral lithotripsy Oral lithotrips (2) PNL/ESWL + oral lithotrips (3) ESWL + PN (4) Open surgery Cystine stones (1) ESWL (1) PNL (1) PNL (1) PNL (2) PNL + ESWL (2) PNL + ESWL (3) Open or laparoscopic (3) PNL + flexible nephroscopy (3) ESWL + PNL Surgery (4) Open surgery PNL = Percutaneous Nephrolithotripsy: ESWL including piezoelectric lithotrips. Table 8: Recommended medications for abnormal urine composition Drug Treatment group Thiazide diuretic 1 Thiazide diuretic + magnesium 1 (1) Hypercalciuria (2) Stones containing calcium phosphate dihydrate (3) Other abnormalities Alkaline citrate (1) Hypocitraturia (1) Renal tubular acidosis (2) Hyperoxaluria of intestinal origin (3) Low inhibitory activity of crystalline growth 2 (4) Other abnormalities Allopurinol (1) Hyperuricuricuria Vitamin B6 (pyridoxine) (1) Primary hyperuricuricuria type I (2) Mild hyperuricosuria Calcium supplementation (1) Enteric hyperoxaluria Orthophosphates 3 (1) Hypercalciuria Potassium supplementation is required to prevent hypokalemia and hypo-citraturia secondary to hypokalemic intracellular acidosis When crystal growth inhibitory activity is present Orthophosphates are not the first line of medication but may be used in patients intolerant of thiazide diuretics 5.5 Pharmacological treatment of uric acid stones This can be prevented by a high fluid intake to make 24-hour urine output more than 2000ml. Uric acid stone formation can be prevented by a high fluid intake that results in a 24-hour urine output of more than 2,000 ml. Alkalinization of the urine is very important in the prevention of uric acid stones and can be achieved by giving 3-7 mmol of potassium citrate or 9 mmol of sodium potassium citrate 2-3 times a day. If the concentration of uric acid in the serum or in the urine is high, a 300 mg dose of allopurinol should be given daily. To achieve stone dissolution, 6-10 mmol of potassium citrate or 9-18 mmol of potassium sodium citrate three times a day must be added to the high fluid intake therapy, and 300 mg of allopurinol should be given daily even if blood and urine uric acid are normal. 5.6 Pharmacologic treatment of cystine stones The 24-hour fluid intake should be more than 3,000 ml, whereby a minimum of 150 ml of fluid per hour should be ingested. Alkalize the urine with carbonate or potassium citrate to bring the urinary pH above 7.5. Potassium citrate 3-10 mmol in 2-3 divided intakes can be used for this purpose.Patients with more than 3 mmol of cystine excretion in 24 hours must be given mercaptopropionylglycine (thiopronin) 250-2000 mg/day or captopril 75-150 mg/day. 5.7 Pharmacologic treatment of infected stones For magnesium ammonium phosphate and carbonate apatite stones caused by urease-producing bacterial infections, complete surgical removal of the stones is done whenever possible. Antibiotic therapy is selected based on drug sensitivity tests, and extended dosing cycles are recommended to eradicate the infection. 6, Summary Urinary stone formation is a pathological state. Urinary stones affect most of the world’s population and have a high prevalence. Urinary stones put a lot of pressure on the healthcare system. Due to the recurrent nature of the disease, it is more important that these patients are provided with appropriate metabolic interventions, in addition to performing urolithotripsy and assisting patients with spontaneous stone removal. Minimally invasive means have made stone treatment relatively safe and routine.