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Plenary 7: What do we need for the future of stone treatment?

“I need water. It would be embarrassing to form a kidney stone during this presentation,” Prof. Palle Osther joked during his talk on the future of kidney stone treatment. His expansive talk marked the end of the plenary session on stones, and, in a way, also the end of EAU18, with only the summarising souvenir sessions remaining.

As former EULIS chairman and stone specialist, Prof. Osther offered his opinions on where stone treatment could still develop, specifically in prevention, the improvement of SWL (training), improvement in laser tech and further cost-effectiveness in single-use scopes.

Advantages of miniaturization?

Earlier in the session, Prof. Liatsikos (GR) and Dr. Hoznek (FR) had a spirited discussion on the merits of mini PCNL, each wholly committed to larger and mini instruments, respectively. Prof. Liatsikos hailed the superior stone clearance and shorter operating time with the larger tools, and lamented the poorer quality of the smaller scopes and the potential of stone fragments to spread without active suction on hand.

Dr. Hoznek on the other hand, was an enthusiastic user of mini-PCNL. When asked in which circumstances he might favour the large perc, he answered: “when my mini-perc is broken.” AUA Secretary Prof. Monga (US), who was chairing the debate asked for an audience vote, which revealed a small but noticeable preference for regular-sized PCNL.

Guidelines

Dr. Christian Türk (AT) compared and contrasted the AUA and EAU Guidelines on stones, noting a strong philosophical difference between the two guidelines in general, and some specific differences in treatment recommendations when it comes to stones.

Generally, the AUA Guidelines are produced on an ad-hoc basis, being updated when new developments dictate it and data is sufficiently clinically relevant. The EAU Guidelines are reviewed and updated on an annual basis. Levels of evidence and the strength of recommendations differs too, as do the manner in which recommendations are presented. The AUA Guidelines are offered on the basis of defined clinical questions whereas the EAU Guidelines are in a comprehensive “textbook” style.

When it comes to URS pre-stenting, there is a marked difference between the two guidelines, the AUA strongly recommending not to place a stent on the basis of absence of prospective data and high level evidence, as well as added costs and negative impact on QoL. The EAU on the other hand strongly recommends it, arguing that pre-stenting facilitates URS and improves URS outcomes.

Similar differences occur around PNL best practice, dealing with residual fragments and prophylaxis.