EAU 2025 Guidelines: Urolithiasis

What This Guideline Covers

The EAU 2025 Urolithiasis guideline provides evidence-based recommendations across 22 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

• Immediate imaging is indicated with fever or solitary kidney, and when diagnosis is doubtful.
• Use non-contrast-enhanced computed tomography to confirm stone diagnosis in patients with acute flank pain following initial ultrasound assessment.

Recommendations: basic laboratory analysis - emergency stone patients

• Serum blood sample: • creatinine; • uric acid; • (ionised) calcium; • sodium; • potassium; • blood cell count; • C-reactive protein.
• Perform a coagulation test (partial thromboplastin time and international normalised ratio) if intervention is likely or planned.

Recommendations related to non-emergency stone analysis

• Perform stone analysis in first-time formers using a valid procedure (X-ray diffraction or infrared spectroscopy).

• Repeat stone analysis in patients presenting with: • recurrent stones despite drug therapy; • early recurrence after complete stone clearance; • late recurrence after a long stone-free period because stone composition may change.

• Use ultrasound (US) as the preferred method of imaging in pregnant women.

• Use magnetic resonance imaging as a second-line imaging modality in pregnant women.

• Use low-dose computed tomography as a last-line option in pregnant women.

• Complete a metabolic evaluation based on stone analysis in all children.

• Collect stone material for analysis to classify the stone type.

• Perform US as first-line imaging modality in children when a stone is suspected; it should include the kidney, fluid-filled bladder, and the ureter.

• Perform a kidney-ureter-bladder radiography (or low-dose non-contrast- enhanced computed tomography) if US will not provide the required information.

• Offer a non-steroidal anti-inflammatory as the first drug of choice; depending on cardiovascular risk factors and side effects.

• Offer renal decompression or ureteroscopic stone removal in case of analgesic refractory colic pain.

• Urgently decompress the collecting system in case of sepsis with obstructing stones, using percutaneous drainage or ureteral stenting.

• Delay definitive treatment of the stone until sepsis is resolved.

• Collect (again) urine for antibiogram test following decompression.

• Start antibiotics immediately (+ intensive care, if necessary).

• Re-evaluate antibiotic regimen following antibiogram findings.

• Offer α-blockers as medical expulsive therapy as one of the treatment options for (distal) ureteral stones > 5 mm*.

Recommendations (oral chemolysis of uric acid stones)

• Inform the patient how to monitor urine- pH by dipstick and to modify the dosage of alkalising medication according to urine pH, as changes in urine pH are a direct consequence of such medication.

• Carefully monitor patients during/after oral chemolysis of uric acid stones.

• Ensure correct use of the coupling agent because this is crucial for effective shock wave transportation.

• Maintain careful fluoroscopic and/or ultrasonographic monitoring during shock wave lithotripsy (SWL).

• Use proper analgesia because it improves treatment results by limiting pain-induced movements and excessive respiratory excursions.

• Prescribe antibiotics prior to SWL in the case of infected stones or bacteriuria.

• Use holmium: yttrium-aluminium-garnet (Ho:YAG) or Thulium fiber laser (TFL) laser lithotripsy for (flexible) ureteroscopy (URS).

• Perform stone extraction only under direct endoscopic visualisation of the stone.

• Do not insert a stent in uncomplicated cases.

• Offer medical expulsive therapy for patients suffering from stent-related symptoms and after Ho:YAG laser lithotripsy to facilitate the passage of fragments.

• Use percutaneous antegrade removal of ureteral stones as an alternative when shock wave lithotripsy (SWL) is not indicated or has failed, and when the upper urinary tract is not amenable to retrograde URS.

• Use flexible URS (even for stones > 2 cm) in cases where percutaneous nephrolithotomy or SWL are not an option. However, in this case, there is a higher risk that a follow-up procedure and placement of a ureteral stent may be needed.

• Perform pre-procedural CT imaging, including contrast medium when indicated or retrograde study when starting the procedure, to assess stone comprehensiveness and anatomy of the collecting system to ensure safe access to the renal stone.

• Perform a tubeless (without nephrostomy tube) or totally tubeless (without nephrostomy tube and ureteral stent) percutaneous nephrolithotomy (PCNL) procedure, in uncomplicated cases.

• Take a stone culture or urine culture directly from the renal pelvis at time of PCNL, if possible.

• Obtain a urine culture or perform urinary microscopy before any treatment is planned.

• Exclude or treat urinary tract infections prior to stone removal.

• Offer peri-operative antibiotic prophylaxis to all patients undergoing endourological treatment.

• Decide on temporary discontinuation, or bridging of antithrombotic therapy in high-risk patients, in consultation with the internist.

• Retrograde (flexible) ureteroscopy is the preferred intervention if stone removal is essential and antithrombotic therapy cannot be discontinued since it is associated with less morbidity.

• If active removal is not indicated in patients with newly diagnosed small* ureteral stones, observe patient initially with periodic evaluation.

• Offer α-blockers as medical expulsive therapy as one of the treatment options for (distal) ureteral stones > 5 mm**.

• Inform patients that ureteroscopy (URS) has a better chance of achieving stone-free status with a single procedure.

• Inform patients that URS has higher complication rates when compared to shock wave lithotripsy.

• Use URS as first-line therapy for ureteral (and renal) stones in cases of severe obesity.

• Evaluate stone composition before deciding on the method of removal, based on patient history, former stone analysis of the patient or Hounsfield unit (HU) on unenhanced CT.

• Perform percutaneous nephrolithotomy (PCNL) as first-line treatment of larger stones > 2 cm.

• Treat larger stones (> 2 cm) with flexible ureteroscopy or shock wave lithotripsy (SWL), in cases where PCNL is not an option. However, in such instances there is a higher risk that a follow-up procedure and placement of a ureteral stent may be needed.

• Perform PCNL or retrograde intrarenal surgery (RIRS) for the lower pole, even for stones > 1 cm, as the efficacy of SWL is limited (depending on favourable and unfavourable factors for SWL).

• Offer laparoscopic or open surgical stone removal in rare cases in which shock wave lithotripsy, retrograde or antegrade ureteroscopy and percutaneous nephrolithotomy fail, or are unlikely to be successful.

• Treat all uncomplicated cases of urolithiasis in pregnancy conservatively (except where there are clinical indications for intervention).

• Perform percutaneous lithotomy to remove large renal stones in patients with urinary diversion, as well as for ureteral stones that cannot be accessed via a retrograde approach, or that are not amenable to shock wave lithotripsy.

• Offer patients with transplanted kidneys, any of the contemporary management options, including shock wave lithotripsy, flexible ureteroscopy and percutaneous nephrolithotomy.

• Offer children with single ureteral stones less than 10 mm shock wave lithotripsy (SWL) if localisation is possible as first-line option.

• Ureteroscopy is a feasible alternative for ureteral stones not amenable to SWL.

• Offer children with renal stones with a diameter of up to 20 mm (~300 mm2) SWL.

• Offer children with renal pelvic or calyceal stones with a diameter > 20 mm (~300 mm2) percutaneous nephrolithotomy.

• Prescribe thiazide in case of hypercalciuria > 8 mmol/24 hours.

Therapeutic measures of infection stones

• Surgically remove the stone material as completely as possible.

• Prescribe antibiotics in case of persistent bacteriuria.

• Use ultrasound (US) as first-line imaging with symptoms suggestive of a bladder stone.

• Use cystoscopy or computed tomography (CT), or kidney-ureter-bladder X-Ray (KUB) to investigate adults with persistent symptoms suggestive of a bladder stone if US is negative.

• Offer adults with bladder stones transurethral cystolithotripsy where possible.

• Offer adults percutaneous cystolithotripsy where transurethral cystolithotripsy is not possible or advisable.