LAUSR

Dear Editor Great success has been achieved in the management of urolithiasis in China over the decades [1]. However, whether and how Chinese urologists follow the accepted guidelines [2–5] is unknown. To answer the question, we performed a nationwide survey in China. Here we briefly report the results, point out current issues, and propose recommendations on urolithiasis management in China. Between April and June 2019, a 38-item questionnaire was sent to 690 urologists at tertiary/teaching, provincial/municipal, and county hospitals in China, of whom 683 (98.9%) responded, and 681 (68.7%) returned valid responses. As shown in Table 1, for the first-time uncomplicated upper urinary tract stones between 0.6 and 1.0 cm, 397 (58.4%) urologists recommended extracorporeal shockwave lithotripsy (ESWL), whereas 279 (41.0%) recommended lifestyle adjustment (n = 64, 9.4%) or medical expulsive therapy (n = 215, 31.6%). For the stones between 1.0 and 2.0 cm, 287 (42.2%) urologists recommended ESWL, and 280 (41.2%) recommended ureteroscopic laser lithotripsy, whereas 67 (9.9%) recommended percutaneous nephrolithonomy (PCNL). For the stones between 1.0 and 2.0 cm, 468 (68.8%) urologists recommended PCNL, and 127 (18.7%) recommended laser lithotripsy. Most (658, 96.8%) urologists acknowledged the importance of the guidelines and would like to follow them. Based on the survey, along with our experience, we have learned that most urologists managed urolithiasis following the guidelines published in China [5]. However, several issues existed. First, the recommended inclusion and exclusion criteria in the guidelines were not fully followed. For example, different management approaches may be applied by different hospitals or even by different urologists at the same hospitals for the same patients, as highlighted by the Urological Association of Asia [3]. Thus, the recommended criteria should be made known to all urologists, and more attention be paid to ESWL and medical expulsive therapy. Second, some urologists did not search for the etiology and paid little attention to stone recurrence prevention. We would encourage urologists to take more efforts to investigate the causes of the stones. Third, advanced technology and equipment were insufficient at some hospitals, which was one of the reasons for failing to comply with the guidelines. Thus, medical resources, including advanced technology and equipment, should be provided to all hospitals qualified to manage urolithiasis. Fourth, the unique characteristics of Chinese patients, in terms of ethnical, genetic, dietary and environmental factors, should be considered. For example, thinner flexible or rigid nephroscopes are required for Chinese patients due to smaller diameters of the urinary tract. Finally, Chinese urologists should be more innovative and help develop advanced techniques and equipment, such as a fine percutaneous nephroscope with a pressure-monitoring device in the tip, a better extracorporeal shock wave lithotripter with artificial intelligence to avoid the kidney injuries, and a laser lithotripter that can break the stones without thermal damage to the kidney. We believe that the findings of our survey and our opinions are of value for a comprehensive evaluation on current clinical practice and better compliance with the guidelines for urolithiasis management in China.