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The coronavirus has challenged all medical systems worldwide. Herein both waves of COVID-19 (coronavirus disease 2019) in spring and autumn 2020 differ principally. Whereas Europe was hit by the first wave more or less unprepared, which was aggravated by the high virulence of COVID-19, the second wave is characterized by a much higher contagiosity of the virus with very high incidences. On the other hand the virus has attenuated, which is reflected by the significantly lower incidence-related mortality rate. However, the overall increasing number of infected patients represents again a great challenge for the medical management of the disease. France and Spain are doing better in comparison to Germany and Italy this time. The absolute number of deaths per week is higher than during the peak of the first wave. However, urologists in these countries have also experienced greater restrictions in their activities in the second shutdown than in Germany, where there is only a reduction of beds to between 75 and 90%. Mostly all levels are operated. Of importance for Germany, however, is the plateau on a high level for several weeks probably due to the reduced efficacy of a light lock-down. This finally resulted in a total lock-down in mid-December 2020. Subsequently in Germany some hospitals are also reaching their limits with similar consequences for the departments of urology facing a 50% reduction of beds and operating only level III and IV indications. Nevertheless, the management of urologic patients during the COVID-19 pandemic is carried out in Europa on a high standard. Therefor the risk of secondary harm to our patients is expected to be rather minimal in the long run.

The increase of medical knowledge and technical innovations together with the demographic change represent a challenge for the new conception of guidelines and clinical studies. The present S2k guidelines, which are exclusively concerned with kidney and ureteral stones, should support the treatment of urolithiasis in hospitals and private practices and provide information on urolithiasis for patients. Increasing interdisciplinary collaboration in stone treatment is also demonstrated in the number of professional and working groups participating in the update of the new guidelines. The present S2k guidelines emerged from a consensus process and demonstrate the current recommendations in step with actual practice. They provide decision-making guidance for diagnostics, treatment and metaphylactic measures based on expert opinions and available published fundamental evidence from the literature.

The treatment of urolithiasis is still one of the most frequent tasks in the daily urological practice. Driven by the technological developments, patient demands and also personal experiences of urologists, many interventional treatment options have been established. To identify the most suitable treatment option, it is of utmost importance to consider not only stone size and localization but also the individual situation of the patient and the published evidence, which despite all efforts often lags behind the technical and clinical reality.

Background: Urolithiasis is a widespread disease. Diagnostic imaging plays an important role in the evaluation and management of patients with suspected urolithiasis. Furthermore, modern imaging methods may provide information on stone location, size, fragility and composition aiding the urologist to determine the appropriate treatment modality., Purpose: Based on the current literature and guidelines, this review reports on the various new and established diagnostic imaging modalities., Results: Ultrasound should always be the initial imaging modality. Following ultrasound, noncontrast CT-principally using a low-dose protocol-is the imaging modality of choice in the evaluation of patients with acute flank pain and suspected urolithiasis. New imaging modalities like dual energy CT, Uro Dyna CT and digital tomosynthesis are currently under investigation but not yet part of daily clinical practice. Magnetic resonance imaging can be used to detect obstruction caused by urinary stones but is not a first-line imaging modality.

Every tenth German citizen will suffer from at least one urinary calculus during the lifetime. The diagnostics, treatment and follow-up treatment of urolithiasis are, therefore, part of the daily routine practice for all urologists in hospitals and private practices as well as in many other disciplines, such as general practitioners, internists, nephrologists and pediatricians. Although the diagnostics and therapy have experienced substantial alterations over the last 10 years, the possibilities of metabolic diagnostics and secondary prevention for patients at risk are, unfortunately and unjustly, in many places very poorly represented. The present S2k guidelines, which for the first time were established in an interdisciplinary consensus process, represent the current practical recommendations and, whenever possible, use tables and algorithms in order to facilitate easy reference in the routine daily work. Last but not least, this greatly simplifies the measures for metaphylaxis.

Background: Numerous studies have shown that thulium vapoenucleation of the prostate (ThuVEP) is a size-independent minimally invasive procedure for the treatment of benign prostatic enlargement. All ThuVEP series have been performed with a 2-µm thulium laser device so far. The aim of this study was to evaluate the complications and early postoperative results of two thulium-devices with different wavelengths for ThuVEP in prostates larger than 80 ml., Materials and Methods: A retrospective bi-centric matched-paired analysis with 296 patients was performed. Based on prostate size, 148 were matched at each centre and laser device, respectively. A 2-µm (RevoLix, LISA Laser products, Katlenburg, Germany n=148) and a 1.9-µm (vela XL, starmedtec, Starnberg, Germany, n=148) thulium laser with a power output of 90 and 80 W was used. Patients' data were assessed and compared., Results: The median prostate volume (interquartile) was 100 ml (range 86.25-120 ml). At discharge, Qmax (preoperative 7.9 and 9 ml/s vs. postoperative 19.35 and 16.2 ml/s) and postvoiding-residual urine (preoperative 130 and 45 ml vs. postoperative 20 and 25 ml) were significantly improved after 2-µm and 1.9-µm ThuVEP (p<0.001). The median catheterization time and hospitalization times were 2 and 4 days in both groups. Perioperative complications occurred in 89 patients (30.1%): Clavien 1 (12.2%), Clavien 2 (9.1%), Clavien 3a (0.7%), Clavien 3b (7.1%), and Clavien 4a (1%). Regarding the occurrence of complications, there were no differences between the two thulium devices., Conclusion: ThuVEP represents a safe and effective treatment for prostates larger than 80 ml. Both thulium laser devices give satisfactory immediate micturition improvement with low perioperative morbidity.

Background: Following its introduction in the 1980s extracorporeal shock wave lithotripsy (SWL) became the gold standard for therapy of ureteral and renal calculi. The research data published during the last decade suggest a paradigm shift to endourological techniques., Objectives: The purpose of this study was to compare whether the suggested loss of status for SWL corresponds with actual real-life treatment in Germany. A further aim was to assess the quality of SWL therapy in German hospitals., Materials and Methods: The board of the German Society for Shock Wave Lithotripsy (DGSWL) sent a questionnaire to 306 urological departments in Germany, which encompassed medical, technical and organizational topics in the therapy of ureteral and renal calculi. A total of 99 (33%) questionnaires were returned., Conclusion: With the exception of a few departments, non-invasive SWL still plays a major role in the treatment of urolithiasis and a loss of the gold standard status is not in sight. The performance of SWL in German hospitals is carried out at a high level of quality. To maintain and optimize this status a structured SWL training and adherence to clinical practice guidelines are needed.

Rigid and flexible uretero(reno)scopy (URS) are safe and effective methods in interventional calculus therapy. Complications are rare and can be avoided in advance in many cases. In ureteroliths, URS has in many cases replaced extracorporeal shock wave lithotripsy (ESWL) as the method of first choice. However, it is important to describe in detail the advantages and disadvantages as well as the risks of the procedure to the patient.

Urinary stone disease is relatively rare in children with an overall incidence of 1-2 %; however, it is often associated with metabolic abnormalities that may lead to recurrent stone formation. Stone analysis and subsequent metabolic evaluation is therefore mandatory for this high-risk group after the first stone event. The objectives of stone management in children should be complete stone clearance, prevention of stone recurrence, preservation of renal function, control of urinary tract infections, correction of anatomical abnormalities and correction of the underlying metabolic disorders. The full range of minimally invasive procedures is available if active stone removal is necessary. The majority of stones in children can be managed either with extracorporeal shock wave lithotripsy which has a higher efficacy in children than in adults, percutaneous nephrolithotomy, ureterorenoscopy or a combination of these modalities while open or laparoscopic surgery is limited to well-selected cases with underlying anatomical abnormalities.

The current guidelines recommend percutaneous nephrolithotomy (PCNL) as the first choice procedure for large stone masses. Complex stone situations, such as formed stones or large peripheral stone masses, however, often necessitate several access points and multiple stage procedures. In such cases open surgical stone removal is often used. An alternative is simultaneous antegrade-retrograde stone therapy in which PCNL is combined with flexible ureterorenoscopy (fURS). Both procedures complement each other in that fURS allows access to narrow calyces and PCNL the simple removal of buried concretions via the percutaneous shaft without excessive disintegration. Even difficult stone situations can be resolved simultaneously. Disadvantages are the high personnel and instrumental involvement (two endoscopic procedures with two endoscope towers and two operators) which is not adequately reflected in the diagnosis-related groups (DRG) remuneration system. Additionally simultaneous stone treatment is normally carried out in the supine lithotomy position so that even an experienced percutaneous surgeon is confronted with a new situation and a certain learning curve. Our own experiences and that of other working groups show, however, that the simultaneous approach represents an attractive and effective addition to minimally invasive stone therapy if the appropriate equipment and corresponding expertise are available.

The Academy Spring Forums held as part of the Southwest German Congress in Tübingen and the Congress of North Rhine-Westphalia in Aachen offer urologists in private practice and likewise hospital urologists a compact overview of new developments. This article summarizes the newest work on e.g. interventional therapy, uroliths, and extracorporeal shock wave lithotripsy for benign prostatic hyperplasia and urolithiasis.

Due to its particular anatomical position below the ureteropelvic junction, the lower pole group of calices plays a special role in the treatment of nephrolithiasis. The extracorporeal shock-wave lithotripsy (ESWL) often attains dissatisfactory stone-free rates, even after optimal disintegration of lower pole stones, and thus necessitates secondary therapeutic procedures. Due to the favorable stone-free rates, retrograde intrarenal surgery with its low complication rate has taken up an important role in the treatment of lower pole stones since the development of modern flexible ureterorenoscopes. The long treatment times in the case of a large stone burden and considerable costs for materials constitute limiting factors. In line with the advancement of percutaneous nephrolitholapaxy (PCNL), a promising method also for the treatment of larger lower pole stones is available today with minimally invasive PCNL (MIP).

The new guidelines of the European (EAU), American (AUA), German, and Austrian associations of urology are based on thorough and consistent research and analysis of the published literature. However, the methodology is very diverse. In the case of the EAU-AUA guidelines on ureteral stones, the evidence was generated by a laborious meta-analysis of the entire available published literature on the subject. These guidelines represent the 1A level of evidence. The traditional European guidelines evaluate each statement separately and assign a level of evidence to each. The following aspects are new: the even greater effort to formulate guidelines accompanied by the initiation of international cooperative projects, clarity of presentation and evaluation of the individual statements (including levels of evidence), information on medication-based treatment to facilitate spontaneous passage of ureteral stones as well as stone fragments after extracorporeal shock wave lithotripsy (ESWL), a shift in the value of ESWL and ureterorenoscopy for ureteral stones, retrograde intrarenal surgery for small kidney stones refractory to ESWL or in settings unsuitable for ESWL, the use of laparoscopy in those rare cases that represent an indication for open surgery, and the additional value given to metaphylaxis in diagnosis and therapy. All of the new guidelines take these developments into account, although they differ slightly in the importance they assign to the individual items. The modifications represent the developments secondary to electronic data processing and preparation on the one hand and the rapid development of medical instruments on the other. Although ESWL is still the most important procedure for treating urinary stones, advances in flexible endoscopes, intracorporeal lithotripsy, and extraction instruments have led to a shift in the range of indications. These developments are fully accommodated in the new guidelines.

Calcium oxalate (CaOx) urolithiasis is a very common disorder. Surprisingly, the pathogenetic mechanisms leading to CaOx stone formation have been largely unknown so far. The long-accepted simple explanation by an exceeding of the solubility product of lithogenic substances in the urine cannot sufficiently describe the complex processes. Deviating from the hypothesis that proclaims that the initial crystal deposition takes place in the lumens of renal tubules, new insights suggest a primary plaque formation in the interstitial space of the renal papilla. Initially, calcium phosphate (CaPh) crystals and organic matrix are deposited along the basement membranes of the thin loops of Henle and extend further in the interstitial space to the urothelium, constituting the so-called Randall's plaques that can be regularly found during endoscopy of CaOx-stone-forming patients. These CaPh crystals seem to be the origin for the development of future CaOx stones, which form by the attachment of further matrix molecules and CaOx from the urine to the plaque. The driving forces, the exact pathogenetic mechanisms, and the involved matrix molecules remain largely unknown. Possibly, completely different pathomechanisms lead to the common clinical diagnosis of"CaOx stone former."

The female patient underwent multiple extracorporal shockwave treatments and an ureterorenoscopy during which an amorphous renal mass was found. A retroperitoneoscopy was performed with extraction of a large amorphous matrix calculus. Today, the prevalence of matrix calculi is very low. They are associated with and caused by urinal-infections. Delayed diagnosis in radiological-imaging procedures is typical for these stones. The minimal-invasive approach via retroperitoneoscopy seems to be an intriguing alternative to the established procedures like percutaneous nephrolitholapaxy.

The introduction of percutaneous nephrolithotomy (PNL) marked a turning point in the interventional treatment of nephrolithiasis. For the first time, the minimally invasive removal of larger kidney stones, which had previously required open surgery, became possible. With the increasing use of extracorporeal shock wave lithotripsy (SWL) during the 1980s, PNL lost clinical importance. However, since SWL has revealed its limitations, and both the patients' wishes and economic demand require a fast stone removal, the importance of PNL has risen again. Given the correct indications and performance, PNL is an efficient treatment modality reaching stone free rates of up to 100%. When PNL is performed by an experienced urologist, complications are low and can be managed conservatively in most cases. The most important step in the performance of a PNL is the anatomically correct puncture of the kidney gaining optimal access to the stone. To reach this, a lower calyx is punctured whenever possible, under combined sonographic and fluoroscopic guidance.