Urolithiasis is a common urological condition that significantly impacts patients’ quality of life and represents a considerable burden on healthcare systems worldwide [1]. Urolithiasis’ management requires adherence to national and international guidelines to ensure evidence-based care. As part of them, the European Association of Urology (EAU) and American Urological Association (AUA) guidelines are the most used worldwide [2, 3]. Sharing many common concerns and opinions on medical and surgical management of urolithiasis, EAU and AUA differed on surgical indications [4]. Nevertheless, the French Association of Urology Urolithiasis section (“Comité Lithiase de l’Association Française d’Urologie” [CLAFU]) updated their guidelines in November 2022 in France, providing for the first time dedicated recommendations on laser utilization, endoscopic stone and papilla recognition, and metabolic evaluation [5, 6, 7, 8, 9]. Despite the availability of these guidelines, the extent to which they are implemented in clinical practice remains variable.
As mentioned, guidelines serve as valuable tools for standardizing care, reducing variability in treatment approaches, and improving patient outcomes. However, the effectiveness of guidelines largely depends on their dissemination and the degree to which healthcare professionals are aware of and adhere to them. Various factors, including format and accessibility can influence their uptake and impact on practice or adherence. Therefore, understanding how urologists use and perceive guidelines is crucial to identify potential barriers to their implementation and to enhance the dissemination strategies.
Within the development of Evidence-Based-Medicine since the 1990s, numerous guidelines have been published, based on the available scientific literature [10]. Thus, today’s challenge relies on guidelines’ dissemination, especially with new communication concepts and tools, such as social media [11, 12]. Differently speaking, “is simple online and paper dissemination sufficient enough?” The ability social network for the dissemination of information has been demonstrated but requires quality control especially for patients [13]. The use of social networks and videos allows information to be disseminated interactively with take home messages and also allows for exchange between surgeons [14].
For instance, the use of international guidelines such as the European Association of Urology (EAU) and the American Urological Association (AUA) varies across regions and institutions [2, 3]. In France, the CLAFU guidelines specifically address local clinical practices and healthcare infrastructure, making them particularly relevant for French urologists. However, it remains unclear how these guidelines are being implemented into daily practice and what impact they have on clinical decision-making. Previous studies have also highlighted the importance of using various methods to disseminate guidelines among healthcare professionals [15].
The present study aimed to evaluate the impact and diffusion of the CLAFU guidelines among the French urologists. By surveying urologists on their knowledge, guidelines used, and perceptions of the guidelines, this study seeks to identify factors that influence the effective use of recommendations in clinical practice. Additionally, the study compares the responses between urologists working in different structure (public/academic hospital vs. private practice) and at different stages of their careers (in-training vs. certified) to understand the variability in guideline utilization.
A national audit was conducted using an online and anonymous survey (via Google Form) for all surgeons and residents working in France, members of the French Association of Urology (AFU) or the French Association of Urology Trainees (AFUF). The questionnaire was developed according to validated guidelines for reporting surveys studies [16, 17]. Before filling the survey, participants were given a covering text to avoid selection bias and incorrectly filled questionnaires. The questions were set up by endourology experts and in-training urologists (FPT, SK, MC, CA, OT) including both open and closed questions (grouped under various headers) on:
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demographic and professional characteristics: age, professional status, and type of healthcare institution (e.g., public hospital, academic hospital, clinic, private practice);
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clinical practice: involvement in managing urolithiasis;
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guidelines: type of used guidelines (e.g. CLAFU, EAU, AUA), CLAFU guidelines and impact on practice (scale of 0 to 10);
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preferred methods of dissemination (e.g., printed materials, social network, podcast, videos…).
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A complete overview of the questionnaire is available in the Appendix A. After being tested by an expert panel, the survey was circulated through mail and social media from April to May 2024, with follow-up reminders sent to increase response rates.
Ethics committee approval was not required because survey research does not impose risks on participants and only enrolls competent adults. Moreover, participation in the survey was voluntary, and all participants provided informed consent before completing the questionnaire. Data confidentiality was maintained throughout the study, with all responses anonymized.
Descriptive statistics were used to summarize the demographic and professional characteristics of the participants. Quantitative variables were reported in median and interquartile range [IQR]. Categorical variables were described as numbers and percentages. Univariate analyses were conducted to compare responses between different groups of urologists (public/academic hospital vs. private practice, in-training vs. certified). Chi-square tests were used for categorical variables, and Mann-Whitney U tests were applied for continuous variables. A P -value<0.05 was considered statistically significant. Data analysis was performed using the free software environment for statistical computing and graphic R in version R 4.2.2®.
Two hundred and twenty-eight urologists completed the survey, whose demographic and professional characteristics are presented in Table 1. The age distribution shows that 32% of participants are aged 31 to 40 years, followed by the 41 to 50 years group (24%). Of the participants, 83% were experienced urologists (Associate Professor of Urology, Professor of Urology, public/academic or private urologists), with similar proportions between private and public/academic hospital-based urologists (54% vs. 46%, respectively). Among participants, 17% were residents at the moment of the survey.
For 55% of participants, the management of urinary stones represented 11 to 30% of their practice, and for 25%, it represented 31 to 50%. Only 6% of participants declared to treat more than 50% of their practice. The repartition is shown in Fig. 1.
Fig. 1.
Number of stone procedures. SWL: shock wave lithotripsy; URS: ureteroscopy; PCNL: percutaneous nephrolithotomy.
Seventy-four percent of urologists declared to preferentially follow the CLAFU guidelines, whilst 19% used both CLAFU and EAU recommendations. AUA guidelines were used for 1% in our population. Eighty-six percent of participants were aware of the CLAFU recommendations recent release. Among them, 51% and 25% read the summary and both full version and summary, respectively. The impact on practice was assessed with a median score of 6/10 (4–8), and 53% of urologists expressed a desire for additional diffusion methods (Fig. 2). Videos and podcasts were the most requested methods of dissemination (50%), 25% of participants asking also for social media content.
Fig. 2.
Other desired dessimination methods.
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| Private practice and public/academic hospital urologists |
Fifty-six percent of public/academic hospital urologists and 51% of private practice urologists desired other dissemination methods (P =0.5) (Table 2). The impact of the CLAFU guidelines on practice was slightly higher among public/academic hospital urologists compared to private practice urologists (7 vs 6 [P =0.3] respectively). Forty-two percent of public/academic hospital urologists were keener to read the full version of the CLAFU guidelines compared to private practice urologists, who read preferentially the summary (30% vs 20% and 42% vs 59%, P =0.047).
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| In-training and certified urologists |
Sixty-seven percent of in-training urologists desired other dissemination methods, compared to 50% of certified urologists (P =0.06). The impact of these recommendations on practice was similar in both groups (P =0.2). Fifty-four percent of certified urologists read the summary compared to 33% of those in-training. Additionally, 41% of urologists in training read both the full version and the summary, compared to 21% of certified urologists (P =0.024).
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Guidelines adherence and adoption in daily practice
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The result of this study reveals that a significant majority of French urologists is aware of and refers the CLAFU guidelines for the management of urinary stones. Specifically, 86% of participants reported being familiar with these guidelines, and 74% to actively integrate them into their clinical practice. This high level of awareness and usage reflects the relevance and applicability of the CLAFU recommendations to the daily practice of urologists in France. Moreover, the structured and accessible format of these recommendations, with a notable preference for the summarized version, suggests that urologists favor concise and practical information that can be easily referenced during clinical decision-making.
However, the study also highlights areas for improvement. Despite the high adoption rate, 14% of urologists are still unaware of the CLAFU recommendations, pointing out the need for enhanced and new dissemination strategies. Additionally, an important consideration for future dissemination efforts is the utilization of multiple forms of communication, particularly through social media platforms. Social media has emerged as a powerful tool for professional engagement, education, and information sharing among healthcare professionals. By using platforms such as Twitter, LinkedIn, and dedicated medical forums, the CLAFU can enhance the visibility and accessibility of their recommendations. These platforms offer opportunities for real-time updates, interactive discussions, and the sharing of practical insights and experiences among urologists [11, 12]. This approach not only broadens the reach but also fosters a more dynamic and engaged professional community, ensuring that the guidelines are continuously integrated and discussed within the context of evolving clinical practices.
It would also be possible to integrate these recommendations into a decision support application by entering the characteristics of the patient and the stone to be managed. Additionally, utilization of artificial intelligence platforms such as ChatGPT or specialized models like UroGPT could further enhance decision-making by providing real-time, evidence-based recommendations tailored to individual patient [18].
This study, although observational, provides an overview of the type of dissemination expected by urologists for recommendations or other updates. Two studies by the French Association of Urology had already shown the promising use of social networks in our field, in particular with tweets to relay major information [15, 19].
Social medial has become popular within the urology community for both patients and medical professionals for various purposes [20]. With all the platforms available, it is possible to share information in a variety of ways, from tweets and videos to podcasts, as requested by participants to the questionnaire. A review by Rodler et al. has shown a growing interest among residents in using social networks and the media for training since the Covid pandemic [21]. In future, all these tools should be used to promote scientific information and guidelines written by the committee.
Finally, the CLAFU guidelines were preferentially used among participants. Differences between private practice and public/academic hospital urologists, as well as between in-training and certified urologists, highlight variations in dissemination preferences and the reading of recommendations. Major adoption of the French guidelines can be explained by different factors. Firstly, the CLAFU guidelines are available in French, making them accessible to all French-speaking urologists. This is particularly important as not all urologists are proficient in English, the language in which many international guidelines, such as those from the EAU and AUA, are published. This allows that the recommandations are easily understood and implemented. Additionally, the CLAFU recommendations cover topics that are absent from other international guidelines. These include detailed sections on laser settings, endoscopic descriptions, and metabolic evaluations. These parts ensure that French urologists have access to the most relevant and up-to-date information, tailored to their specific needs and practices. The summary version gives an overview of the recommendations and makes them easy to read in French.
Our study presents some inherent limitations that need to be addressed. Firstly, as any survey investigation, the formulation of the questions may have influenced our findings and the questionnaire was developed based on validated guidelines but the questionnaire itself was not validated. Then, participants were invited to participate through social media and email, which could have consisted in a selection bias. The participants may have different characteristics or levels of engagement in stone management compared to those who do not participate. Additionally, there is the risk of self-reporting bias, where participants may overstate their familiarity or usage of the guidelines to align with perceived expectations.
Our study underscores the importance of national recommendations like those from CLAFU in guiding clinical practice. It also emphasizes the need for ongoing efforts to increase awareness and accessibility of the latest and most relevant information to provide optimal patient care. Embracing diverse dissemination methods, especially through social media, can further enhance the impact and adoption of these essential guidelines.
Frédéric Panthier received a French Asssociation of Urology research grant in 2023.
Stessy Kutchukian received a French Asssociation of Urology research grant in 2022.
Disclosure of interest
The authors declare that they have no competing interest but:
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Frédéric Panthier: declared as consultant for Dornier;
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Olivier Traxer: declared as consultant for Karl Storz, Coloplast, IPG photonics, Ambu, Quanta System and Rocamed;
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Christophe Almeras: declared as consultant for Storz, AseptinMed and Coloplast;
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Nadia Abib: declared as consultant for Alnylam and Ambu.
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Appendix A. Supplementary material
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