with a high risk of recurrent stone disease undergo metabolic evaluation by any physician. 9 81% of patients interviewed would prefer to take prophylactic medication than undergo another stone episode, and 92% of respondents preferred medication to undergoing surgery. 10 Although patients indicate they would be interested in using medication to prevent future stones, compliance studies suggest otherwise. Close to 50% of patients prescribed pharmacological prevention were non-compliant, especially those on potassium citrate. 11 This data stresses the importance of a comprehensive metabolic assessment with implementaiton of individualized prevention strategies. With directed therapy and proper patient education, patient compliance and therapeutic success may be optimized.The economic burden of recurrent stone disease is also significant. Estimates of direct costs for patient care and the indirect costs related to lost work time exceed $5 billion USD. 12,13 Given the rising rates of obesity and diabetes and their association with stone formation, the cost of managing stone disease is expected to increase to 1.24 billion dollars yearly in the US by 2030. 14 This guideline is an update of the 2016 document and aims to identify patients at heightened risk of stone recurrence, to outline the required investigations to assess these patients, and to provide contemporary advice on dietary and medical interventions of proven benefit in the Canadian context. This current guideline addresses the evaluation and medical prophylaxis of upper urinary tract stones and not bladder stones. Literature reviewThe updated content included in this document is based on a review of the English language literature. A PubMed search was conducted encompassing the period from January 1, 2015 to July 1, 2021 to include the following terms: "nephrolithiasis", "urolithiasis", "kidney stone", "renal stone", or "urinary stone". In total, 11,640 article titles were reviewed and 293 were identified as potentially relevant for inclusion in the literature assessment for this guideline update. Management recommendations were modified if needed based on the most current literature since the last guideline was published in 2016. Studies were evaluated and recommendations made based on Oxford levels of evidence and grades of recommendation as per the CUA Guidelines Committee's directive. 15

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