Nifedipine and methylprednisolone in facilitating ureteral stone passage: a randomized, double-blind, placebo-controlled study

Role of adjunctive medical therapy with nifedipine and deflazacort after extracorporeal shock wave lithotripsy of ureteral stones

OBJECTIVES

To increase the success rate of the first treatment of ureteral stones through extracorporeal shock wave lithotripsy (ESWL), we tested the efficacy of a medical therapy with nifedipine and deflazacort administered to patients who had undergone ESWL for ureteral stones.

METHODS

This prospective study lasted from October 1998 to September 2000 and involved 80 patients. All the patients underwent ESWL with Sonolith 4000+. The patients were randomly divided into two groups: 40 patients (group 1) received an "adjunctive" treatment with oral medical therapy (nifedipine and deflazacort); the other 40 patients (group 2) were used as the control group.

RESULTS

Complete fragment expulsion occurred in 30 (75%) of the 40 patients of group 1 and in 20 (50%) of the 40 patients of group 2 at the endpoint. A statistically significant difference was observed in the stone-free rate (P = 0.02). Concerning the symptomatic therapy, the average diclofenac use was 37.5 mg per patient in group 1 and 86.25 mg per patient in group 2 (P = 0.02).

CONCLUSIONS

The results of this study have shown the role that adjunctive medical therapy with nifedipine and deflazacort given after an ESWL procedure can play in increasing the success rate of ureteral stone treatment. Furthermore, these results would suggest that adjunctive medical therapy can reduce total analgesic consumption after the ESWL procedure.

[Ureteral lithiasis, what treatment?]

Extracorporeal shock wave lithotripsy and ureteroscopy are minimal invasive techniques, both of which have definitively become essential for the treatment of ureteral stones resistant to conservative treatment. At the time of evidence-based medicine, no study makes it possible to recommend one of these methods rather than the other. For stones of identical size and location, this review of the literature shows that extracorporeal shock wave lithotripsy and ureteroscopy prove of comparable effectiveness and innocuousness. The urologist thus has two alternatives of which the technical control, the availability of the endoscopes or lithotriptors as well as the desire and comfort of the patients are the factors which condition his choice of the method for the treatment of ureteral stones.

Use of glyceryl trinitrate patches in patients with ureteral stones: a randomized, double-blind, placebo-controlled study

OBJECTIVES

To report a randomized, double-blind, placebo-controlled trial of glyceryl trinitrate (GTN) patches. The primary outcome measure was stone passage at 6 weeks. GTN is a potent smooth muscle relaxant that may offer benefit by both reducing pain and facilitating ureteral stone passage.

METHODS

Fifty consecutive patients, with a single radiopaque calculus less than 10 mm, were randomized to receive a 6-week course of patches containing either 5 mg GTN or placebo. Patients used a diary to record pain episodes during the 6-week study period and were reviewed weekly with x-ray imaging. Analysis was by intention to treat.

RESULTS

Twenty-six patients were randomized to the GTN group and 24 to the placebo group. Seven patients in the GTN group discontinued therapy because of headaches. One patient in the placebo group discontinued because of a skin reaction to the patches. No serious adverse events were recorded. No difference was observed in the stone-free rate at 6 weeks (18 patients in each group), interval to stone passage (median GTN 11.5 days versus placebo 13 days), or interventions performed (5 patients each). Although the GTN group reported fewer pain episodes (median 3.5 versus 6.0), this did not achieve statistical significance.

CONCLUSIONS

Our preliminary results did not demonstrate a significant advantage in using GTN compared with placebo, with regard to the stone-free rate at 6 weeks, interval to stone passage, or number of episodes of pain experienced.

Effectiveness of nifedipine and deflazacort in the management of distal ureter stones

OBJECTIVES

To evaluate the effectiveness of medical therapy during watchful waiting in patients with distal ureter stones.

METHODS

Ninety-six patients with radiopaque stones located in the distal tract of the ureter and with stone sizes of 1 cm or smaller were involved in the study. The patients were randomly divided into two groups. Group A (n = 48) received oral treatment with 30 mg of deflazacort daily (maximum 10 days) plus 30 mg of slow-release nifedipine daily (maximum 4 weeks). Group B (n = 48) underwent a wait-and-watch approach. Both groups of patients were allowed to use diclofenac on demand. Statistical analyses were carried out using Student's t test, the chi-square test, and Fisher's exact test.

RESULTS

The average stone size was 5.8 +/- 1.8 mm for group A and 5. 5 +/- 1.4 mm for group B. No statistically significant difference was found in stone size. Stone expulsion was observed in 38 (79%) of 48 patients in group A and in 17 (35%) of 48 patients in group B. The average expulsion time was 7 days (range 2 to 10) for group A and 20 days (range 10 to 28) for group B. A statistically significant difference was observed in both the expulsion rate and the expulsion time (P <0.05). The mean amount of sodium diclofenac used was 15 mg per patient for group A and 105 mg per patient for group B (P <0.05).

CONCLUSIONS

The medical treatment proved to be effective and safe, as demonstrated by the increased stone expulsion rate, decreased expulsion time, and reduced need for analgesic therapy.

Intensive medical management of ureteral calculi

OBJECTIVES

To compare two treatment regimens in patients with ureteral calculi. One regimen (control arm) used routine drugs, and the second regimen (treatment arm) used the same routine drugs plus uncommonly used drugs.

METHODS

Between February and October 1998, 70 consecutive patients were evaluated for symptomatic ureteral calculi. Thirty-five patients were randomized to a control arm and received ketorolac, oxycodone, and acetaminophen combination tablets and prochlorperazine suppositories. Thirty-five patients were randomized to the treatment arm and received the same medications plus nifedipine XL, prednisone, and trimethoprim/sulfa combination tablets and plain acetaminophen. Stone passage rates, work days lost, emergency room visits, surgical interventions, and possible side effects of the drugs were recorded.

RESULTS

The treatment arm (addition of nifedipine XL, prednisone, trimethoprim/sulfa, and plain acetaminophen) had higher (86% versus 56%) stone passage rates and fewer lost work days (mean 1.76 versus 4.9), emergency room visits (1 versus 4), and surgical interventions (2 versus 15). Both arms exhibited similar potential drug side effects.

CONCLUSIONS

The addition of a calcium channel blocking agent, steroids, antibiotics, and more acetaminophen effected a higher stone passage rate and fewer lost work days, emergency room visits, and surgical interventions.

Contemporary management of ureteral stones

The management of ureteral stones has undergone revolutionary changes in the past 15 years. The parallel advances in extracorporeal shock wave lithotripsy, percutaneous and retrograde endoscopic access to the collecting system, and intracorporeal lithotripsy devices almost completely have supplanted the need for a traditional ureterolithotomy. The merits of the various technologies that are available are discussed as they apply to treating calculi in different ureteral segments.