The use of tamsulosin in the medical treatment of ureteral calculi: where do we stand?

Alpha-blockers as medical expulsive therapy for ureteral stones

BACKGROUND

Ureteral colic is a common reason for patients to seek medical care. Alpha-blockers are commonly used to improve stone passage through so-called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant.

OBJECTIVES

To assess effects of alpha-blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease.

SEARCH METHODS

On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies.

SELECTION CRITERIA

We included RCTs of ureteral stone passage in adult patients that compared alpha-blockers versus standard therapy.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta-analysis using a random-effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per-outcome basis using the GRADE approach.

MAIN RESULTS

We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo.Stone clearance: Based on the overall analysis, treatment with an alpha-blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low-quality evidence). A subset of higher-quality, placebo-controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate-quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants.Major adverse events: Based on the overall analysis, treatment with an alpha-blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low-quality evidence). A subset of higher-quality, placebo-controlled trials suggest that alpha-blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants.Patients treated with alpha-blockers may experience shorter stone expulsion times (mean difference (MD) -3.40 days, 95% CI -4.17 to -2.63; low-quality evidence), may use less diclofenac (MD -82.41, 95% CI -122.51 to -42.31; low-quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate-quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low-quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants.A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha-blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha-blocker type.

AUTHORS' CONCLUSIONS

For patients with ureteral stones, alpha-blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha-blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm).

The efficacy and safety of adrenergic alpha-antagonists in treatment of distal ureteral stones in pediatric patients: A systematic review and meta-analysis

OBJECTIVE

We carried out a systematic review and meta-analysis to evaluate the efficacy and safety of adrenergic alpha-antagonists as a medical expulsive therapy for ureteral stones in pediatric patients.

METHODS

The PubMed, EMBASE and Cochrane Controlled Trials Register databases were searched up to January 2016. All randomized controlled trials and all cohort studies in which patients were randomized to receive either adrenergic alpha-antagonists or placebo for ureteral stones were identified. The outcome measures assessed were overall stone expulsion rate (primary), expulsion time (secondary), and treatment-emergent adverse events.

RESULTS

Five trials with a total of 406 pediatric patients met the inclusion criteria. According to the doses of adrenergic alpha-antagonists, the pooling effects of adrenergic alpha-antagonists were analyzed, with a higher expulsion rate obtained than in controls, the stone expulsion rate (OR=2.70, 95% CI 1.49 to 4.91, P=0.001). Adrenergic alpha-antagonists statistically did not significantly decrease the number of the stone expulsion time with the placebo, the stone expulsion time (SMD=-4.65, 95% CI -9.76 to 0.45, P=0.07). Safety assessments included common treatment-emergent adverse events (TEAEs) (OR=2.01, 95% CI 0.74 to 5.48, P=0.17). Compared with placebos, there was a higher stone expulsion rate with the adrenergic alpha-antagonists; in addition, fewer adverse effects were observed.

CONCLUSIONS

This meta-analysis may suggest that adrenergic alpha-antagonists are a safe and effective medical expulsive therapy choice for ureteral stones in pediatric patients. As the level of classification of evidence-based medicine, the level of evidence of our article is Ia. But it remains to need a large-scale multicenter randomized controlled study to be further confirmed.

LEVEL OF EVIDENCE

The level of evidence of our study is V.

Spontaneous forniceal rupture: Can it be treated conservatively?

CONTEXT

Spontaneous forniceal rupture is one of the possible complications of urolithiasis. The mechanism of forniceal rupture is not well explained in the literature. Most of the cases presented with sudden onset of acute renal colic and diagnosed by noncontrast CT (NCCT). Until now there is no solid consensus about the ideal management of such a condition.

AIM

To study indications and validity of conservative management of spontaneous caliceal rupture.

SETTINGS AND DESIGN

This is an observational prospective study.

MATERIALS AND METHODS

All cases diagnosed as spontaneous forniceal rupture in our departments from 2011 to 2015 were enrolled. All cases were diagnosed with NCCT or CT-Urography.. Non complicated patients were primarily managed conservatively. Intervention (DJ stent insertion, nephrostomy tube insertion, or urgent ureteroscopy) was reserved to complicated cases or solitary kidney. Drainage of urinoma was done in cases with sizable urinoma (more than 100 ml³).

RESULTS

A total of 40 patients: Twenty eight (70%) patients had normal serum creatinine level at presentation, while 12 (30%) patients had elevated serum creatinine. Twenty three (57.5%) patients were successfully managed conservatively, their mean size of stone was 6.2 ± 2 mm and the hospital stay was 3.1 ± 1.9 days. Eighteen patients (42.5%) underwent interventions. Their stone size was 4.5 ± 2.1 mm and the hospital stay for the interventional group was 4.2 ± 1.8 days.

STATISTICAL ANALYSIS USED

Mann-Whitney test was used for testing difference between means because the data groups are not parametric. Otherwise, simple descriptive statestics were used.

CONCLUSION

Spontaneous forniceal rupture is more likely to occur with smaller distal ureteric stones. Conservative management is a valid option in non-complicated cases. Intervention should be reserved to complicated cases or cases with sizable urinoma.

Alpha blockers in the management of ureteric lithiasis: A meta-analysis

INTRODUCTION

Effective medical expulsion for ureteric stones with α-blockers offers numerous advantages over surgical alternatives. However, its effectiveness remains uncertain and with the publication of new trial data, the available evidence requires reappraisal.

OBJECTIVE

The aim of this study was to assess the efficacy of α-blockers the management of ureteric lithiasis.

METHODS

A systematic review of the literature, with predefined search criteria, was conducted using PubMed and Embase. All randomised trials comparing α-blocker monotherapy to placebo or standard therapy were included. Stone expulsion rate was the primary outcome measure. Secondary outcome measures were time to stone expulsion, analgesic usage and pain scores. Subgroup analyses assessed individual adrenergic antagonists and variations in standard therapy. Sensitivity analysis was based on stone location, stone size, Cochrane Risk of Bias score and study protocol. Summary effects were calculated using a random-effect model and presented as Relative risks (RR) and mean differences (MD) for dichotomous and continuous outcome measures, respectively.

RESULTS

Sixty-seven studies randomising 6654 patients were included in the meta-analysis. Stone expulsion rates improved with α-blockers (RR, 1.49; 95% CI 1.38-1.61). Contrast enhanced funnel showed evidence of publication bias. Stone expulsion time was 3.99 days (CI -4.75 to -3.23) shorter with α-blockers. Similarly, patients required 106.53 mg [CI -148.20 to -64.86] less diclofenac compared with control/placebo, and had 0.80 [CI -1.07 to -0.54] fewer pain episodes. Visual Analogue Scores were also reduced, -2.43 [CI -3.87 to -0.99]. All formulations of α-antagonists all demonstrated beneficial effects over conservative treatment/placebo. Sensitivity analysis demonstrated significant effects of stone location, stone size and study design.

CONCLUSIONS AND RELEVANCE

Despite the opposing results of recently published trial, current evidence continues to demonstrate a potential benefit of α-blocker treatment particularly for distal stones over 5 mm.

Pharmacologic Expulsive Treatment of Ureteral Calculi

Objective:

TO evaluate the role of nifedipine and the α1-adrenoreceptor antagonists tamsulosin, terazosin, and doxazosin in the expulsive treatment of ureteral calculi.

Data Sources:

Literature was searched via MEDLINE (1966–February 2006) with subsequent bibliographic review. MeSH headings included ureteral calculi, nifedipine, doxazosin, and adrenergic α-antagonists. Key terms were ureteral calculi, nifedipine, tamsulosin, terazosin, and doxazosin.

Study Selection and Data Extraction:

Trials evaluating nifedipine, tamsulosin, terazosin, and doxazosin for expulsion of ureteral stones were reviewed. All were published in English-language, peer-reviewed journals.

Data Synthesis:

Several trials have evaluated the effects of nifedipine and tamsulosin on ureteral stone passage rates and mean time to stone passage in stones no larger than 15 mm. In 28 day trials, the rates of ureteral stone passage were 35–70% in the control groups compared with 77.1–80% in patients treated with nifedipine and 79.3–100% in patients treated with tamsulosin. Average number of days to stone passage in the control groups was 4.6–20, and the time to stone passage was only 5–9.3 days in patients receiving nifedipine and 2.7–7.9 days in those receiving tamsulosin. The stone passage rates and time to stone passage appeared to be similar in one trial that compared tamsulosin with terazosin and doxazosin. Limited data suggest that these agents may have a role as adjuncts to shock wave lithotripsy. Adverse drug reactions were uncommon.

Conclusions:

Nifedipine, tamsulosin, terazosin, and doxazosin are safe and effective options in enhancing ureteral stone expulsion in selected patients with uncomplicated presentations.

Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo-controlled, randomised controlled trial and cost-effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin) (the SUSPEND trial)

BACKGROUND

Ureteric colic, the term used to describe the pain felt when a stone passes down the ureter from the kidney to the bladder, is a frequent reason for people to seek emergency health care. Treatment with the muscle-relaxant drugs tamsulosin hydrochloride (Petyme, TEVA UK Ltd) and nifedipine (Coracten(®), UCB Pharma Ltd) as medical expulsive therapy (MET) is increasingly being used to improve the likelihood of spontaneous stone passage and lessen the need for interventional procedures. However, there remains considerable uncertainty around the effectiveness of these drugs for routine use.

OBJECTIVES

To determine whether or not treatment with either tamsulosin 400 µg or nifedipine 30 mg for up to 4 weeks increases the rate of spontaneous stone passage for people with ureteric colic compared with placebo, and whether or not it is cost-effective for the UK NHS.

DESIGN

A pragmatic, randomised controlled trial comparing two active drugs, tamsulosin and nifedipine, against placebo. Participants, clinicians and trial staff were blinded to treatment allocation. A cost-utility analysis was performed using data gathered during trial participation.

SETTING

Urology departments in 24 UK NHS hospitals.

PARTICIPANTS

Adults aged between 18 and 65 years admitted as an emergency with a single ureteric stone measuring ≤ 10 mm, localised by computerised tomography, who were able to take trial medications and complete trial procedures.

INTERVENTIONS

Eligible participants were randomised 1 : 1 : 1 to take tamsulosin 400 µg, nifedipine 30 mg or placebo once daily for up to 4 weeks to make the following comparisons: tamsulosin or nifedipine (MET) versus placebo and tamsulosin versus nifedipine.

MAIN OUTCOME MEASURES

The primary effectiveness outcome was the proportion of participants who spontaneously passed their stone. This was defined as the lack of need for active intervention for ureteric stones at up to 4 weeks after randomisation. This was determined from 4- and 12-week case-report forms completed by research staff, and from the 4-week participant self-reported questionnaire. The primary economic outcome was the incremental cost per quality-adjusted life-year (QALY) gained over 12 weeks. We estimated costs from NHS sources and calculated QALYs from participant completion of the European Quality of Life-5 Dimensions health status questionnaire 3-level response (EQ-5D-3L™) at baseline, 4 weeks and 12 weeks.

RESULTS

Primary outcome analysis included 97% of the 1167 participants randomised (378/391 tamsulosin, 379/387 nifedipine and 379/399 placebo participants). The proportion of participants who spontaneously passed their stone did not differ between MET and placebo [odds ratio (OR) 1.04, 95% confidence interval (CI) 0.77 to 1.43; absolute difference 0.8%, 95% CI -4.1% to 5.7%] or between tamsulosin and nifedipine [OR 1.06, 95% CI 0.74 to 1.53; absolute difference 1%, 95% CI -4.6% to 6.6%]. There was no evidence of a difference in QALYs gained or in cost between the trial groups, which means that the use of MET would be very unlikely to be considered cost-effective. These findings were unchanged by extensive sensitivity analyses around predictors of stone passage, including sex, stone size and stone location.

CONCLUSIONS

Tamsulosin and nifedipine did not increase the likelihood of stone passage over 4 weeks for people with ureteric colic, and use of these drugs is very unlikely to be cost-effective for the NHS. Further work is required to investigate the phenomenon of large, high-quality trials showing smaller effect size than meta-analysis of several small, lower-quality studies.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN69423238. European Clinical Trials Database (EudraCT) number 2010-019469-26.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 63. See the NIHR Journals Library website for further project information.

[CLINICAL FACTORS ASSOCIATED WITH SPONTANEOUS PASSAGE OF URETER STONES IN CONSERVATIVE MANAGEMENT: 6 mm IN MAXIMAL STONE SIZE MEASURED BY ULTRASONOGRAPHY CAN BE A PREDICTIVE BORDER]

(Purpose) To date there was no consensus regarding expectant size of stone and time to expulsion in the conservative treatment of ureter stones. The aim of this study was to find the clinical factors associated with stone passage by evaluating the outcome of ureter stones with expectant management in Japanese. (Materials and methods) A total of 679 ureter stone cases who visited our hospital with acute real colic and/or hematuria between 2009 and 2013, and who had decided to be treated by expectant management with or without medical expulsive therapy were enrolled in this study. All cases were examined size, location and presence of stone, and degree of hydronephrosis with ultrasonography. The examined data plus clinical data such as gender, age, side and body mass index were analyzed to find the factors related to spontaneous passage of ureter stones. Statistical analysis was performed to predict whether the factors were associated with the ureteral stone expulsion or not. (Results) Accumulated residual stone curve using Kaplan-Meier method showed time to 50%-expulsion as 15.7 days in cases with stone size no more than 6.0 mm and that as 21.8 days in those with greater than 6.0 mm, and time to 50%-expulsion as 28.8 days in cases with upper ureter stone whereas 15.6 days in those with middle or distal ureter stone. Analysis in groups with 1 mm-interval in stone size showed statistical significance only when compared 5-6 mm group with 6-7 mm group in size. Multivariate analysis showed stone size and location as statistically significant and independent factors to predict time to expulsion within 30 days. (Conclusion) Stone size and location was statistically reconfirmed to be associated with spontaneous passage in expectant management of ureter stones. This study statistically demonstrated the possibility that 6 mm in maximal stone size measured by ultrasonography can be a predictive border. 75% of ureter stones within 6 mm in maximal size measured by ultrasonography may expect to be expelled within 30 days.

The Efficacy and Safety of Tamsulosin Combined with Extracorporeal Shockwave Lithotripsy for Urolithiasis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND PURPOSE

Many studies have been conducted to investigate adjunctive tamsulosin therapy after extracorporeal shockwave lithotripsy (SWL) for urolithiasis. The results from those studies, however, are still inconsistent. Therefore, we performed a meta-analysis to provide an update on the clinical efficacy and safety of tamsulosin combined with SWL for urolithiasis.

METHODS

A systematic search was performed in PubMed, Cochrane Library, and Embase to identify all relevant randomized controlled trials until January 2015. Two reviewers independently assessed trial quality and extracted data. Meta-analysis was conducted with Review Manager (RevMan), version 5.1.

RESULTS

Twenty-one studies (2093 subjects in total) were identified in the current meta-analysis. Compared with a control group, the experimental group (tamsulosin combined with SWL) showed an increased overall benefit for stone expulsion, with pooled risk ratio (RR) of 1.20 (95% confidence interval [CI], 1.15-1.26). With respect to the different geographic regions, European and American had a high possibility of improvement in stone expulsion (RR: 1.33, 95% CI, 1.19-1.49). According to the stone locations (renal, upper and lower ureteral) and sizes (4-10 mm and 11-24 mm), tamsulosin is more useful for lower ureteral stone (RR: 1.28; 95% CI, 1.14-1.43) and larger sized stones (RR: 1.49; 95% CI, 1.28-1.75). The effect estimates did not vary markedly when stratified by follow-up durations but varied by dose of tamsulosin. Furthermore, a shorter expulsion time, reduced occurrence of steinstrasse, fewer incidences of colic, and lower analgesic requirements were observed within the experimental group. In addition, tamsulosin is well tolerated, and its adverse events rarely led to dropouts of patients.

CONCLUSIONS

Overall, evidence suggests that tamsulosin combined with SWL is safe and effective in enhancing stone expulsion for patients with urolithiasis. Furthermore, high-quality, randomized and placebo-controlled trials evaluating the efficacy and safety of tamsulosin should be performed.

Tamsulosin for treatment of unilateral distal ureterolithiasis: a systematic review and meta-analysis

OBJECTIVES

The lifetime prevalence of ureterolithiasis is approximately 13% for men and 7% for women in the United States. Tamsulosin, an α-antagonist, has been used as therapy to facilitate the expulsion of lithiasis. Whether it is a good treatment for distal lithiasis remains controversial. We conducted a systematic review and meta-analysis to evaluate the effect of tamsulosin on the passage of distal ureterolithiasis.

METHODS

A systematic search was conducted using MEDLINE, EMBASE, and Cochrane Central. Trial eligibility was evaluated by two investigators. All randomized controlled trials (RCTs) comparing tamsulosin to standard therapy or placebo for the treatment of a single distal ureterolithiasis ≤ 10 mm in adult patients with renal colic confirmed by radiographic imaging were included. Data extraction was conducted in duplicate. Primary outcome was the expulsion rate, and secondary outcomes were the mean time for ureterolithiasis expulsion, analgesic requirements, and side effects. Mantel-Haenszel random effect models were used, and heterogeneity was assessed using I² statistics. Data were presented with relative risks (RRs).

RESULTS

The search strategy identified 685 articles, of which 22 studies were included. Combined results suggested a benefit for the expulsion of ureterolithiasis (≤ 10 mm) when tamsulosin was used compared to a standard treatment (RR 1.50 [95% CI 1.31-1.71], I²  =  70%). A decrease in the average time of expulsion of the ureterolithiasis of 3.33 days in favour of tamsulosin was observed (95% CI -4.23, -2.44], I²  =  67%).

CONCLUSION

Tamsulosin increases the rate of spontaneous passage of distal ureterolithiasis (≤ 10 mm).

Alpha-blockers as medical expulsive therapy for ureteral stones

BACKGROUND

Urinary stone disease is one of the most common reasons for patients visiting a urology practice, affecting about 5% to 10% of the population. Annual costs for stone disease have rapidly increased over the years and most patients with ureteral colic or other symptoms seek medical care. Stone size and location are important predictors of stone passage. In most cases medical expulsive therapy is an appropriate treatment modality and most studies have been performed with alpha-blockers. Alpha-blockers tend to decrease intra-ureteral pressure and increase fluid passage which might increase stone passage. Faster stone expulsion will decrease the rate of complications, the need for invasive interventions and eventually decrease healthcare costs. A study on the effect of alpha-blockers as medical expulsive therapy in ureteral stones is therefore warranted.

OBJECTIVES

This review aimed to answer the following question: does medical treatment with alpha-blockers compared to other pharmacotherapy or placebo impact on stone clearance rate, in adult patients presenting with symptoms of ureteral stones less than 10 mm confirmed by imaging? Other clinically relevant outcomes such as stone expulsion time, hospitalisation, pain scores, analgesic use and adverse effects have also been explored.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register to 9 July 2012 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, handsearching conference proceedings, and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs), comparing alpha-blockers with other pharmacotherapy or placebo on ureteral stone passage in adult patients were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Reporting bias was investigated using funnel plots. Subgroup analysis was used to explore possible sources of heterogeneity. Sensitivity analysis was performed removing studies of poor methodological quality.

MAIN RESULTS

Thirty-two studies (5864 participants) were included. The stone-free rates were significantly higher in the alpha-blocker group (RR 1.48, 95% CI 1.33 to 1.64) when compared to standard therapy. Stone expulsion time was 2.91 days shorter with the use of alpha-blockers (MD -2.91, 95% CI -4.00 to -1.81). Use of alpha-blockers reduced the number of pain episodes (MD -0.48, 95% CI -0.94 to -0.01), the need for analgesic medication (diclofenac) (MD -38.17 mg, 95% CI -74.93 to -1.41) and hospitalisation (RR 0.35, 95% CI 0.13 to 0.97). Patients using alpha-blockers were more likely to experience adverse effects when compared to standard therapy (RR 2.74, 95% CI 1.38 to 5.45) or placebo (RR 2.73, 95% CI 1.50 to 4.96). Most adverse effects were mild of origin and did not lead to cessation of therapy, and several studies reported no adverse events in either the treatment or control group.In 7/32 studies patients and doctors were both blinded. In the other studies blinding was not described in the methods or no blinding had taken place. Two studies described incomplete data and only one study showed a relatively high number of patients who withdrew from the study. These factors limited the methodological strength of the evidence found.

AUTHORS' CONCLUSIONS

The use of alpha-blockers in patients with ureteral stones results in a higher stone-free rate and a shorter time to stone expulsion. Alpha-blockers should therefore be offered as part of medical expulsive therapy as one of the primary treatment modalities.

Early hospital admission and treatment onset may positively affect spontaneous passage of ureteral stones in patients with renal colic

OBJECTIVE

To evaluate the impact of early hospital admission and onset of medical expulsive therapy (MET) in spontaneous passage of ureteral stones causing renal colic.

METHODS

We recruited 392 patients referred to the emergency room with symptoms of renal colic. All patients received standard MET of oral tamsulosin 0.4 mg at the time of diagnosis. In group A, patients who received MET in <2 hours from the symptom onset were included, whereas group B consisted of patients treated in >2 hours. The association of MET onset and stone-free rates after 6 weeks of follow-up was evaluated. Early MET onset predictive impact on spontaneous stone passage was evaluated as well.

RESULTS

The stone-free rate in group A and B patients was 71.2% and 59.7% (P=.018), respectively. A significant association was observed between spontaneous calculus elimination and stone size (P≤.001), location within the ureter (P=.007), and the interval between pain onset and pharmaceutical management (P=.018). Patients who received a late-onset MET had an increased risk to develop febrile upper urinary tract infection during the follow-up period (P=.040). In the multivariate analysis, size (P≤.001) and early therapy onset (P=.019) were statistically important predictors for stone-free status after the surveillance period.

CONCLUSION

Patients with renal colic who admitted to the emergency department earlier since symptom onset may have increased potential to be stone free during the surveillance period.

The effect of tamsulosin on pain and clearance according to ureteral stone location after shock wave lithotripsy

Background

Medical expulsion therapy has shown encouraging results in facilitating spontaneous clearance of ureteral stones after extracorporeal shock wave lithotripsy. However, no other study has yet determined the benefit of medical expulsion therapy for stones in different ureteral locations.

Objective

The aim of the study was to evaluate tamsulosin as adjunctive therapy to extracorporeal shock wave lithotripsy (SWL) in terms of pain clearance of stones in the upper, middle, and lower ureter.

Methods

Between June 2008 and July 2011, patients with a solitary ureteral stone that was ≥6 mm up to 15 mm and located in the upper, middle, or lower ureter undergoing SWL were evaluated. The patients were randomly allocated to a conservative treatment (group 1) and a tamsulosin treatment group (group 2). Administration of the drug was started immediately after SWL and was continued for a maximum of 28 days. Patients were evaluated for stone clearance, time to stone clearance, and number of SWL sessions. The pain intensity was evaluated by visual analog scale.

Results

There were 64 patients in the control group and 59 in the tamsulosin group. The average stone sizes were 10.70 (3.20) mm and 11.40 (3.01) mm (P = 0.24). Group 1 and group 2 received 2507 (984) and 2759 (775) shock waves (P = 0.86), 1.53 (0.8) and 1.49 (0.75) sessions (P = 0.85), respectively. Mean visual analog scale scores and times to clearance were 3.81 (2.74) and 2.73 (2.28) (P = 0.00) and 12.59 (8.63) days and 8.34 (7.60) days (P = 0.00), respectively, for all stones in groups 1 and 2. Only the clearance time of upper ureteral stones between groups showed statistical significance (13.54 [8.32] days vs 7.10 [6.40] days; P = 0.00).

Conclusions

Tamsulosin may help in the treatment of all ureteral stones after SWL, particularly stones in the upper ureter, with a shorter time to clearance and less need for analgesic drugs.

The effect of tamsulosin, an alpha-1 receptor antagonist as a medical expelling agent in success rate of ureteroscopic lithotripsy

BACKGROUND

Tamsulosin is an α-1A-specific blocker which induces selective relaxation of ureteral smooth muscle with subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen and facilitates stone expelling.

OBJECTIVES

In this study we aimed to assess the efficacy of tamsulosin for improving the success rate of ureteroscopic lithotripsy (URS) for lower ureteral stones.

PATIENTS AND METHODS

In a prospective study by a randomized controlled clinical trial, which was performed from June 2008 to December 2010, we enrolled one hundred and forty-two subjects and eventually 102 patients completed the clinical trial. All the patients underwent ureteroscopic lithotripsy with the pneumatic wolf lithotripsy. The patients were randomly divided into 2 groups: the study group including 52 patients, received tamsulosin with our traditional treatment (hydration and analgesic when required), and the control group with 50 patients who received placebo with traditional treatment. The number of colic episodes, lower urinary tract symptoms, analgesic dosage, and days of spontaneous passage of the stones through the ureter were recorded in a diary after lithotripsy.

RESULTS

The results showed that tamsulosin treatment group had low expulsion time (P = 0.011), low urinary tract symptoms, least analgesic needs and low adverse effects, all with statistically significant differences comparable with the control group (P < 0.05).

CONCLUSIONS

Administration of α-1A-specific blocker reduced analgesic dosage and colic episodes and rate of adverse effects after ureteroscopic lithotripsy of lower ureteral stones and decreased gravel expulsion time after URSL.

Spontaneous renal pelvis rupture: unexpected complication of urolithiasis expected to passage with observation therapy

Seventy percent of ureteral stones are located at distal ureter. Effective and safe passage of distal ureter stones is mediated by observation or medical expulsive treatment. Most of stones located at distal ureter pass spontaneously under observation; however, some are complicated with urinary tract infection, hydronephrosis, and renal function disturbances. Spontaneous perforation of the upper ureter is a rare condition that poses diagnostic and therapeutic problems. This case is reported, because the patient developed an unexpected spontaneous renal pelvis rupture (SRPR), while she was under observation and expected to pass her right ureteral stone spontaneously through hydration and analgesic treatment.

Comparing the efficacy of tamsulosin and silodosin in the medical expulsion therapy for ureteral calculi

BACKGROUND

Urolithiasis is a chronic disease of mankind, which has enormous public health importance and it accounts for a substantial economic burden on our society. Hence, it becomes all the more important to formulate cheaper and easier means for treating this condition. The past few years have seen a number of drugs being introduced and successfully used in the medical expulsion therapy of small, uncomplicated ureteral calculi, with each drug claiming to provide better results than the others. Ours is perhaps the first study which has compared the efficacy of tamsulosin and silodosin in the medical expulsion therapy for ureteral calculi.

AIMS

To compare the efficacy of tamsulosin (0.4mg) vs silodosin (8mg), both in terms of the stone expulsion rate and the time to stone expulsion.

SETTINGS AND DESIGN

A prospective and a randomized controlled study was conducted in the Department of Urology, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, India.

MATERIAL AND METHODS

From February to August 2012, 100 patients who were between the age group of 18-50 years, who had unilateral, uncomplicated middle or lower ureteral stones </= 1cm were enrolled and they were divided into two groups. Group 1 received tamsulosin (0.4mg) daily, whereas Group 2 received silodosin (8mg) daily for a maximum period of 4 weeks. The patients were followed up weekly or biweekly with imaging studies. The primary endpoint was the stone expulsion rate and the secondary endpoints were the stone expulsion time, the rate of the interventions and the side effects.

STATISTICAL ANALYSIS

The statistical analysis was performed by using the Student's t-test and the Chi-squared test. A p value of < 0.05 was considered to be statistically significant. The SPSS-16 software was used for the statistical analysis of the data.

RESULTS

A spontaneous stone expulsion was observed in 58% of the patients in group 1 and in 82% of the patients in Group 2, which was statistically significant. There was also a significant difference between the groups with regards to the mean stone expulsion time. A lower analgesic use was found in Group 2.

CONCLUSION

In our study, silodosin was found to be clinically superior to tamsulosin, both in terms of the stone expulsion rate and the stone expulsion time.

Tamsulosin for ureteral stones: a systematic review and meta-analysis of a randomized controlled trial

BACKGROUND/AIMS

To evaluate the efficacy of tamsulosin as a medical expulsive therapy of ureteral stones.

METHODS

We searched PubMed, EMBASE, the Cochrane Library, and ISI-Science Citation Index up to December 2011. All randomized controlled trials were identified in which patients were randomized to receive either tamsulosin or standard therapy with/without placebo for ureteral stones. Outcome measures assessed were overall stone expulsion rate (primary) and expulsion time, and the number of pain episodes (secondary). Three authors independently assessed study quality and extracted data. All data were analyzed using RevMan 5.0.

RESULTS

Twenty-nine trials with a total of 2,763 patients met the inclusion criteria. The pooled analysis showed a 19% improvement in stone clearance with tamsulosin. According to the doses of tamsulosin, the pooling effects of tamsulosin were analyzed, with a higher expulsion rate obtained than in controls. Compared with calcium channel blockers, there was a higher stone expulsion rate in tamsulosin. In addition, a shorter expulsion time, fewer colic episodes and adverse effects were observed.

CONCLUSIONS

Tamsulosin is a safe and effective medical expulsive therapy choice for ureteral stones. It should be recommended for most patients with distal ureteral stones before stones are 10 mm in size. In future, high-quality multicenter, randomized and placebo-controlled trials are needed to evaluate the outcome.

Efficacy of tamsulosin oral controlled absorption system after extracorporeal shock wave lithotripsy to treat urolithiasis

OBJECTIVE

To determine the efficacy of the tamsulosin oral controlled absorption system as an adjuvant therapy to extracorporeal shock wave lithotripsy (ESWL) for the expulsion of ureteral and renal stones.

METHODS

A consecutive sample of 248 patients with ureteral or renal stones who underwent ESWL in an academic hospital was included in a 12-week, prospective, open-label, randomized clinical trial. Of the 248 patients, 186, including 77 with ureteral stones (mean size 9 mm) and 109 with renal stones (mean size 13 mm) completed the study. After successful ESWL, the patients were randomized to standard medical care (corticosteroids and analgesics) or standard care plus the tamsulosin oral controlled absorption system 0.4 mg/d for 1 month. The stone clearance rate, interval to the elimination of stone fragments, incidence of renal colic, and the need for rehospitalization were assessed at 4, 8, and 12 weeks.

RESULTS

The stone clearance rate was significantly greater for the patients treated with tamsulosin than for those in the standard care group at 4 (73.4% vs 55.9%, respectively; P < .001) and 12 (91.3% vs 74.6%, respectively; P < .05) weeks. Tamsulosin treatment was also associated with a significantly lower interval to the elimination of stone fragments (P < .001), a significantly lower rehospitalization rate (P < .001), and a significantly lower proportion of patients with acute renal colic (P < .05) than standard care alone. No severe adverse events leading to treatment discontinuation were observed.

CONCLUSION

Adjuvant treatment with tamsulosin, in addition to standard treatment with steroids and analgesics, improved the outcome of ESWL.

Emergency management of ureteral stones: Recent advances

Most ureteral stones can be observed with reasonable expectation of uneventful stone passage. When an active ureteral stone treatment is warranted, the best procedure to choose is dependent on several factors, besides stone size and location, including operators’ experience, patients’ preference, available equipment and related costs. Placement of double-J stent or nephrostomy tube represents the classical procedures performed in a renal colic due to acute ureteral obstruction when the conservative drug therapy does not resolve the symptoms. These maneuvers are usually followed by ureteroscopy or extracorporeal shockwave lithotripsy, which currently represent the mainstay of treatment for ureteral stones. In this review paper a literature search was performed to identify reports dealing with emergency management of renal colic due to ureteral stones. The main aspects related to this debated issue are analyzed and the advantages and disadvantages of each treatment option are carefully discussed.

Management of ureteral calculi and medical expulsive therapy in emergency departments

Introduction:

Ureteral stones are a common problem in daily emergency department practice. Patients may be offered medical expulsive therapy (MET1) to facilitate stone expulsion and this should be offered as a treatment for patients with distal ureteral calculi, who are amenable to waiting management. Emergency department clinicians and family practitioners are often in the front line regarding the diagnosis and treatment of symptomatic nephrolithiasis and this commentary is dedicated to them because their decisions directly influence the outcome of the acute stone episode and appropriate referral patterns.

Materials and Methods:

The aim of this systematic review and meta-analysis was to understand the role of MET in the treatment of obstructing ureteral calculi. A bibliographic search covering the period from January 1980 to March 2010 was conducted in PubMed, MEDLINE and EMBASE. The searches were restricted to publications in English. This analysis is based on the 21 studies that fulfilled the predefined inclusion criteria.

Results:

A metaregression analysis of expulsion time showed a statistically significant advantage in the experimental group, in which the mean expulsion time was 6.2 days compared to 10.3 days in controls. The treatment effect on expulsion rate (P = 0.53) was partially lost as the size of the stones decreased because of the high spontaneous expulsion rate of small stones and the expulsion time was not influenced by pharmacological treatment (P = 0.76) if the stone size was smaller than 5 mm. Analysis of the tamsulosin database. A total of 1283 participants were included in the 17 studies. These studies showed that compared to standard therapy or placebo, tamsulosin had significant benefits, being associated with both a higher stone expulsion rate (P < 0.001) and reduction of the expulsion time (P = 0.02). Reductions in the need for analgesic therapy, hospitalization and surgery are also shown. Analysis of the nifedipine database. The number of participants in each trial ranged from 25 to 70. Compared to standard therapy, the use of nifedipine significantly improved the spontaneous stone expulsion rate (P < 0.001). The mean expulsion time was slightly, but not statistically significantly, different (P = 0.19) between the treatment and control groups. A possible benefit of nifedipine, in terms of significantly reducing the doses of analgesics required, was reported in three studies. There was no difference between the tamsulosin- and nifedipine-treated groups with regard to expulsion time (P = 0.17) or expulsion rate (P = 0.79).

Conclusions:

Despite all its advantages, MET is rarely used, representing a failure of the translation of medical science into practice. These data raise concerns not only about the quality of care of patients who could benefit from resolution of stones without anaesthetic and surgical risks but also with regard to potential cost savings. MET should be offered as a treatment for patients with distal ureteral calculi who are amenable to a waiting management.

Facilitation of expulsion of ureteral stones by addition of α1-blockers to conservative therapy

OBJECTIVE

An antispasmodic agent and a medicine that facilitates stone expulsion are given commonly as conservative therapy for ureteral stones in Japan. The goal of this study was to compare the efficacy of the addition of various α(1)-blockers to the conservative therapy for spontaneous passage of ureteral stones.

MATERIAL AND METHODS

The subjects were 132 patients with stones from the upper to the lower ureter who were randomly placed into one of four groups and followed for 1 month to assess spontaneous passage of stones. The control group received daily doses of 240 mg flopropione as an antispasmodic agent and 1350 mg extract of Quercus salicina Blume/Quercus stenophylla Makino as a medicine that facilitates stone expulsion. The other three groups received this therapy and daily doses of 30 mg urapidil, 0.2 mg tamsulosin or 50 mg naftopidil, respectively. The characteristics of the stones and stone expulsion were evaluated by urinalysis, a kidney, ureter and bladder (KUB) X-ray, ultrasound and computed tomography.

RESULTS

All patients completed the study and there were no major side-effects. There was no difference in age, stone position or stone size among the groups. Multivariate analysis using a Cox proportional hazards model indicated that the probability of stone expulsion for 1 month was increased 2.38 times (95% confidence interval 1.23-4.61) by naftopidil compared with control therapy alone (p = 0.01).

CONCLUSION

Naftopidil in combination with an antispasmodic agent and a medicine that facilitates stone expulsion produces a significantly increased rate of ureteral stone expulsion.

Does tamsulosin change the management of proximally located ureteral stones?

The objective of this study is to assess the efficacy of an alpha-1 adrenergic receptor blocking agent on the spontaneous passage of proximal ureteral calculi < or =10 mm. 92 patients having single radio-opaque proximal ureteral stone < or =10 mm were randomized into two groups. Group 1 patients (n = 50) were followed with classical conservative approach and patients in Group 2 (n = 42) additionally received tamsulosin, 0.4 mg/day during 4 weeks follow-up. The stone passage rates, stone expulsion time, VAS score, change in colic episodes, and hospital re-admission rates for colicky pain were compared. The patients were furthermore stratified according to stone diameters <5 and 5-10 mm. The data of these subgroups were also compared. Stone expulsion rates showed statistically significant difference between tamsulosin receivers and non-receivers (35.7 vs 30%, p = 0.04). Time to stone expulsion period was also shortened in those receiving tamsulosin (8.4 +/- 3.3 vs 11.6 +/- 4.1 days, p = 0.015). Likewise, the mean VAS score and renal colic episodes during follow-up period were significantly diminished in Group 2 patients (4.5 +/- 2.3 vs 8.8 +/- 2.9, p < 0.01 and 66.6 vs 36%, p = 0.001, respectively). Among the stones <5 mm, tamsulosin receiving patients had higher spontaneous passage rate (71.4 vs 50%, p < 0.001). The prominent effect of tamsulosin on the 5-10 mm stones was the relocation of the stones to a more distal part of ureter (39.3 vs 18.7%, p = 0.001). Administration of tamsulosin in the medical management of proximal ureteral calculi can facilitate the spontaneous passage rate in the stone <5 mm and the relocation of the stones between 5 and 10 mm to more distal part of the ureter.

[Use of alfuzosin for expulsion of stones in the distal third of ureter]

INTRODUCTION

Ureteral stones occur in approximately 12% of the population worldwide, and their incidence has significantly increased in recent years in Western countries. Seventy percent of ureteral stones are located in the distal third of the ureter. Several factors have a strong influence on spontaneous passage of ureteral stones, including stone size, shape, and location. Alpha blockers are currently attributed a potential role in rapid expulsion of stones in the distal third of the ureter.

MATERIALS AND METHODS

Thirty patients diagnosed of stones in the distal third of ureter of sizes ranging from 4 mm and 10 mm were divided into two groups. The first group was given Buscopan 10 mg plus ketorolac 10 mg every 8 hours, while the second group received alfuzosin 10 mg every 24 hours.

RESULTS

In group 1, mean stone size was 6.4 mm. Stone expulsion occurred in only 4 patients after a mean of 11.4 days. In group 2, mean stone size was 5.8 mm, and stone expulsion occurred in 13 patients after a mean of 3.3 days.The two stones that were not passed where the biggest ones (9 mm and 10 mm).

CONCLUSIONS

Use of alpha-adrenergic blockers for ureteral distal third stones has been shown to be effective for increasing the stone expulsion rate and even the number of stones passed, and for faster symptom relief.

The ideal analgesic treatment for acute renal colic – Theory and practice

OBJECTIVE

With an annual incidence of 0.1-0.4%, renal colic is certainly a frequent disorder. Thanks to recent findings, the approach to treatment is changing. This prompted us to conduct a survey amongst all urologists in Switzerland regarding the analgesic measures they use in patients suffering from acute renal colic.

MATERIAL AND METHODS

In March 2005, we sent a total of 170 questionnaires to all practising urologists who are also members of the Swiss Urology Society. The questions covered the types of drugs used for first- and second-line analgesic therapy in acute renal colic and the approach to acute and follow-up analgesic therapy. Dosage adjustments in patients with renal failure were also included. The responses were compared with recent literature findings and international guidelines.

RESULTS

The response rate was 58%. Non-opioid analgesics are used for first-line therapy by 81% of respondents, with metamizol being used in 64% of cases. First-line therapy is given intravenously in 65% of cases. An opioid (pethidine) is used most frequently as acute second-line therapy (74% of cases). In the presence of renal failure, half of the respondents make a dose adjustment to the analgesic. Follow-up therapy consists mainly of non-steroidal anti-inflammatory drugs (75%). This complies with the literature and with the recommendations of the European Association of Urology.

CONCLUSION

First-line therapy for acute renal colic should consist of a non-opioid analgesic, and only if the response to this is inadequate should opioids then be used.

Efficacy of tamsulosin in medical expulsive therapy for distal ureteral calculi

OBJECTIVE

To evaluate the potential role of tamsulosin in the medical treatment of distal ureteral stones.

MATERIAL AND METHODS

Ninety patients with symptomatic distal ureteral calculi were enrolled. They were randomly divided into two groups: Group A (n=45) received diclofenac 100 mg on demand for 4 weeks plus levofloxacin 250 mg daily for the first week and were well hydrated; and Group B (n=45) received the same therapy plus tamsulosin 0.4 mg/daily for 4 weeks. Abdominal ultrasound scans and KUB X-rays were performed weekly. Stone expulsion rates, time to expulsion, pain episodes and analgesic usage were determined. Intervention by means of shock-wave lithotripsy (SWL) or ureteroscopy was evaluated.

RESULTS

The stone expulsion rate was 51.1% for Group A, compared to 88.9% for Group B (p=0.001). The average time to expulsion was 12.53+/-2.12 days for Group A and 7.32+/-0.78 days for Group B (p=0.04). The number of pain episodes was significantly lower in Group B and mean use of analgesics was lower for Group B (0.14+/-0.5 vials) than Group A (2.78+/-2.7 vials). Twenty-two patients in Group A failed to pass their stones after 4 weeks but only five in Group B. Of the patients who were not stone-free, 19 were treated with SWL and eight underwent ureteroscopy.

CONCLUSION

Our study reveals the efficacy of tamsulosin for the treatment of distal ureteral stones. Tamsulosin should be added to the standard medical approach for treating these stones.

Medical therapy to facilitate the passage of stones: what is the evidence?

CONTEXT

Medical expulsive therapy (MET) for urolithiasis has gained increasing attention in the last years. It has been suggested that the administration of alpha-adrenoreceptor antagonists (alpha-blockers) or calcium channel blockers augments stone expulsion rates and reduces colic events.

OBJECTIVE

To evaluate the efficacy and safety of MET with alpha-blockers and calcium channel blockers for upper urinary tract stones with and without prior extracorporeal shock wave lithotripsy (ESWL).

EVIDENCE ACQUISITION

A systematic review of the literature was performed in Medline, Embase, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews searched through 31 December 2008 without time limit. Efficacy and safety end points were evaluated in 47 randomised, controlled trials assessing the role of MET. Meta-analysis was conducted using Review Manager (RevMan) v.5.0 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).

EVIDENCE SYNTHESIS

Pooling of alpha-blocker and calcium channel blocker studies demonstrated a higher and faster expulsion rate compared to a control group (risk ratio [RR]: 1.45 vs 1.49; 95% confidence interval [CI]: 1.34-1.57 vs 1.33-1.66). Similar results have been obtained after ESWL (RR: 1.29 vs 1.57; 95% CI: 1.16-1.43 vs 1.21-2.04). Additionally, lower analgesic requirements, fewer colic episodes, and fewer hospitalisations were observed within treatment groups.

CONCLUSIONS

Pooled analyses suggest that MET with alpha-blockers or calcium channel blockers augments stone expulsion rates, reduces the time to stone expulsion, and lowers analgesia requirements for ureteral stones with and without ESWL for stones < or = 10 mm. There is some evidence that a combination of alpha-blockers and corticosteroids might be more effective than treatment with alpha-blockers alone. Renal stones after ESWL also seem to profit from MET. The vast majority of randomised studies incorporated into the present systematic review are small, single-centre studies, limiting the strength of our conclusions. Therefore, multicentre, randomised, placebo-controlled trials are needed.

Medical therapy of stone disease: from prevention to promotion of passage options

Medical therapy has been used for many years in the prevention of urinary stones. Medications directed at correcting urinary metabolic abnormalities responsible for promoting stone formation include thiazide diuretics, citrate salts, and allopurinol. All have proven to be efficacious. In addition, intake of citrate-rich juices, such as lemonade, may help to reduce urinary stone formation. More recently, there has been increasing interest in and use of medical therapy to aide in the passage of ureteral stones. Medical expulsive therapy (MET) has been shown to be cost effective compared with observation followed by treatment. Alpha-adrenergic receptor blockers are most commonly prescribed to promote passage of ureteral stones. They are able to facilitate stone passage, reduce time to passage, and decrease pain. Calcium-channel blockers also increase stone-passage rates. Steroids are useful adjuncts in MET.

Is there a role for tamsulosin in the treatment of distal ureteral stones of 7 mm or less? Results of a randomised, double-blind, placebo-controlled trial

BACKGROUND

Numerous randomised trials have confirmed the efficacy of medical expulsive therapy with tamsulosin in patients with distal ureteral stones; however, to date, no randomised, double-blind, placebo-controlled trials have been performed.

OBJECTIVE

The objective of this trial was to evaluate the efficacy of medical expulsive therapy with tamsulosin in a randomised, double-blind, placebo-controlled setting.

DESIGN, SETTING, AND PARTICIPANTS

Patients presenting with single distal ureteral stones < or = 7 mm were included in this trial.

INTERVENTION

Patients were randomised in a double-blind fashion to receive either tamsulosin or placebo for 21 d. The medication was discontinued after either stone expulsion or intervention. Abdominal computed tomography was performed to assess the initial and final stone status. MEASUREMENTS AND LIMITATIONS: The primary end point was the stone expulsion rate. Secondary end points were time to stone passage, the amount of analgesic required, the maximum daily pain score, safety of the therapy, and the intervention rate.

RESULTS

Ten of 100 randomised patients were excluded from the analysis. No statistically significant differences in patient characteristics and stone size (median: 4.1 mm [tamsulosin arm] vs 3.8 mm [placebo arm], p=0.3) were found between the two treatment arms. The stone expulsion rate was not significantly different between the tamsulosin arm (86.7%) and the placebo arm (88.9%; p=1.0). Median time to stone passage was 7 d in the tamsulosin arm and 10 d in the placebo arm (log-rank test, p=0.36). Patients in the tamsulosin arm required significantly fewer analgesics than patients in the placebo arm (median: 3 vs 7, p=0.011). A caveat is that the exact time of stone passage was missing for 29 patients.

CONCLUSIONS

Tamsulosin treatment does not improve the stone expulsion rate in patients with distal ureteral stones < or = 7 mm. Nevertheless, patients may benefit from a supportive analgesic effect. CLINICALTRIALS.GOV: NCT00831701.

The effect of alpha-blockade in emergency department patients with ureterolithiasis

BACKGROUND

Recent studies suggest that alpha-blockade with tamsulosin may be useful in the treatment of ureterolithiasis by increasing the success of, and decreasing the time to, stone passage.

OBJECTIVES

We sought to determine stone passage success rates in patients diagnosed with ureterolithiasis and discharged from our Emergency Department (ED) with tamsulosin.

METHODS

We conducted a non-randomized retrospective cohort study over a 1-year period during which we made monthly follow-up telephone calls to patients discharged from our ED with a diagnosis of ureterolithiasis determined by computed tomography (CT) scan. Stone size and location (proximal, middle, or distal ureter) were determined from radiologist reports and prescriptions were determined from electronic medical records. Patients were asked if they spontaneously passed their stone, how much time was required before stone passage, and if any subsequent hospital visit was required after discharge due to pain or complication resulting from the ureteral stone.

RESULTS

During the study, a total of 213 patients were discharged from the ED with ureterolithiasis diagnosed by CT scan; of these, 119 (56%) were successfully contacted and 113 (53%) agreed to participate. Of the 113 patients, 83 (73%) had been prescribed tamsulosin and 30 (27%) had not. Overall age (43 years), gender (67% male), median stone size (3 mm, interquartile range 2-4 mm), and location (71% distal ureter) were similar in the two cohorts. Of tamsulosin recipients, 84% (95% confidence interval [CI] 75-91%) reported passing their stone, whereas 60% (95% CI 42-75%) of non-recipients passed their stone.

CONCLUSION

Patients with ureterolithiasis discharged from our ED and given tamsulosin by prescription had moderately high ureteral stone passage success rates in our non-randomized retrospective cohort study. Compared to non-recipients of tamsulosin, patients receiving tamsulosin seemed to have greater success in stone passage.