Efficacy of alpha-blockers for the treatment of ureteral stones

Pooled-analysis of tadalafil and tamsulosin for ureteral calculi

Objective

Urolithiasis is a common urological diseases and affects the daily life of patients. Medical expulsive therapy has become acceptable for many parents. We conducted a meta-analysis to determine the efficacy and safety of tadalafil compared with tamsulosin for treating distal ureteral stones less than 10 mm in length.

Methods

Related studies were identified via searches of the PubMed, Embase, and Cochrane Library databases. All the articles that described the use of tadalafil and tamsulosin for treating distal ureteral stones were collected.

Results

A total of 14 studies were included in our meta-analysis. Our results revealed that tadalafil enhanced expulsion rate [odds ratio (OR) = 0.68, 95% confidence interval (CI): 0.47 to 0.98, p = 0.04]; reduced expulsion time [mean difference (MD) = 1.22, 95% CI (0.13, 2.30), p = 0.03]; lowered analgesia use [MD = 38.66, 95% CI (7.56, 69.77), p = 0.01] and hospital visits [MD = 0.14, 95% CI (0.06, 0.22), p = 0.0006]. According to our subgroup analysis, either tadalafil 5 mg or 10 mg did not promote expulsion rate and accelerate expulsion time compared with tamsulosin. But patients receiving 5 mg tadalafil decreased analgesia usage [MD = 101.04, 95% CI (67.56, 134.01), p < 0.00001].

Conclusion

Compared with tamsulosin, tadalafil demonstrates a higher expulsion rate and less expulsion time for patients with distal ureteral stones less than 10 mm with a favorable safety profile.

Silodosin versus Tamsulosin for Medical Expulsive Therapy of Ureteral Stones: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: This systematic review and meta-analysis of randomized controlled trials was performed to compare the therapeutic effects and safety profiles of silodosin and tamsulosin for medical expulsive therapy (MET) of ureteral stones. Materials and Methods: We searched PubMed, EMBASE, the Cochrane Library, and Web of Science to identify articles published before July 2022 that described randomized controlled trials comparing silodosin and tamsulosin for MET of ureteral stones. Endpoints were stone expulsion rate, stone expulsion time, and total complication rate. Results: In total, 14 studies were included in our analysis. The size of ureteral stones was <1 cm. Compared with tamsulosin, silodosin resulted in a significantly higher stone expulsion rate (p < 0.01, odds ratio (OR) = 2.42, 95% confidence interval (CI) = 1.91 to 3.06, I2 = 0%) and significantly shorter stone expulsion time (p < 0.01, mean difference = −3.04, 95% CI = −4.46 to −1.63, I2 = 89%). The total complication rate did not significantly differ between silodosin and tamsulosin (p = 0.33, OR = 1.15, 95% CI = 0.87 to 1.52, I2 = 7%). Conclusions: Compared with tamsulosin, silodosin resulted in significantly better expulsion of ureteral stones <1 cm. The total complication rate did not significantly differ between silodosin and tamsulosin. Thus, silodosin may be superior to tamsulosin for MET of ureter stones <1 cm.

EFFICACY OF DOXAZOSIN VERSUS TAMSULOSIN IN LOWER URETERIC STONE EXPULSION IN ADULT POPULATION OF DISTRICT DERA ISMAIL KHAN, PAKISTAN

Background: Urolithiasis is the third common disease of the urinary tract after UTIs and pathological diseases of the prostate. The objective of this study was to compare the efficacy of doxazosin versus tamsulosin in lower ureteric stone expulsion in adult population of District Dera Ismail Khan, Pakistan.Materials Methods: This non-randomized control trial was conducted in the Department of Urology, Gomal Medical College, Dera Ismail Khan, Pakistan from February 2020 to December 2020. The 252 patients included in our study were divided in to two groups. The patients in experimental group received Tab. doxazosin 4 mg daily for 4 weeks and Tab. diclofenac sodium 50 mg B.D for 5 days and then on need basis. The patients in control group received Cap. tamsulosin 0.4 mg daily for 4 weeks and similarly Tab. diclofenac sodium 50 mg as in experimental group. All the patients were followed regularly for expulsion of ureteric stones for four weeks. Sex, age and stone size were matching, while stone expulsion was a research variable. Hypothesis was verified by McNemar chi-square test.Results: Out of 252 patients, 113 (89.68%) patients in experimental group, while 77 (61.11%) patients in control group passed the stones. There was statistically significant difference in efficacy in doxazosin group as compared to tamsulosin group (p-value=.0001).Conclusion: The use of doxazosin as the medical expulsion therapy for the lower ureteric stone proved to be more effective as compared to tamsulosin as demonstrated by our results.

EFFICACY OF ALFUZOSIN VERSUS CONTROL GROUP IN UPPER URETERIC STONE EXPULSION IN ADULT POPULATION OF LAHORE, PAKISTAN

Background: Urinary stone disease is one of the commonest urological diseases worldwide. The objective of this study was to compare the efficacy of alfuzosin versus control group in upper ureteric stone expulsion in adult population of district Lahore, Pakistan.Materials Methods: This trial was conducted in Department of Urology, Sheikh Zayed Hospital, Lahore, Pakistan form January 2017 to June 2017. All adult patients with upper ureteric stone size 5-10 mm were eligible. Those with multiple stones, having fever, severe pain, history of surgery in past two weeks and growth on urine culture or pyuria were excluded. Experimental and control groups each had 30 patients. Experimental group received Tab. alfuzosin 10 mg daily for four weeks and Tab. diclofenac sodium 50 mg SOS for acute pain. The control group received Tab. diclofenac sodium 50 mg SOS for acute pain. We followed all patients for four weeks for expulsion of ureteric stones by X-ray KUB or CT KUB. Sex, age and stone size were matching variables. Stone expulsion (yes, no) was research variable. We compared count of stone expulsion between two groups by using McNemar chi-square test at alpha 0.5 using GraphPad.Results: Out of 30 patients in experimental group, 23 (76.67%) were men and seven (23.33%) women and out of 30 in control group, 20 (66.67%) were men and 10 (33.33%) women, almost similar in both groups. Mean age in experimental group was 39.45±10.33 years and in control group it was 37.38±8.28 years, almost similar in both groups. Mean stone size was 7.45±1.47 (5-10) mm in the experimental and 7.28±1.68 (5-10) mm in control group, being comparable in both the groups. In experimental group, stone expulsion was achieved in 23 (76.67%) cases and not in seven (23.33%) cases and in control group, it was achieved in 16 (53.33%) cases and not in 14 (46.67%) cases. There was statistically no significant difference in efficacy of alfuzosin versus control group (p=.1213).Conclusion: Our study showed no difference in efficacy of alfuzosin versus control group for upper ureteric stone expulsion in adult population of district Lahore, Pakistan.

Tamsulosin attenuates high glucose- induced injury in glomerular endothelial cells

Diabetic nephropathy (DN) is a common complication of diabetes. Tamsulosin is a selective α1-AR antagonist. α1-AR is expressed widely in kidney tissues and has displayed its various physiological functions. However, whether Tamsulosin has affects DN is unknown. To our knowledge, this is the first time it has been examined whether Tamsulosin possesses a beneficial effect in high glucose-challenged glomerular endothelial cells (GECs). Firstly, we found that Tamsulosin reduced high glucose-induced expressions of TNF-α, IL-6, and IL-8. Secondly, Tamsulosin alleviated high glucose-induced expressions of MMP-2 and MMP-9. Thirdly, Tamsulosin inhibited the expressions of VCAM-1 and ICAM-1. Importantly, our results indicate that Tamsulosin inhibited high glucose-induced expressions of fibrosis factors such as Col-1 and TGF-β1. Additionally, we found that Tamsulosin ameliorated oxidative stress via reducing the generation of ROS and preventing the activation of p38. Mechanistically, we found that Tamsulosin attenuated high glucose-induced activation of NF-κB. Based on these findings, we conclude that Tamsulosin could attenuate high glucose-induced injury in GECs through alleviating oxidative stress and inflammatory response.

Adjunctive medical expulsive therapy with tamsulosin for repeated extracorporeal shock wave lithotripsy: a systematic review and meta-analysis

Purpose:

To evaluate the efficacy of adjunctive medical expulsive therapy (MET) with tamsulosin for the promotion of stone fragments clearance for repeated extracorporeal shock wave lithotripsy (ESWL).

Materials and Methods:

This meta-analysis was conducted by systematic search for randomized controlled trial (RCT) studies in PubMed/Medline, Scopus, Cochrane Library, Web of Science databases in January 2020, which compared tamsulosin with either placebo or non-placebo control for repeated ESWL. The primary endpoint was stone-free rate (SFR), the second endpoints were stone clearance time and complications. The quality assessment of included studies was performed by using the Cochrane System and Jadad score.

Results:

7 RCTs were included in this meta-analysis. Tamsulosin provided higher SFR (for stones larger than 1cm, OR: 5.56, p=0.0003), except for patients with stones less than 1cm. For patients with renal stones (OR: 2.97, p=0.0005) or upper ureteral stones (OR: 3.10, p=0.004), tamsulosin can also provide a higher SFR. In addition, tamsulosin provided a shorter stone clearance time (WMD: −9.40, p=0.03) and lower pain intensity (WMD=-17.01, p <0.0001) and incidences of steinstrasse (OR: 0.37, p=0.0002).

Conclusion:

Adjunctive MET with tamsulosin is effective in patients with specific stone size or location that received repeated ESWL. However, no well-designed RCT that used computed tomography for the detection and assessment of residual stone fragments was found. More studies with high quality and the comparison between tamsulosin and secondary ESWL are needed in the future.

Silodosin versus Tamsulosin as Medical Expulsive Therapy for Children with Lower-Third Ureteric Stones: Prospective Randomized Placebo-Controlled Study

AIM

To compare the efficacy and safety of silodosin versus tamsulosin as medical expulsive therapy for stones of lower-third ureter in children.

PATIENTS AND METHODS

This prospective single-blind placebo-controlled randomized study included 167 pediatric patients who presented with distal ureteric stone (DUS) less than 1 cm. Patients were randomized into 3 groups; group I received silodosin 4 mg once daily, and group II received tamsulosin 0.4 mg while those in group III had placebo. The side effects of the used drugs, both rate and time of stone expulsion, and number of pain episodes were compared among the study groups for a maximum of 4 weeks.

RESULTS

Follow-up data of our patients after treatment revealed that the stone expulsion rate was significantly higher and the time to stone expulsion was significantly shorter in group I (89.3%, 12.4 ± 2.3 days) and group II (74.5%, 16.2 ± 4.2 days) compared to group III (51.8%, 21.2 ± 5.6). However, a statistically significant difference between silodosin and tamsulosin groups in favor of the former one was reported regarding the 2 studied items. Meanwhile, pain episodes requiring analgesia were statistically fewer in group I and II in contrast to placebo group. Adverse events were comparable among all groups.

CONCLUSION

Silodosin provides significantly better stone expulsion rate and shorter expulsion time than tamsulosin for treatment of DUS. Both medications showed good safety profiles in children. However, further studies are required on a larger scale to confirm our results. Assessment of drug safety on younger age-group is still needed.

Efficacy of Tamsulosin plus Tadalafil versus Tamsulosin as Medical Expulsive Therapy for Lower Ureteric Stones: A Randomized Controlled Trial

Introduction

Urolithiasis is one of the common disorder with which about 1/5^th is found in the ureter, of which 2/3^rd is seen in the lower ureter. Medical expulsive therapy is one of the routine modalities of treatment which uses various drugs acting on the ureter smooth muscle by different mechanism. We aim to compare the efficacy of combination vs. single drug.

Methods

This randomized controlled trial was done in 176 consecutive patients over a period of six months (March 2019 to August 2019) in Department of Urology and Kidney Transplant Surgery, Tribhuvan University Teaching. Participants were divided into two groups (Group A, tamsulosin plus tadalafil, and Group B, tamsulosin) from computer-generated random numbers. Therapy was continued for a maximum of 3 weeks. Stone expulsion rate, time to stone expulsion, analgesic use, number of colic and emergency room visits for pain, early intervention, and adverse effects of drugs were recorded.

Results

Among 176 patients who were enrolled in study, 7 were lost to follow-up, and 5 people required immediate intervention. There was a significant higher stone passage rate in group A than group B (64 vs. 50; P=0.025) and shorter expulsion time (1.66 vs. 2.32 weeks P=0.001) and less number of emergency room visits and colic episodes. No significant side effects were noted during study.

Conclusion

Tamsulosin plus Tadalafil is more effective than tamsulosin with early passage of stone and decreased number of colic episodes and emergency visits without significant side effects for lower ureteric calculi of 5 mm to 10 mm.

Association between serum high-sensitivity C-reactive protein levels and erectile dysfunction: a cross-sectional study of Chinese male population

Inflammation has been known to affect endothelial function and is involved in the progression of erectile dysfunction (ED). Thus, our present study was conducted to investigate the association between inflammatory marker high-sensitivity C-reactive protein (hs-CRP) and ED in a Chinese male population. A total of 1515 participants with anthropometric measurements, serum analyses and hs-CRP values available were included in our cross-sectional study. Data involving socioeconomic and lifestyle factors were also collected. ED was assessed by the 5-item International Index Erectile Function (IIEF-5), and hs-CRP levels were measured by the immunoturbidimetric assay. Logistic regression was applied to estimate the association between the serum hs-CRP and the risk of ED, and receiver operating characteristics (ROC) curve analysis was performed to identify the predictive value of hs-CRP. Serum hs-CRP levels were significantly higher in ED patients, and increased progressively with the incremental severity of ED (P < 0.001 for trend). In the multivariate-adjusted model, men in the highest quartile of hs-CRP level versus those in the lowest quartile had a 50% increased likelihood for ED (OR = 1.50; 95% CI = 1.08–2.08). When subjects were stratified by age, the risk of ED was more prominently in the middle-aged and elderly men. Based on the ROC analysis, serum hs-CRP has a poor diagnostic value for ED with an AUC of 0.58 (95% CI: 0.56–0.61) but has a good diagnostic performance for differentiating severe ED (AUC: 0.79; 95% CI: 0.77–0.81). Our study indicates that increased serum hs-CRP levels are associated with the severity of ED and an increased ED risk in a Chinese male population. These findings suggest that hs-CRP may be of value as an inflammatory marker for the assessment of ED risk and may play an important role in the etiology of ED.

Role of silodosin as medical expulsive therapy in ureteral calculi: a meta-analysis of randomized controlled trials

The objective of this study is to investigate the efficacy of silodosin in medical expulsive therapy (MET) for ureteral stones. We conducted a systematic review and meta-analysis to determine the efficacy and safety of silodosin in MET for ureteral calculi. We searched PubMed, Embase, Medline, Central (the Cochrane Library, Issue 1,2013), Google Scholar from the inception to March 2015 for randomized controlled trials (RCTs), comparing silodosin with tamsulosin or control on ureteral stone passage. Eight RCTs with a total of 1145 ureteral stone patients (300 patients in the control group, 287 patients in the tamsulosin group, 558 patients in the silodosin group) were included in this meta-analysis. When compared with control, silodosin significantly improved expulsion rate of distal ureteral stones (RR: 1.42; 95% CI, 1.21-1.67; P < 0.0001), while there was no significant difference between silodosin and the control in expulsion rate of proximal (RR: 0.99; 95% CI, 0.69-1.43; P < 0.97) or mid (RR: 1.13; 95% CI, 0.60-2.16; P < 0.0001) ureteral stones. There was no significant difference between silodosin and tamsulosin in terms of expulsion time (WMD: -2.47; 95% CI, -5.32 to 0.39; P = 0.09), analgesic use (WMD: -0.39; 95% CI, -0.91 to 0.13; P  = 0.14) and retrograde ejaculation rate (RR: 1.85; 95% CI, 0.95-3.59; P = 0.07) in MET for distal ureteral stones. However, silodosin provided a significantly higher expulsion rate (RR: 1.25; 95% CI, 1.13-1.37; P < 0.0001) than tamsulosin for distal ureteral stones. Silodosin significantly improved expulsion rate of distal ureteral stones and was clinically superior to tamsulosin. Silodosin was ineffective in MET for proximal and mid ureteral stones. More RCT studies are needed to compare the efficacy of silodosin versus tamsulosin in MET for distal ureteral stones.

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.

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.

Tamsulosin versus tadalafil as a medical expulsive therapy for distal ureteral stones: A prospective randomized study

PURPOSE

This study aimed to compare the safety and efficacy of tamsulosin and tadalafil as medical expulsive therapy for distal ureteral stones.

MATERIALS AND METHODS

This prospective randomized study was conducted at the Department of Urology of Bir Hospital over a period of 12 months in patients with distal ureteral stones sized 5 to 10 mm. Patients were randomly divided into 2 groups: group A received tamsulosin 0.4 mg and group B received tadalafil 10 mg at bedtime for 2 weeks. Stone expulsion rate, number of ureteric colic episodes and pain score, analgesic requirements, and adverse drug effects were noted in both groups. Statistical analyses were performed by using Student t-test and chi-square test.

RESULTS

Altogether 85 patients, 41 in group A and 44 in group B, were enrolled in the study. The patients' average age was 31.72±12.63 years, and the male-to-female ratio was 1.5:1. Demographic profiles, stone size, and baseline investigations were comparable between the 2 groups. The stone expulsion rate was significantly higher in the tadalafil group than in the tamsulosin group (84.1% vs. 61.0%, p=0.017). Although the occurrence of side effects was higher with tadalafil, this difference was not significant (p=0.099). There were no serious adverse effects.

CONCLUSIONS

Tadalafil has a significantly higher stone expulsion rate than tamsulosin when used as a medical expulsive therapy for distal ureteral stones sized 5-10 mm. Both drugs are safe, effective, and well tolerated with minor side effects.

Comparative efficacy of tadalafil versus tamsulosin as the medical expulsive therapy in lower ureteric stone: a prospective randomized trial

Introduction

In recent years, medical expulsive therapy has been used in the management of distal ureteric stones as a supplement to conservative treatment. Therefore, we conducted a prospective randomized study to evaluate the possible role of tadalafil individually in comparison with proven tamsulosin therapy in ureteric stone expulsion.

The aim of this study is to compare the safety and efficacy of a phosphodiesterase-5 inhibitor (tadalafil) and an α-1 blocker (tamsulosin) as medical expulsive therapy for distal ureteric calculi.

Material and methods

Between August 2014 and October 2015, 207 patients who presented with distal ureteric stones of size 5–10 mm were randomly divided into two groups: tadalafil (Group A) and tamsulosin (Group B). Therapy was given for a maximum of 4 weeks. Stone expulsion rate, time to stone expulsion, analgesic use, number of hospital visits for pain, follow-up, endoscopic treatment and adverse effects of drugs were noted. Both groups were compared for normally distributed data by percentage, analysis of variance, and T-test. All the classified and categorical data were analyzed for both groups using the chi-square test.

Results

A statistically significant expulsion rate of 84.0% in Group A compared with 68.0% in Group B (P value = 0.0130), and shorter stone expulsion time in Group A (14.7±3.8) in comparison to Group B (16.8 ±4.5) was observed. Statistically significant differences were noted in renal colic episodes and analgesic requirement in Group A than Group B. No serious adverse effects were noted.

Conclusions

Tadalafil is safe, efficacious, and well tolerated as medical expulsive therapy for distal ureteric stones. This study showed that tadalafil increases ureteric stone expulsion quite significantly along with better control of pain and significantly lower analgesic requirement.

Comparison of silodosin to tamsulosin for medical expulsive treatment of ureteral stones: a systematic review and meta-analysis

This study aimed at comparing the success rates of silodosin to the most commonly used for medical expulsive therapy (MET) tamsulosin for the management of ureteral stones. A systematic review using the search string: "silodosin AND (ston* OR calcu* OR expul*)" was conducted on Pubmed, SCOPUS, Web of Science, Cochrane Central Register. The Primary endpoint was the stone expulsion rate. Secondary endpoint was the time to stone expulsion. Two authors independently screened the studies depending on inclusion and exclusion criteria. Meta-analysis and forest-plot figures were calculated with the software Review Manager (RevMan 5.3.5). Variations were evaluated with the χ ² statistical method and heterogeneity with I ² index. After screening of 39 publications obtained by the initial search, three randomized controlled trials were eligible to be included in the meta-analysis. 407 patients were pooled. Favorable results were observed for silodosin in terms of stone expulsion rates with a risk ratio of 1.33 (95 % CI 1.17-1.50) (I ² = 0 %). Similarly, faster stone expulsion times were observed with silodosin when compared with tamsulosin. Mean difference -2.49 (95 % CI -3.40 to 1.58) (I ² = 89 %). This meta-analysis showed significantly higher stone expulsion rates and faster expulsion times in favor of silodosin when compared to tamsulosin.

The Use of Medical Expulsive Therapy During Pregnancy: A Worldwide Perspective Among Experts

INTRODUCTION

Medical expulsive therapy (MET) is a pharmacologic approach thought to augment the spontaneous passage of ureteral calculi. The usage of MET pharmacologics for presumed ureteral calculi during pregnancy has not been studied and their safety and utility are unknown. We sought to characterize the worldwide usage of MET in the setting of pregnancy with presumed ureteral calculus (P-MET), as well as factors associated with physician use. Experts in stone management were specifically sought.

MATERIALS AND METHODS

A nine-question survey was delivered through society-administered e-mail. Questions gathered physician's worldwide region, degree of specialization in stone disease, practice type, interval since training, and willingness to use both MET and P-MET. We assessed drugs of choice in those using P-MET and reasons for avoidance in non-P-MET users. Finally, we assessed the impact of physician-perceived medicolegal risk on usage of P-MET.

RESULTS

Five hundred sixty-five responses were recorded. Sixty-three percent were US-based practitioners and the remaining represented a worldwide distribution. Worldwide usage of MET was 97.6%, and tamsulosin was globally preferred by over 90% of urologists. P-MET was endorsed by only 44.3%. 23.6% of European practitioners used this strategy compared with 51.1% of US physicians. Time from training and practice type did not significantly interact with adoption of P-MET; experts were less likely to use P-MET. Physician nonuse of MET during pregnancy was adverse outcome related: 76.7% reported either the fear of legal risk (52.8%) or concerns about safety (23.9%).

CONCLUSION

Respondents report impressive worldwide adoption of MET. P-MET is less trusted, and fears of legal risk and safety far outweigh questions about effectiveness. The effectiveness of drugs during pregnancy-induced ureteral dilation is unknown. Still, 44% of global respondents embrace usage of this drug strategy despite a paucity of evidence supporting either safety or effectiveness during pregnancy.

Effects of Alpha-Blockade on Ureteral Peristalsis and Intrapelvic Pressure in an In Vivo Stented Porcine Model

INTRODUCTION

Clinical studies have shown beneficial role of oral alpha-blockers for ureteral stent-related morbidity. However, the in vivo effects of oral alpha-blockers on a stented ureter are unclear. We evaluated the effects of alpha-blockade on ureteral dynamics in a stented porcine ureter.

METHODS

Twenty-seven female pigs were used in this study. Fourteen pigs received oral alpha-blocker medication (silodosin, 8 mg daily), and 13 pigs received no medication. Under cystoscopic guidance, a 5F ureteral catheter was positioned in the renal pelvis and attached to a pressure monitor. A Foley catheter was placed in the bladder along with a bladder pressure transducer. A lumbotomy was performed, and the ureter was identified. A magnetic sensor was placed on the extraluminal surface of the ureter to monitor ureteral peristalsis. We measured renal pelvic and bladder pressures, urine output, and ureteral peristalsis every hour for 10 minutes for a total of 5 hours. The pigs were then euthanized.

RESULTS

The mean weight was 42.5 kg in the drug group and 45.9 kg in the nondrug group (p = 0.008). Mean hourly urine output was 140 mL in the drug group and 144 mL in the nondrug group (p = 0.76). Mean baseline renal pressure was 13.2 and 13.8 mm Hg (p = 0.69) in the drug and nondrug groups, respectively. Mean peristaltic renal pelvic pressure was 19.1 mm Hg in the drug group and 19.2 mm Hg in the nondrug group (p = 0.97). Mean number of peristalsis was 11/10 and 14/10 minutes (p = 0.03) in the drug and nondrug groups, respectively.

CONCLUSIONS

Alpha-blockade in an in vivo stented porcine ureter resulted in no significant effect on renal pelvic pressure but a significant decrease in the number of ureteral peristalsis. Further investigation of the effects of alpha-blocker on ureteral dynamics is required to better understand its effects on stent-related symptoms.

Efficacy and safety of silodosin in the medical expulsion therapy for distal ureteral calculi: a systematic review and meta-analysis

AIMS

Using a selective α-adrenoceptor blocker for medical expulsive therapy (MET) is an effective treatment approach widely used for ureteral stones. The aim of the review was to assess the efficacy and safety of silodosin in medical expulstion therapy compared with placebo and tamsulosin.

METHODS

A systematic search was performed in PubMed, Cochrane Library and Embase to identify randomized controlled trials that compared silodosin with a placebo or tamsulosin for ureteral calculi.

RESULTS

Eight publications involving a total of 1048 patients were used in the analysis, which compared silodosin with placebo and tamsulosin. We found that silodosin was effective in treating ureteral calculi in our meta-analysis and was superior to tamsulosin in its efficacy. The expulsion rate of all ureteral stones (OR 1.59, 95% CI 1.08, 2.36, P = 0.02), the expulsion rate of distal ureteral stones (OR 2.82, 95% CI 1.70, 4.67, P < 0.0001) and the expulsion time (days) of distal ureteral stones (standard mean difference (SMD) -4.71, 95% CI -6.60, -2.83, P < 0.00001) indicated that silodosin was more effective than the placebo. Moreover, expulsion rate (OR 2.54, 95% CI 1.70, 3.78, P < 0.00001), expulsion time (days) (SMD -2.64, 95% CI -3.64, -1.64, P < 0.00001) and pain episodes (P < 0.00001) indicated that silodosin was more effective than the tamsulosin. Even though silodosin had a significant increase in abnormal ejaculation compared with tamsulosin, no significant differences were observed for complications (OR 1.00, 95% CI 0.58, 1.74, P = 1.00).

CONCLUSIONS

This meta-analysis indicated that silodosin was superior to placebo or tamsulosin in the efficacy for distal ureteral calculi with better control of pain. The safety profile of silodosin was similar to tamsulosin though retrograde ejaculation was worse for silodosin use. We conclude that silodosin might have potential as a MET for ureteral stones.

Silodosin vs tamsulosin in the management of distal ureteric stones: A prospective randomised study

OBJECTIVES

To compare the efficacy of silodosin (8 mg) vs tamsulosin (0.4 mg), as a medical expulsive therapy, in the management of distal ureteric stones (DUS) in terms of stone clearance rate and stone expulsion time.

PATIENTS AND METHODS

A prospective randomised study was conducted on 115 patients, aged 21-55 years, who had unilateral DUS of ⩽10 mm. Patients were divided into two groups. Group 1 received silodosin (8 mg) and Group 2 received tamsulosin (0.4 mg) daily for 1 month. The patients were followed-up by ultrasonography, plain abdominal radiograph of the kidneys, ureters and bladder, and computed tomography (in some cases).

RESULTS

There was a significantly higher stone clearance rate of 83% in Group 1 vs 57% in Group 2 (P = 0.007). Group 1 also showed a significant advantage for stone expulsion time and analgesic use. Four patients, two in each group, discontinued the treatment in first few days due to side-effects (orthostatic hypotension). No severe complications were recorded during the treatment period. Retrograde ejaculation was recorded in nine and three patients in Groups 1 and 2, respectively.

CONCLUSION

Our data show that silodosin is more effective than tamsulosin in the management of DUS for stone clearance rates and stone expulsion times. A multicentre study on larger scale is needed to confirm the efficacy and safety of silodosin.

[Diagnosis and treatment of nephrolithiasis. What is established?]

BACKGROUND

Kidney stones are a common and increasing problem worldwide. Nephrolithiasis is frequently a chronic disease given the risk of recurrence following passage of a first stone.

OBJECTIVES

In the present article, an update on the diagnosis and treatment of kidney stones relevant for internal medicine physicians is provided.

METHODS

This review is based on a selective literature search and our own work.

RESULTS AND CONCLUSION

The diagnosis of kidney stones is based on the clinical history and physical examination. Confirmatory radiologic tests include noncontrast computerized tomography or ultrasonography with both techniques having recently been shown to have equivalent overall outcomes. The therapy of kidney stones is based on the clinical presentation and diagnostic findings (e.g., fever, response to pain management, and demonstration of relevant obstruction) as well as location, size, and composition of the stone. If invasive treatment is being considered, the urology department should be consulted. Given the high risk of recurrence, stone analysis must be performed as well as the concentration of lithogenic and litholytic substances measured in a 24-h urine collection. The newly established recurrence of kidney stone nomogram (ROKS nomogram) identifies kidney stone formers at greatest risk for a second symptomatic episode who may benefit from medical intervention.

Naftopidil versus flopropione as medical expulsive therapy for distal ureteral stones: results of a randomized, multicenter, double-blind, controlled trial

PURPOSE

A multicenter, double-blind, randomized, controlled trial was conducted to determine the efficacy of naftopidil as medical expulsive therapy (MET) for patients with distal ureteral stones.

METHODS

Ninety-two patients presenting with a single distal ureteral stone ≤10 mm were randomly assigned to receive either naftopidil (75 mg of naftopidil once in the morning and placebo twice a day) or flopropione (80 mg three times a day). The primary end point was time to stone expulsion calculated by the Kaplan-Meier method. Secondary end points were the percentages of patients who required analgesics, hospital admission, and surgery, the number of working days lost to the disease, and treatment safety.

RESULTS

Overall, three patients were excluded from the final analysis. No significant differences were noted in age, stone size, and stone side between the treatment arms. The median time to stone expulsion was 8 days [95 % confidence interval (CI), 3-16] for the naftopidil group, and this was significantly less than the 18 days (95 % CI, 11 to not reached) for the flopropione group (p = 0.03). On multivariate Cox regression analysis, the hazard of expulsion was 1.8-fold higher for the naftopidil group than for the flopropione group after adjustment for age, sex, stone side, and stone size. No significant differences were noted in the secondary end points.

CONCLUSIONS

The administration of naftopidil significantly improved time to stone expulsion in patients with distal ureteral stones ≤10 mm. We believe that this is the first multicenter, double-blind, randomized, controlled trial demonstrating the efficacy of naftopidil for MET.

Update on medical expulsive therapy for distal ureteral stones: Beyond alpha-blockers

Medical expulsive therapy (MET) has been described as an effective conservative treatment option in the initial management of small distal ureteral stones. Therapies that have been investigated include alpha-blockers, calcium channel blockers, corticosteroids, and most recently phosphodiesterase-5 inhibitors (PDE5) inhibitors. While alpha-blockers are currently the only recommended monotherapy, corticosteroids have received increased attention as a potential useful adjunct in the medical management of distal stones. PDE5 inhibitors are a novel treatment alternative, requiring further investigation. This review provides an overview of recent MET best practices, with a focus on novel therapies beyond alpha-blockers.

Silodosin versus Tamsulosin as Medical Expulsive Therapy for Distal Ureteral Stones: A Prospective Randomized Study

Introduction

The aim of this study was to compare the safety and efficacy of silodosin (8 mg) versus tamsulosin (0.4 mg) as a medical expulsive therapy for distal ureteral stones.

Methods

136 patients (aged 18 years or older) had presented with renal colic, were diagnosed to have a single, unilateral, radiopaque, proximal ureteral stone (range 4–10 mm in size), and agreed to undergo conservative management. For a 3-week period, 68 patients per group were assigned to the following treatments: Group A (gA) received tamsulosin 0.4 mg once daily, and Group B (gB) received silodosin 8 mg once daily. The time to expulsion, analgesic use, follow-up, endoscopic treatment and adverse effects of drugs were noted.

Results

Considering all the patients enrolled (136), one patient in gA and two patients in gB were unable to continue the study because of orthostatic hypotension within a week from commencing the treatment. A total of 133 patients (gA: 67; gB: 66) were included in this study. A stone expulsion rate of 61.2% (41 out of 67 patients) was observed in gA, and 80.3% (53 out of 66) was observed in gB. gB showed a statistically relevant advantage in terms of stone expulsion rate (p: 0.003), as well as in terms of expulsion time (weeks) (p: 0.002). No severe complications were recorded in both groups. Four patients (10.2%; 4/39) in gA and ten patients (22.7%; 10/44) in gB experienced retrograde ejaculation (<0.002).

Conclusion

The patients treated with silodosin showed a significant increase in expulsion rate and a decrease in expulsion time of lower ureteral stones in our study.

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.

Comparative efficacy of tamsulosin versus tamsulosin with tadalafil in combination with prednisolone for the medical expulsive therapy of lower ureteric stones: a randomized trial

PURPOSE

To compare the safety and efficacy of tamsulosin and tamsulosin with the phosphodiesterase-5 inhibitor tadalafil in combination with prednisolone as medical expulsive therapies for lower ureteric stones.

MATERIALS AND METHODS

Between July 2011 and December 2012, 62 adult patients presenting with distal ureteric stones sized 5 to 10 mm were randomized equally to treatment with tamsulosin (group A) or tamsulosin with tadalafil (group B). Therapy was given for a maximum of 6 weeks. In addition, patients in groups A and B were given 5-mg prednisolone once daily (maximum 1 week). The stone expulsion rate, time to stone expulsion, analgesic use, number of hospital visits for pain, follow-up and endoscopic treatment, and adverse effects of the drugs were noted. Statistical analyses were done by using Student t-test and chi-square test.

RESULTS

There was a higher expulsion rate (83.9% in group B and 74.2% in group A) and a lower time to expulsion in both treatment groups than in historical controls used in earlier studies. However, these results were not statistically significant (p=0.349, p=0.074, respectively). Statistically significant differences were noted in hospitalization for colic and analgesic requirement, which were less in group B than in group A. There were no serious adverse events. Another important finding was improvement in erectile function in group B.

CONCLUSIONS

Medical expulsive therapy for distal ureteric stones using tamsulosin and tadalafil with prednisolone is safe and efficacious. Also, the prescription of tadalafil in cases of erectile dysfunction with the development of lower ureteric stones may provide additional advantages.

Therapeutic approaches for renal colic in the emergency department: a review article

Context:

Renal colic is frequently described as the worst pain ever experienced, and management of this intense pain is necessary. The object of our review was to discuss different approaches of pain control for patients with acute renal colic in the emergency department.

Evidence Acquisition:

Studies that discussed the treatment of renal colic pain were included in this review. We collected articles from reputable internet databases.

Results:

Our study showed that some new treatment approaches, such as the use of lidocaine or nerve blocks, can be used to control the severe and persistent pain of renal colic.

Conclusions:

Some new approaches are discussed and their impact on renal colic pain control was compared with traditional therapies. The effectiveness of the new approaches in this review is similar or even better than in traditional treatments.

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.

Efficacy of alfuzosin after shock wave lithotripsy for the treatment of ureteral calculi

PURPOSE

We evaluated the efficacy of alfuzosin for the treatment of ureteral calculi less than 10 mm in diameter after extracorporeal shock wave lithotripsy (ESWL).

MATERIALS AND METHODS

A randomized, single-blind clinical trial was performed prospectively by one physician between June 2010 and August 2011. A total of 84 patients with ureteral calculi 5 to 10 mm in diameter were divided into two groups. Alfuzosin 10 mg (once daily) and loxoprofen sodium 68.1 mg (as needed) were prescribed to group 1 (n=41), and loxoprofen sodium 68.1 mg (as needed) only was prescribed to group 2 (n=44). The drug administration began immediately after ESWL and continued until stone expulsion was confirmed up to a maximum of 42 days after the procedure.

RESULTS

Thirty-nine of 41 (95.1%) patients in group 1 and 40 of 43 (93.0%) patients in group 2 ultimately passed stones (p=0.96). The number of ESWL sessions was 1.34±0.65 and 1.41±0.85 in groups 1 and 2, respectively (p=0.33). The patients who required analgesics after ESWL were 8 (19.5%) in group 1 and 13 (30.2%) in group 2 (p=0.31). Visual analogue scale pain severity scores were 5.33±1.22 and 6.43±1.36 in groups 1 and 2, respectively (p=0.056). The time to stone expulsion in groups 1 and 2 was 9.5±4.8 days and 14.7±9.8 days, respectively (p=0.005). No significant adverse effects occurred.

CONCLUSIONS

The use of alfuzosin in combination with ESWL seems to facilitate stone passage and to reduce the time of stone expulsion but does not affect the stone-free rate.

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.

Cats and calcium oxalate: strategies for managing lower and upper tract stone disease

PRACTICAL RELEVANCE

Calcium oxalate (CaOx) containing stones are among the most common of the urinary tract stones identified in cats.

RISK FACTORS

Risk factors for CaOx stone formation include such things as breed, gender and diet; stress and obesity have also been hypothesized to be risk factors for this disease.

MANAGEMENT APPROACH

A tailored, individual management strategy for preventing CaOx stone recurrence is important and should include addressing the diet, environment and any other comorbid conditions present. Increasing the cat's moisture intake is one of the key mechanisms for preventing recurrence.

CLINICAL CHALLENGES

CaOx ureterolithiasis has emerged as a difficult and sometimes life-threatening problem for cats. In those cats where stones are found incidentally, periodic monitoring may be required to assess for disease progression. Interventional procedures such as ureteral stent placements are now increasingly being performed for recurrent cases or those with larger stone burdens. Periodic radiographs for more severe cases and frequent client communication can help ensure successful outcomes for cats with lower and upper CaOx stone disease.

EVIDENCE BASE

Limited evidence-based studies are published regarding management of feline upper and lower urinary tract CaOx stone disease, making this a difficult condition to manage in some cats. Studies designed to evaluate the relationship to dietary modifications, medical management, stress, obesity and surgical techniques are warranted in cats with upper and lower urinary tract CaOx stones.

Medical expulsive therapy using alfuzosin for patient presenting with ureteral stone less than 10mm: a prospective randomized controlled trial

OBJECTIVES

To assess the spontaneous passage rate for patients being treated with alfuzosin 10mg daily after presenting with an acute ureteral stone compared with a control group, and to assess the respective pain control status.

METHODS

This was a prospective randomized controlled trial. Patients presenting with an acute ureteral stone (size 5-10mm) were enrolled and randomized into a medical expulsive therapy (MET) group or control group. The MET group received alfuzosin slow release (SR) 10mg daily for 4weeks and dologesic (paracetamol+dextropropoxyphene, four tablets daily on demand) for 2weeks. The control group received the same analgesics for 2weeks only. Diclofenac sodium SR 100mg daily for 2weeks was added in case of suboptimal pain control. All the patients were assessed through phone interview at week 2 and with kidney-ureter-bladder X-ray at week 5 to check for any evidence of stone passage.

RESULTS

A total of 67 patients were included in the analysis. The overall spontaneous passage rate was increased by 31.8% with MET (P=0.006). For an upper ureteral stone, the rate was increased by 51.3% (P=0.01). The MET group used significantly less dicolofenac sodium (1.5 tablets vs 6.7 tablets, P=0.031).

CONCLUSIONS

MET using alfuzosin SR 10mg daily is effective to enhance the ureteral stone spontaneous passage rate, particularly for upper ureteral stones. Fewer analgesic drugs are consumed and more patients can avoid ureteroscopic lithotripsy and/or extracorporeal shock wave lithotripsy.

Meta-analysis showing the beneficial effect of α-blockers on ureteric stent discomfort

What's known on the subject? and What does the study add? Ureteric stents cause significant discomfort and this is probably related to ureteric smooth muscle spasm and trigonal irritation. Alpha-adrenoceptor antagonists reduce smooth muscle activity and are already widely used in medical expulsive therapy to aid passage of ureteric calculi. This meta-analysis incorporating five randomized controlled trials provides evidence that alpha-adrenoceptor antagonists reduce stent-related pain and storage symptoms as assessed by the Ureteric Stent Symptoms Questionnaire (USSQ).

OBJECTIVES

• To evaluate the efficacy of α-blockers with respect to improving stent-related symptoms. • Ureteric stents remain a source of marked discomfort and their placement is often required after certain ureteroscopic procedures or in the acute setting. This analysis identifies and reviews the several studies that have investigated the role of α-blockers after stent placement.

MATERIALS AND METHODS

• Pubmed/Medline, EMBASE, CINAHL and Cochrane Library databases were scrutinized using standard MeSH headings. • Randomized or controlled trials comparing α-blockers with control or standard therapy were included. • In all studies, patients completed the Ureteral Stent Symptom Questionnaire (USSQ). • The study data were independently reviewed by two assessors.

RESULTS

• In total, five studies of varying quality were identified, including 461 patients receiving either tamsulosin or alfuzosin, or control. • On meta-analysis, all five studies showed a reduction in USSQ urinary symptom score and body pain scores. There was mean reduction of 8.4 (95% CI, 5.6-11.1) in the urinary symptom score and 7.2 (95% CI, 2.5-11.8) in the body pain score. • In three studies, the numbers of patients experiencing stent related pain were stated: 45% (51/114) of patients receiving an α-blocker experienced painful episodes within the follow-up period defined for that study compared to 76% (88/116) in the control groups, which is equivalent to a relative risk of pain of 0.59 (95% confidence interval, 0.47-0.71). • There were also reductions in other aspects of the USSQ, such as the general health score and sexual matters score, although these were not statistically significant or uniformly reported.

CONCLUSION

• There is evidence that α-blockers provide an improvement in discomfort after placement of a ureteric stent.

α(1)-Adrenoceptors in the urinary tract

α(1)-Adrenoceptors have been identified and characterized extensively by functional, radioligand-binding, and molecular biological techniques. Molecular clones have been isolated for three α(1)-subtypes (α(1a), α(1b), and α(1d)), and these subtypes are also functionally characterized. α(1)-Adrenoceptors are present in the prostate, urethra, bladder (urothelium, smooth muscle, and afferent nerves), ureter, vas deferens, peripheral ganglia, nerve terminals, vascular tissues, and central nervous system (CNS), and they could all potentially influence overall urinary function and contribute to both the therapeutic and adverse effects of α(1)-adrenoceptor antagonists in patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). This review aimed to discuss the relevant physiological and pharmacological roles and molecular biology of α(1)-adrenoceptor subtypes in the prostate, urethra, bladder, ureter, and CNS.