Medical Expulsive Therapy for Ureteral Calculi in the Real World: Targeted Education Increases Use and Improves Patient Outcome

Standardization of the management of pediatric urolithiasis in the emergency department

INTRODUCTION

The incidence of urolithiasis in the pediatric population is rising and medical expulsive therapy (MET) using alpha-adrenergic antagonists has been found to be effective in aiding in the passage of ureteral stones in children. A prior review of patients presenting to our quaternary children's hospital with urolithiasis found only 54 % were prescribed MET and these patients had increased rates of spontaneous stone passage. Thus, an ED urolithiasis management protocol was created to standardize evaluation and care of children with suspected urolithiasis.

OBJECTIVE

To compare management of children with urolithiasis presenting to the ED before and after urolithiasis management protocol implementation.

METHODS

This is a retrospective review of patients with urolithiasis who presented to our children's ED from 2011 to 2022. The primary outcome was rate of MET prescribing before and after pathway implementation in July 2017, thus the pre-implementation group comprises patients who presented to the ED from July 2011 to July 2017, and the post-protocol group includes those who presented from August 2017 to April 2022. Secondary outcomes included CT utilization in the ED, surgical intervention rate, proportion with spontaneous stone passage, and frequency of urology consultation. Two-sample t-test and Fisher's exact test were used to compare the outcomes of interest before and after protocol implementation.

RESULTS

Of 337 patients who presented to the ED after protocol implementation, 120 met inclusion criteria. When comparing outcomes before and after implementation of the protocol, there was significantly decreased use of CT scans (79 % vs 50 %, p < 0.0001) and increased prescribing of MET (54 % vs 82 %, p < 0.0001). There was a significant decrease in opioids prescribed (44 % vs 26.7 %, p = 0.0040), and an increased rate of spontaneous stone passage (34 % vs 46 %, p = 0.0483). Lastly, there was a significant reduction in the rate of surgery for stone management after the implementation of protocol (35 % vs 17 %, p = 0.0020) DISCUSSION: As the ED is the primary site of presentation for many children with urolithiasis, standardization of evaluation and management provides an opportunity to improve outcomes in this population. We found that implementation of an ED urolithiasis management protocol was associated with decreased use of CT scans, decreased opioid prescribing, increased spontaneous stone passage, and decreased rate of surgical management for children with ureteral stones.

CONCLUSIONS

This study demonstrates the positive impact of standardizing care for children presenting to the ED with urolithiasis.

Can serum procalcitonin levels be useful in predicting spontaneous ureteral stone passage?

Background

Medical expulsive therapy (MET) is recommended for ureteral stones when there is no indication for interventional treatment. Spontaneous passage (SP) may not always be perceived in patients undergoing MET. We aimed to demonstrate the effects of inflammatory factors on spontaneous ureteral stone passage in patients undergoing MET.

Methods

Our study was conducted between August and November, 2016, in healthy volunteers and patients with a single distal ureteral stone between 5 and 10 mm in diameter and no indications for interventional therapy. Blood and urine samples from all patients and healthy volunteers were tested. The patients were followed up every 2 weeks for 1 month unless emergency situations appeared. Patients with stone-free status at follow-up were concluded to have achieved complete stone passage [SP(+)], and failure [SP(−)] was concluded if the patient had not passed the stone by the end of the study. Blood samples of the patients and the control group were analyzed, recording WBC (white blood cell), CRP (c-reactive protein), SED (sedimentation), MPV (mean platelet volume), NLR (neutrophil-to-lymphocyte ratio), and serum procalcitonin levels. Abnormalities in urine samples were recorded. All patients received diclofenac sodium 75 mg/day, tamsulosin 0.4 mg/day, and at least 3 l/day fluid intake. Patients were followed for a month with kidney, ureter, bladder (KUB) plain films, ultrasonography (USG), and unenhanced abdominal CT scans while undergoing MET. Comparative statistical analyses were performed between the SP(+) and SP(−) groups.

Results

The procalcitonin levels of the SP(−) group were significantly higher (207 ± 145.1 pg/ml) than in the SP(+) group (132.7 ± 28.1 pg/ml) (p = 0.000). The leucocyturia rate of the SP(−) group was significantly higher than in the SP(+) group (p = 0.004). Based on the ROC curve analysis, 160 pg/ml (86.7% sensitivity, 70.8% specificity, p < 0.001; AUC: 0.788 95% CI (0.658–0.917) was identified as the optimal cut-off value for procalcitonin. In logistic regression analysis, a significant efficacy of procalcitonin and leucocyturia was observed in the univariate analysis on spontaneous passage. In the multivariate analysis, significant independent activity was observed with procalcitonin. (p < 0.05).

Conclusion

Our findings suggest that high procalcitonin levels and the presence of leucocyturia have a strong negative effect on SP of ureteral stones between 5 and 10 mm in diameter. This relationship can be explained by stone impaction, possibly caused by increased mucosal inflammation.

Analysis of Patients with Urolithiasis Visiting the Emergency Department between 2014 and 2016 in Korea: Data from the National Emergency Department Information System

This study investigated the characteristics of patients with urolithiasis visiting an emergency department based on a national database system in Korea. This study spanned a period of three years from January 1, 2014 to December 31, 2016. A retrospective census was conducted using the National Emergency Department Information System for urolithiasis patients. Patient data, including age, sex, insurance type, emergency department visit date and time, discharge date and time, emergency department treatment result, visit flow, and hospitalization route, were extracted and analyzed. Overall, 103,981, 112,083, and 120,647 patients/year during the 2014-2016 study period visited an emergency department with a diagnosis related to urolithiasis. Total monthly emergency department visits ranged from 35,927 in August (highest) to 24,008 in February. Overall, 13.2% of patients were hospitalized and the hospitalization rate was stable (estimated annual percent change) over the study period. Patients aged <9 years or ≥70 years and those with medical aid had higher hospitalization rates. A higher number of visits occurred in the hot season, on weekends, and in the 6 a.m. and 8 p.m. time slots. This nationwide study revealed that the percentage of patients visiting an emergency department with urolithiasis was higher in August, in the early morning, and at weekends.

Meta-analysis of the efficacy of sexual intercourse for distal ureteric stones

OBJECTIVE

This meta-analysis was performed to evaluate the efficacy of sexual intercourse for treatment of distal ureteral stones.

METHODS

Randomized controlled trials (RCTs) of sexual intercourse for treatment of distal ureteral stones were searched using PubMed, EMBASE, and the Cochrane Controlled Trials Register.

RESULTS

Three RCTs comprising 240 patients were included in the meta-analysis, which showed that sexual intercourse was effective in treating distal ureteral stones. The expulsion rate of distal ureteral stones at the second week (odds ratio [OR] = 6.61, 95% confidence interval [CI]: 3.66 to 11.94), expulsion rate of distal ureteral stones at the fourth week (OR = 4.00, 95% CI: 2.09 to 7.64), and number of analgesic injections (mean difference [MD] = -0.79, 95% CI: -1.51 to -0.08) indicated that sexual intercourse was more effective than placebo. However, the mean expulsion time of distal ureteral stones (MD = -3.98, 95% CI: -8.77 to 0.81) showed no difference between sexual intercourse and placebo.

CONCLUSIONS

Compared with placebo, sexual intercourse exhibited greater efficacy for the treatment of distal ureteral stones, whilst potentially alleviating pain.

Beyond medical expulsive therapy: evolution to supported stone passage for ureteric stones

OBJECTIVE

To evaluate the impact of removing tamsulosin from standardized ureteric stone clinical protocols on rate of stone surgery.

PARTICIPANTS AND METHODS

We conducted a single-centre, comparison of all patients with unilateral, <1 cm ureteric stones presenting to a stone clinic after discharge from the emergency department during consecutive years. In the initial year, patients were initially offered medical expulsive therapy (MET) with tamsulosin. In the subsequent year, the protocol was modified to focus on symptom control without tamsulosin; this was termed 'supported stone passage' (SSP). The primary outcome was rate of stone surgery within 90 days of the initial clinic encounter.

RESULTS

Among 723 patients (360 MET, 363 SSP), the rate of attempted stone passage increased from 65% to 74%, between the initial and the subsequent year (P < 0.016). Tamsulosin prescription in patients to attempting stone passage decreased from 84% to 13% (P < 0.001). In patients attempting stone passage, the rate of stone surgery was 26% in the METand 19% in the SSP group (P = 0.066). The overall surgery rate decreased from 51% in the MET group to 40% in the SSP group (P = 0.003). Multivariable analysis, controlling for age, sex and stone burden, did not demonstrate a difference in either rate of attempting to pass stones or in rate of failure of passage according to care protocol. We were unable to demonstrate an independent effect of tamsulosin on failure of passage. Overall, surgical intervention was less likely in the SSP phase than in the MET phase, with an odds ratio of 0.64 (confidence interval) 0.44-0.91; P = 0.013).

CONCLUSIONS

Removing tamsulosin from clinical protocols did not impair stone passage in patients attempting to pass stones.

Sexual intercourse as a new option in the medical expulsive therapy of distal ureteral stones in males: a prospective, randomized, controlled study

PURPOSE

To investigate the effect of sexual intercourse on the spontaneous passage of distal ureteral stones 5-10 mm in size.

METHODS

A total of 190 male patients with distal ureteral stones were randomly divided into three groups. Patients in group 1 were administered tamsulosin 0.4 mg/day (n = 60). Patients in group 2 were asked to have sexual intercourse at least three times a week (n = 66). Patients in group 3 received standard medical therapy alone and acted as the controls (n = 64). The expulsion rate was controlled after 2 and 4 weeks. Differences between the groups were analyzed statistically by the Chi-square and Student's t test. p < 0.05 was considered as statistically significant.

RESULTS

The mean ages of the patients in groups 1, 2, and 3 were 34.4 ± 13.5 (18-60), 38.6 ± 14.1 (18-63), and 36.92 ± 12.4 (18-59) years, respectively (p > 0.05). The mean stone size was 7.09 ± 1.4 mm in group 1, 7.01 ± 1.4 mm in group 2, and 7.1 ± 1.3 mm in group 3 (p > 0.05). Spontaneous passage rates in groups 1, 2, and 3 were 81.6, 81.8, and 51.5%, respectively, and it was significantly higher in group 1 (p = 0.0394) and group 2 (p = 0.0350). There was no significant difference between groups 1 and 2 (p = 0.9925). The analgesic needs in groups 1, 2, and 3 were found to be 1.3 ± 0.4, 1.2 ± 0.6, and 1.4 ± 0.4 times, respectively, and were significantly lower in the sexual intercourse group than in the control group (p = 0.0276).

CONCLUSIONS

Tamsulosin and sexual intercourse increase the spontaneous passage of distal ureteral stones 5-10 mm in size. At least three sexual intercourses per week seem to be at least as effective as tamsulosin. Sexual intercourse also reduces the need for analgesics in ureteric colic due to ureteral stones.

Medical expulsive therapy

The objective of this review article is to present the current literature on medical expulsive therapy (MET) and help guide practitioners in the appropriate use of MET for treatment of stone disease. Kidney stones can be treated with multiple modalities including medical therapy, ureteroscopy, shock wave lithotripsy (SWL), percutaneous nephrostolithotomy, open/laparoscopic stone removal, and/or combinations of these modalities. The choice of intervention depends on patient factors, anatomical considerations, surgeon preference, and stone location and characteristics. MET is an excellent treatment modality in the appropriately selected patient. The AUA/EAU guidelines suggest MET as a reasonable treatment choice in select patients. A review of the data suggests the use of alpha antagonist and calcium channel blockers can improve stone expulsion rates. Most data suggests alpha antagonists as superior to calcium channel blockers. There are numerous available alpha antagonists, all of which have supporting data for their use in MET. Evidence suggests that MET can decrease colic events, narcotic use, and hospital visits. MET may also reduce medical costs and prevent unnecessary surgeries and the associated risks. Further, there is a role for alpha antagonists and calcium channel blockers in improving stone passage and decreasing pain in those subjects treated with other modalities (i.e. SWL and ureteroscopy). Despite this evidence, MET remains underutilized as a treatment modality.

Emergency department visits in the United States for upper urinary tract stones: trends in hospitalization and charges

PURPOSE

Using the Nationwide Emergency Department Sample (NEDS) we examined trends in visits, hospitalization and charges for patients with upper urinary tract stones who presented to the emergency department in the United States.

MATERIALS AND METHODS

All visits with a primary diagnosis of kidney calculus (ICD-9-CM code 592.0), ureter calculus (592.1) or urinary calculus unspecified (592.9) were extracted from NEDS between 2006 and 2009. A weighted sample was used to calculate incidence rates. Temporal trends were quantified by the estimated annual percent change. Patient and hospital characteristics associated with hospitalization were evaluated using logistic regression models adjusted for clustering.

RESULTS

Between 2006 and 2009 there were 3,635,054 emergency department visits for upper urinary tract stones. The incidence increased from 289 to 306/100,000 individuals. More men visited than women but women showed significant increases in visits (estimated annual percent change 2.85%, p = 0.018). Total monthly emergency department visits ranged from 5.8% in February to 8.4% in August. Overall 12.0% of patients were hospitalized and the hospitalization rate remained stable (estimated annual percent change -1.02%, p = 0.634). Patients were more likely to be hospitalized if they were female, more ill, seen at an urban teaching or low volume hospital, or had Medicaid or Medicare (each p <0.001). Sepsis was associated with the highest likelihood of hospital admission (OR 69.64, p <0.001). In 2009 charges for emergency department visits increased to $5 billion (estimated annual percent change 10.06%, p = 0.003).

CONCLUSIONS

Women showed significant annual increases in emergency department visits for upper urinary tract stones. While emergency department charges increased substantially, hospitalization rates remained stable. Greater use of computerized tomography and medical expulsive therapy could be the reasons for this observation, which warrants further study.

Medical expulsive therapy versus early endoscopic stone removal for acute renal colic: an instrumental variable analysis

PURPOSE

The use of medical expulsive therapy to hasten stone passage potentially decreases expenditures around episodes of renal colic. However, these efficiency gains may be mitigated if patients treated with medical expulsive therapy have frequent health care encounters due to pain while waiting for the stones to pass.

MATERIALS AND METHODS

Using claims data (2002 to 2006) we identified adult men with acute renal colic. We compared 6-week payments as well as frequency of hospitalization and emergency department revisits associated with an initial course of medical expulsive therapy with those for early endoscopic stone removal. To account for unmeasured confounding we performed an instrumental variable analysis, exploiting variation in recommended treatments based on the day of the week that a patient's first emergency department visit occurred.

RESULTS

Overall 1,835 and 4,397 men underwent medical expulsive therapy or early endoscopic stone removal, respectively. Although minimal differences existed between men with respect to the day of the week of emergency department presentation, weekend encounters were strongly associated with receiving medical expulsive therapy (p <0.001). Two-stage least squares regression revealed 6-week payments to be tenfold lower for men on medical expulsive therapy who were candidates for either treatment (p <0.001). While there was no difference in frequency of hospitalization, these men were more likely to have a repeat emergency department visit compared to those who underwent endoscopic stone removal (68.8% vs 39.6%, respectively, p = 0.025).

CONCLUSIONS

Findings on medical expulsive therapy are mixed, with lower 6-week payments but more frequent repeat emergency department visits. These data inform patients who are candidates for medical expulsive therapy or endoscopic stone removal when making decisions about their care.

Emergency department visits, use of imaging, and drugs for urolithiasis have increased in the United States

The occurrence of urolithiasis in the United States has increased; however, information on long-term trends, including recurrence rates, is lacking. Here we describe national trends in rates of emergency department visits, use of imaging, and drug treatment, primarily using the National Hospital Ambulatory Medical Care Survey to describe trends and the National Health and Nutrition Examination Survey to determine the frequency of lifetime passage of kidney stones. Emergency department visit rates for urolithiasis increased from 178 to 340 visits per 100,000 individuals from 1992 to 2009. Increases in visit rates were greater in women, Caucasians, and in those aged 25-44 years. The use of computed tomography in urolithiasis patients more than tripled, from 21 to 71%. Medical expulsive therapy was used in 14% of the patients with a urolithiasis diagnosis in 2007-2009. Among National Health and Nutrition Examination Survey participants who reported a history of kidney stones, 22.4% had passed three or more stones. Hence, emergency department urolithiasis visit rates have increased significantly, as has the use of computed tomography in the United States. Further research is necessary to determine whether recurrent stone formers receive unnecessary radiation exposure during diagnostic evaluation in the emergency department and allow development of corresponding evidence-based guidelines.