Medical Expulsive Therapy

Causes and management of urinary system problems in children on long-term home invasive mechanical ventilation

Many ventilator-dependent children have comorbid conditions including urinary tract disorders. We aimed to present a focused review of the literature describing the causes and management of urinary system problems in children with long-term home mechanical ventilation. We performed a literature search in PubMed/MEDLINE, Scopus, and Web of Science with keywords "children," "home mechanical ventilation," "urinary system," "urinary tract," "neurogenic bladder," "clean intermittent catheterization," "urinary tract infection," "urolithiasis," and "acute kidney injury." We included original articles, reviews, guidelines, and case reports published in English. Ventilator-dependent children may have neurogenic bladder/bowel dysfunction which renders them prone to urinary tract infection, high bladder pressure, vesicoureteral reflux, hydronephrosis, and renal dysfunction. These children require bladder catheterization, medications affecting parasympathetic/sympathetic nervous systems, or surgical procedures to prevent urinary infections, and to maintain continence and renal functions. However, bladder catheterization or surgical procedures like augmentation cystoplasty may also be complicated with urinary infections, urolithiasis, or urethral strictures. Urolithiasis frequency is also increased due to immobilization-related hypercalciuria, hypocitraturia caused by antiepileptic drugs, urinary stasis, and urinary infections. On the other hand, mechanical ventilation can impair renal function by reduction of cardiac output, redistribution of intrarenal blood flow and stimulation of sympathetic and hormonal pathways. Children requiring long-term invasive home mechanical ventilation may have other comorbid conditions, including urinary system diseases, which become manifest as these patients are being kept alive due to the advances in ventilation strategies. These children must be carefully observed for urological complications and managed accordingly to prevent kidney injury.

Role of Posterior Acoustic Shadow Width in Ultrasound in Determining Stone Size in Urolithiasis

Introduction Ultrasound (US) is frequently the initial diagnostic tool for urolithiasis, though computed tomography (CT) remains the imaging modality of choice. However, due to potential overestimations, the accuracy of US in gauging stone size has been a point of contention. This study aims to compare the accuracy of stone size measurements in US, specifically evaluating the utility of the posterior acoustic shadow (PAS) width, against the CT measurements. Methods We conducted a cross-sectional study where 120 adult patients (aged >18 years) with confirmed urolithiasis through CT participated. Stone sizes were assessed via both CT and US, with the PAS width also being measured in the latter. Statistical analysis compared stone size discrepancies between both CT and US measurement techniques. Results The study enrolled 73 males and 47 females with various stone locations. The average stone sizes were 15.93 ± 4.59 mm (CT), 18.60 ± 4.80 mm (US), and 16.69 ± 4.61 mm (PAS width). There was a mean difference of 2.67 mm (p < 0.0001) between CT and US sizes, whereas the difference between the PAS width and CT sizes was only 0.75 mm (p = 0.203). Stone size miscalculation by US was 16.77%, whereas it was only 4.77% for PAS width. Conclusion US tends to significantly overestimate stone size when compared to CT. Conversely, the measurement of the PAS width in US presents a more aligned estimation to CT outputs. Integrating PAS width into routine US reporting can enhance the accuracy of stone size estimation, optimizing urolithiasis management and patient counseling.

Intradermal sterile water injection versus diclofenac sodium in acute renal colic pain: A randomized controlled trial

OBJECTIVES

We aimed to evaluate the efficacy of intracutaneous sterile water injection (ISWI) to relieve the pain of acute renal colic compared with diclofenac and placebo.

METHODS

The study included 150 patients presented to the Emergency Department with renal colic randomized into 3 groups: control group received intracutaneous injections of 0.5 cm³ isotonic saline in the flank, group A received intracutaneous injections of 0.5 cm³ ISWI in the flank, and group B received an intramuscular injection of 75 mg Diclofenac in the gluteal region. The severity of the pain was assessed by a visual analogue scale system at baseline and 30, 45 min, and 60 min after injections. Subjects with inadequate pain relief at 1 h received rescue analgesia.

RESULTS

The mean baseline pain score was 9.6 ± 0.61 in the ISWI group, 9.72 ± 0.64 in the diclofenac group and 9.26 ± 0.89 in the control group. The mean pain score at 30 min of the control group was reduced to 6.9 ± 1.56. This mean at 30 min after ISWI and diclofenac injections were reduced to 1.98 ± 1.41 and 1.88 ± 1.19 respectively. The mean of pain sore of the ISWI and diclofenac group at 45 and 60 min was constant. Rescue analgesics at 1 h were required by 47 patients receiving the saline injection and by 4 patients and by 7 patients receiving ISWI and diclofenac injection respectively.

CONCLUSIONS

ISWI and diclofenac were equally effective for the pain relief of acute renal colic.

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.

Kidney stones: painful and common--but preventable

Kidney stones are among the more common and painful urological disorders, affecting approximately 10% of Americans. While most stones pass spontaneously, obstructions result in renal colic, often requiring aggressive management of pain. If obstructions persist, extracorporeal shockwave lithotripsy, ureteroscopy, or percutaneous nephrolithotomy may be required for a stone's removal. Recurrence rates are high, and prevention includes increased fluid intake, dietary restrictions, and the use of pharmacotherapy. Stone recurrence increases with age, underscoring the importance of prevention for those 60 years of age and older.

Efficacy of selective alpha1D-blocker naftopidil as medical expulsive therapy for distal ureteral stones

PURPOSE

Naftopidil is a specific alpha1D-adrenergic receptor antagonist. We performed the current randomized, controlled study to determine the expulsive role of naftopidil for distal ureteral stones.

MATERIALS AND METHODS

From March 2006 to January 2007, 60 patients with distal ureteral stones were randomly divided into groups 1 and 2. Group 1 served as the control and underwent watchful waiting, while group 2 received 50 mg naftopidil daily in the morning. All patients were instructed to drink a minimum of 2 l water daily. The stone expulsion rate and time, potential side effects of naftopidil, number of pain episodes and requirements for pain medication were documented during the 14-day followup.

RESULTS

All patients in groups 1 and 2 completed the study. There was no difference between the groups in patient age, sex and stone size. The stone expulsion rate was significantly higher in group 2 than in group 1 (90.0% vs 26.7%, p <0.01). No significant difference in expulsion time was noted between the groups. No patients experienced obvious naftopidil side effects or ureteral colic. Multivariate analysis using a Cox proportional hazards model indicated that the probability of expulsion was increased 5.263 times (95% CI 2.304-12.024) in group 2 compared with that in group 1 (p <0.001).

CONCLUSIONS

The selective alpha1D-blocker naftopidil can significantly facilitate spontaneous passage of distal ureteral stones with few side effects, providing a new choice for medical expulsive therapy.