Intensive medical management of ureteral calculi

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 We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials.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 We sent letters to investigators to request information about unpublished or incomplete studies.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).

POSSIBILITIES TO IMPROVE THE THERAPY OF THE PATIENTS WITH URETERAL CONCRETIONS

The aim of the given study was to improve the results of treatment of patients with concretions of the upper third of the ureter. Materials and methods. The clinical trial was carried out as a non-interventional open, controlled, in two groups of patients with baseline control. The inclusion criteria concerned the patients with concretions of the upper third of the ureter 0.7-0.9 mm in size, which had one session of an extracorporeal shock-wave lithotripsy (ESWL), and after the procedure the size of the concretions fragments was up to3 mm. The study involved 60 patients, all patients in the main group (n = 30) were treated using phytotherapy, within 1 month starting with basic therapy under hospital conditions and continuing with preventative treatment in an outpatient setting. The control group (n = 30) received baseline therapy (up to 10 days) at the stationary stage. Results and discussion. In patients of the main group, fragments of concretions came out significantly faster, namely: in the main group, the fragments came out in 21 patients (70.0 %), while in the control group in 15 patients (50.0 %) (p1- p2, p <0.05) to the 7th day, and in the main group, the fragments came out in one patient more than 14 days, and in the control group – in 5 patients, p <0.05. The "stone path" in the bottom third of the ureter was in 1 patient (3.3 %) of the main group and in 3 patients (10.0 %) in the control group (p1-p2, p <0.05). The "stone path" departure time in patients of the main group was 2 days, and in patients of the control group it was 4.1 days from the time of its formation (p1-p2, p <0.05). Bacteriuria was observed in the main group on the 10th day 6.6 % less relative to the control group. Conclusion. At comparing the obtained results in patients of both groups in 1 month it was noted that high efficacy of the treatment was registered in 6 (20 %) patients of the main group and in 3 patients (10 %) of the control group (p <0.05), moderate efficiency was registered in 23 (76.7 %) patients of the main group and in 22 (73.3 %) patients of the control group respectively, low efficacy was registered in 1 (3.33 %) patient in the main group and 5 (16.7 %) patients of the control group (p <0,05), which points to the effectiveness of Urolesan capsules use in complex therapy of patients with concretions of the one third of ureter.

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.

Impact of colic pain as a significant factor for predicting the stone free rate of one-session shock wave lithotripsy for treating ureter stones: a Bayesian logistic regression model analysis

Purpose

This study was conducted to evaluate colic pain as a prognostic pretreatment factor that can influence ureter stone clearance and to estimate the probability of stone-free status in shock wave lithotripsy (SWL) patients with a ureter stone.

Materials and Methods

We retrospectively reviewed the medical records of 1,418 patients who underwent their first SWL between 2005 and 2013. Among these patients, 551 had a ureter stone measuring 4–20 mm and were thus eligible for our analyses. The colic pain as the chief complaint was defined as either subjective flank pain during history taking and physical examination. Propensity-scores for established for colic pain was calculated for each patient using multivariate logistic regression based upon the following covariates: age, maximal stone length (MSL), and mean stone density (MSD). Each factor was evaluated as predictor for stone-free status by Bayesian and non-Bayesian logistic regression model.

Results

After propensity-score matching, 217 patients were extracted in each group from the total patient cohort. There were no statistical differences in variables used in propensity- score matching. One-session success and stone-free rate were also higher in the painful group (73.7% and 71.0%, respectively) than in the painless group (63.6% and 60.4%, respectively). In multivariate non-Bayesian and Bayesian logistic regression models, a painful stone, shorter MSL, and lower MSD were significant factors for one-session stone-free status in patients who underwent SWL.

Conclusions

Colic pain in patients with ureter calculi was one of the significant predicting factors including MSL and MSD for one-session stone-free status of SWL.

Efficacy of nifedipine and alfuzosin in the management of distal ureteric stones: A randomized, controlled study

INTRODUCTION

Stone disease is a significant and world-wide health problem. Recently, certain drugs have been used as a supplement to observation alone in an effort to improve spontaneous stone expulsion. We evaluated the efficacy of nifedipine and alfuzosin in the medical treatment of symptomatic, uncomplicated distal ureteral stones.

MATERIALS AND METHODS

This was a randomized controlled prospective study to determine the efficacy of alfuzosin and nifedipine as an adjunctive medical therapy, to increases the stone-expulsion rates in distal ureteric calculus of size ≤10 mm. Investigators and patients were blinded to the randomization scheme. Patients were randomly divided into three equal groups of 35 patients each. Patients in Group I received tablet nifedipine 30 mg/day, Group II received alfuzosin 10 mg/day and Group III was the control group received tablet diclofenac sodium. The patient blood pressure, stone position on imaging, number of pain attacks, time of stone-expulsion, hospital re-admission and any adverse events were assessed. Patients were followed-up weekly and continued until the patient was rendered stone free or up to 28 days. Statistical analysis was performed and P < 0.05 was considered to be significant.

RESULTS

Stone-expulsion was observed in 60%, 85.7% and 20% patients in Group I, II and III respectively. A statistically significant difference was noted in between Groups I versus III, Groups II versus III and Groups I versus II (P < 0.0001, P < 0.0001, and P < 0.0315 respectively). The mean number of pain attacks was 2.91 ± 1.01 for Group I, 1.8 ± 0.83 for Group II, and 2.82 ± 1.12 for Group III, which is statistical significant in Groups II versus III, and Groups I versus II (P < 0.001 and P < 0.001). Hospital re-admission rate was less in treatment groups when compare to control group (P < 0.0001).

CONCLUSION

The use of alfuzosin and nifedipine as a medical expulsive therapy for distal ureteric stones proved to be safe and effective in term of increased stone-expulsion rate, reduced pain attacks and decrease hospital re-admissions.

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.

Effect of tamsulosin on stone expulsion in proximal ureteral calculi: an open-label randomized controlled trial

AIM

Medical expulsive therapy (MET) using alpha-blockers is effective for distal ureteral calculi (UC). We aimed to evaluate the efficacy of tamsulosin for proximal UC expulsion.

MATERIALS AND METHODS

An open-label randomized controlled trial was conducted with 108 patients who agreed to conservative management for single, radiopaque, proximal UC ≤ 6 mm and were randomized into group A (n = 54, conservative managements only) or B (n = 54, 0.2 mg tamsulosin once a day). The primary end-point was stone passage rates (SPR) in the intention-to-treat population in 4 treatment weeks. The secondary end-points were estimated in per-protocol population and were time to stone passage, post-trial Euro-quality-of-life (EuroQOL) score, oral analgesic requirements, and willingness to undergo conservative treatment again.

RESULTS

The two groups were well balanced in terms of baseline patient and stone characteristics. Seventy nine patients (73.2%; 35 of group A and 44 of group B) completed the study protocol. The overall SPR was 60.2% (65/108). Group B had a higher SPR (74.1%; 40/54) than group A (46.3%; 25/54; p = 0.003) and a significantly shorter time to stone passage (mean days, A: 19.6 vs. B: 14.3, p = 0.005). The groups did not differ in post-trial EuroQOL score or oral analgesic requirements, whereas 74.3% (26/35) of group A and 90.9% (40/44) of group B were willing to undergo conservative treatment again (p = 0.048). Univariate logistic regression analysis showed that stone size (OR = 1.447, p = 0.045) and tamsulosin treatment (OR = 3.314, p = 0.004) significantly predicted stone expulsion. On multivariate analysis, only tamsulosin was statistically significant (OR=3.198, p = 0.021).

CONCLUSIONS

Tamsulosin was associated with significantly higher stone expulsion rate and shorter expulsion time in proximal UC ≤ 6 mm compared with conservative managements only. Our results indicate that similar to patients with distal UC, MET using tamsulosin is a reasonable treatment option for patients with proximal UC.

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.

Pharmacologic treatment of kidney stone disease

This article reviews the data on pharmacologic treatment of kidney stone disease, with a focus on prophylaxis against stone recurrence. One of the most effective and important therapies for stone prevention, an increase in urine volume, is not discussed because this is a dietary and not a pharmacologic intervention. Also reviewed are medical expulsive therapy used to improve the spontaneous passage of ureteral stones and pharmacologic treatment of symptoms associated with ureteral stents. The goal is to review the literature with a focus on the highest level of evidence (ie, randomized controlled trials).

Medical management of renal stone

Kidney stone is a common clinical problem faced by clinicians. The prevalence of the disease is increasing worldwide. As the affected population is getting younger and recurrence rates are high, dietary modifications, lifestyle changes, and medical management are essential. Patients with recurrent stone disease need careful evaluation for underlying metabolic disorder. Medical management should be used judiciously in all patients with kidney stones, with appropriate individualization. This chapter focuses on medical management of kidney stones.

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.

Emergency ureteroscopic removal of ureteral calculi after first colic attack: is there any advantage?

OBJECTIVE

To comparatively evaluate the efficacy of ureteroscopic stone treatment immediately after the first colic attack and in an electively planned manner.

METHODS

A total of 145 patients underwent semirigid ureteroscopic removal of obstructive ureteral calculi using 2 different approaches (group 1, 69 patients, and group 2, 76 patients). The 69 patients in group 1 were treated with appropriate medical therapy for a period of ≥7 days for colic pain and subsequently underwent either semirigid ureteroscopy or pneumatic lithotripsy in a planned manner. The 76 patients in group 2 underwent semirigid ureteroscopy after the first colic attack. The stone-free status, auxiliary procedures, and complications were evaluated between the 2 groups using the Mann-Whitney U test; for qualitative data, Fisher's exact test was used.

RESULTS

Of the 145 patients who underwent semirigid ureteroscopy, the mean stone size was 11.80±3.95 mm and 8.32±2.08 mm in the 2 groups. No patient experienced a major complication during or after the procedure. The stone-free rate was 87% and 90.7% in groups 1 and 2, respectively. The mean readmission rate to the emergency department for the management of a colic attack was 3.03±2.84 in group 1; no patient in group 2 required readmission.

CONCLUSION

Ureteroscopic stone removal immediately after the first colic attack in the cases of obstructive ureteral stones proved to be safe and effective. It has the main advantage of offering both immediate stone fragmentation and the relief of acute onset colic pain causing extreme discomfort.

A prospective randomized comparison between early (<48 hours of onset of colicky pain) versus delayed shockwave lithotripsy for symptomatic upper ureteral calculi: a single center experience

BACKGROUND AND PURPOSE

The role of early/emergency shockwave lithotripsy (SWL) in symptomatic upper ureteral calculi has still not been established. We have performed a randomized comparison between early (<48 hours) vs delayed (>48 hours) SWL for symptomatic upper ureteral stones less than 1 cm to evaluate the feasibility, safety, and efficacy of early SWL in these patients.

PATIENTS AND METHODS

One hundred and sixty consecutive patients with a single radiopaque upper ureteral stone <1 cm, who presented with an episode of colicky pain and who were undergoing treatment between July 2008 and June 2009 in our department were included. The patients were hospitalized and randomized into two groups-group A: SWL was performed within 48 hours of onset of colicky pain (early SWL) using the electromagnetic lithotripter (Dornier Alpha Compact) along with analgesics and hydration therapy; group B: SWL was performed after 48 hours (delayed SWL) along with analgesics and hydration therapy. The statistical analysis was performed in two groups regarding the patient demographic profile, presence of hydronephrosis, time to stone clearance, success rates, number of sessions needed, auxiliary procedures, modified efficiency quotient (EQ), and complications.

RESULTS

Eighty patients were enrolled in each group. The mean stone size was 7.3 mm in group A vs 7.5 mm in group B (P = 0.52). The stone fragmentation rate was 88.75% in group A vs 91.2% in group B (P = 0.35). The overall 3-month stone-free rate was 86.3% (69/80) for group A vs 76.2% (61/80) for group B (P = 0.34). The mean time taken for stone clearance was significantly less in group A than in group B (10.2 days vs 21.1 days; P = 0.01). The number of sessions needed in group A were significantly less than in group B (1.3 vs 2.7; P = 0.01). The auxiliary procedure rate was also significantly lesser in group A than group B (16.3% vs 32.5%; P = 0.001). The modified EQ (in %) was 67.2 in group A vs 59.4 in group B (P = 0.21). The steinstrasse formation and requirement for percutaneous nephrostomy (PCN) were significantly less in group A (P:0.02 and P:0.01 respectively).

CONCLUSIONS

Early SWL (within 48 hours of onset of colicky pain) is feasible, safe, and highly efficacious in the management of symptomatic proximal ureteral stones <1 cm, resulting in a lesser requirement of number of SWL sessions, time taken for stone clearance, auxiliary procedure rate, and fewer complications in comparison with delayed SWL.

Tamsulosin as an expulsive therapy for steinstrasse after extracorporeal shock wave lithotripsy: a randomized controlled study

OBJECTIVE

Steinstrasse is a well-known complication following extracorporeal shockwave lithotripsy (ESWL). The objective of this study was to evaluate the efficacy of tamsulosin as a management of steinstrasse.

MATERIAL AND METHODS

88 patients with unilateral steinstrasse were treated between January 2005 and December 2008. The patients were randomly allocated into two equal groups. There were no significant differences between groups for age, gender, stone location, stone length or stone fragment size (p > 0.05). Patients in group 1 (study group) received a single daily morning dose of tamsulosin (0.4 mg) for a maximum of 4 weeks, in addition to pain-relieving therapy. Patients in group 2 (control group) received only the pain-relieving therapy. All patients were checked weekly with a plain X-ray of the urinary tract, urinary ultrasonography, urine analysis and serum creatinine. Pain episodes, day of spontaneous stone expulsion, total analgesic dosage and drug side-effects were recorded.

RESULTS

Stone expulsion occurred in 32 of the 44 patients (72.7%) receiving tamsulosin and in 25 of the 44 patients (56.8%) in the control group. Patients receiving tamsulosin had a significantly higher stone expulsion rate (p = 0.017). There were no significant differences between groups for mean stone expulsion time or number of analgesics used. Twelve patients (27.3%) in the group receiving tamsulosin and 19 patients (43.3%) in the control group needed hospitalization; the group difference was statistically significant (p = 0.017).

CONCLUSIONS

When compared with no treatment, tamsulosin can significantly facilitate expulsion of retained ureteral stone fragments following ESWL.

Tamsulosin versus Alfuzosin in the Treatment of Patients with Distal Ureteral Stones: Prospective, Randomized, Comparative Study

Purpose

We evaluated and compared the efficacy of tamsulosin and alfuzosin in the medical treatment of symptomatic, uncomplicated distal ureteral stones.

Materials and Methods

A total of 87 patients with distal ureteral stones of ≤10 mm were randomly divided into 3 groups. Group I patients (n=29) received 0.4 mg tamsulosin daily, group II patients (n=30) received 10 mg alfuzosin daily, and group III patients (n=28) were not given tamsulosin or alfuzosin. Patients in all groups received Diclofenac sodium regularly for 1 week and then on demand. Follow-up was done on a weekly basis for 30 days.

Results

The mean stone size was comparable in the 3 groups (4.97±2.24, 5.47±2.13, and 5.39±1.81 mm, respectively). The stone expulsion rate was 86.2%, 76.6%, and 50% in groups I, II, and III, respectively. The difference in groups I and II with respect to group III was significant (p=0.0028 and 0.035). The mean expulsion time for groups I to III was 7.52±7.06, 8.26±7.34, and 13.90±6.99 days, respectively. The expulsion time was significantly shorter in groups I and II than in group III (p=0.0097 and 0.026). Patients taking tamsulosin and alfuzosin had fewer pain attacks than did group III patients (1.24±0.57 vs. 1.43±0.67 vs. 1.75±1.17). Only 3 cases of drug side effects, 2 in group I and 1 in group II, were recorded.

Conclusions

The use of tamsulosin or alfuzosin for the medical treatment of lower ureteric stones proved to be safe and effective. Moreover, tamsulosin did not have any significant benefits over alfuzosin.

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.

Celecoxib in the management of acute renal colic: a randomized controlled clinical trial

OBJECTIVES

To evaluate the efficacy of celecoxib as an analgesic and medical expulsive agent in acute renal colic.

METHODS

A prospective randomized double-blind study was conducted on patients presenting with an obstructing ureteral calculus < 10 mm in largest diameter. Patients were randomized to 400 mg of celecoxib, followed by 200 mg every 12 hours for 10 days, or to placebo. Patients with a solitary kidney, renal insufficiency (CR > 1.8), urinary tract infection, or significant cardiovascular disease were excluded.

RESULTS

A total of 57 patients provided consent of which 53 completed the study. Four patients were excluded from the analysis because of stone passage or withdrawal of consent before the first dose of study medication. No significant difference was noted in the spontaneous stone passage rate (celecoxib 55.2%, placebo 54.2%) and between celecoxib and placebo with regard to days to stone passage (7.0 vs 9.0, P = .6) or size of stone passed (3.9 vs 4.6 mm, P = .18). No significant difference was noted in pain analog scores (2.6 vs 3.5, P = .71) or narcotic doses (13.2 vs 13.6, P = .74). Furthermore, a 25% decrease in narcotic use (or 19 mg based on placebo mean) was outside the 80% one-sided confidence interval for the change in mean narcotic use between the 2 groups. Thus, it is unlikely (< 20%) that we missed a clinically significant beneficial effect of celecoxib on narcotic consumption because of sample size.

CONCLUSIONS

Celecoxib does not facilitate stone passage or decrease narcotic requirements in patients with acute renal colic.

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.

Prospective randomized trial comparing efficacy of alfuzosin and tamsulosin in management of lower ureteral stones

OBJECTIVES

To study the efficacy of alfuzosin compared with tamsulosin in the management of lower ureteral stones.

METHODS

A total of 102 patients with stones <1 cm size and located in the lower ureter were enrolled in the present study and randomized into 3 equal groups. Group 1 patients (n = 34) received 0.4 mg tamsulosin daily, group 2 patients (n = 34) received 10 mg alfuzosin daily, and group 3 patients (n = 34) received placebo (control group). The patients were given 75 mg diclofenac injection intramuscularly on demand and were followed up for 4 weeks.

RESULTS

The average stone size for groups 1, 2, and 3 was comparable (6.17, 6.70, and 6.35 mm, respectively). Stone expulsion was observed in 28 of 34 patients (82.3%) in group 1, 24 of 34 patients (70.5%) in group 2, and 12 of 34 patients (35.2%) in group 3. The average expulsion time for groups 1, 2, and 3 was 12.3, 14.5, and 24.5 days, respectively. The results of both study groups (groups 1 and 2) were superior to those in the placebo group (P = .003 and P = .001, respectively), but the study failed to show any statistically significant differences between tamsulosin and alfuzosin (P = .25). Alfuzosin was associated with fewer side effects than tamsulosin, especially in terms of retrograde ejaculation.

CONCLUSIONS

Medical treatment of lower ureteral calculi with tamsulosin and alfuzosin resulted in a significantly increased stone expulsion rate, decreased expulsion time, and a reduced need for analgesic therapy.

Myth: nephrolithiasis and medical expulsive therapy

There is a medical myth that ureteral stones larger than 5 mm will not pass spontaneously and require urological intervention for removal. Recent findings indicate that medical expulsive therapy can facilitate spontaneous passage for stones up to 10 mm. For the management of ureteral stones, we recommend administering tamsulosin and a corticosteroid (deflazacort or prednisone) along with the standard therapy of analgesics, antibiotics and hydration.

A systematic review of medical therapy to facilitate passage of ureteral calculi

STUDY OBJECTIVE

Acute renal colic is a common presenting complaint to the emergency department. Recently, medical expulsive therapy using alpha-antagonists or calcium channel blockers has been shown to augment stone passage rates of moderately sized, distal, ureteral stones. Herein is a systematic evaluation of the use of medical expulsive therapy to facilitate ureteral stone expulsion.

METHODS

We searched the databases of MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. Additional sources included key urologic journals and bibliographies of selected articles. We included studies that incorporated a randomized or controlled clinical trial design, patients older than 18 years, treatment in which an alpha-antagonist or calcium channel blocker was compared to a standard therapy group, and studies that reported stone expulsion rates. A random effects model was used to obtain summary risk ratios (RRs) and 95% confidence intervals (CIs) for stone expulsion rate.

RESULTS

A pooled analysis of 16 studies using an alpha-antagonist and 9 studies using a calcium channel blocker suggested that the addition of these agents compared to standard therapy significantly improved spontaneous stone expulsion (alpha-antagonist RR 1.59; 95% CI 1.44 to 1.75; number needed to treat 3.3 [95% CI 2.1 to 4.5]; calcium channel blocker RR 1.50; 95% CI 1.34 to 1.68; number needed to treat 3.9 [95% CI 3.2 to 4.6]) in patients with distal ureteral stones. Subgroup analysis of trials using concomitant medications (ie, low-dose steroids, antibiotics, and elimination of trials using an anticholinergic agent) yielded a similar improvement in stone expulsion rate. Adverse effects were noted in 4% of patients receiving alpha-antagonist and in 15.2% of patients receiving calcium channel blockers.

CONCLUSION

Our results suggest that "medical expulsive therapy," using either alpha-antagonists or calcium channel blockers, augments the stone expulsion rate compared to standard therapy for moderately sized distal ureteral stones.

Treatment Selection and Outcomes: Ureteral Calculi

The most important recent advances in the management of ureteral calculi have been the development of medical expulsive therapy to facilitate passage of ureteral stones, such that many calculi that would previously have required procedural treatment now exit the ureter with only pharmacologic treatment; and the improvements in ureteroscopic technology that have enabled retrograde ureteroscopy to become a first-line option for most ureteral stones. Shock wave lithotripsy still plays an important role for many ureteral calculi, particularly smaller ones, and the addition of percutaneous/antegrade ureteroscopy and laparoscopic ureterolithotomy rounds out the treatment options for large or impacted stones. Selection of treatment based upon factors such as size, location, and others will optimize outcome for patients who have ureteral calculi.

Doxazosin for the Management of Distal-Ureteral Stones

PURPOSE

To evaluate the efficacy of doxazosin in inducing spontaneous passage of stones in the distal ureter and to compare its efficacy according to the size of the stone.

PATIENTS AND METHODS

Seventy-three patients with a mean age of 46.38 +/- 10.17 years who presented with a distal-ureteral stone were divided into four groups according to stone size and drug treatment: <5 mm without doxazosin (group A; n=15); 5-10 mm (group B; n=16); <5 mm with doxazosin 4 mg/day for 4 weeks (group C; n=20); and 5-10 mm with doxazosin 4 mg/day for 4 weeks (group D; n=22). Groups A and B served as controls for groups C and D, respectively.

RESULTS

Spontaneous stone passage was documented in 9 patients (60%) in group A v 17 (85%) in group C (P=0.047) and 7 (43.75%) in group B v 16 (72.73%) in group D (P=0.036). The average expulsion time was 8.78 +/- 1.09 days in group A v 7.59 +/- 0.80 days in group C (P=0.004) and 12.14 +/- 1.35 days in group B v 7.06 +/- 1.29 days in group D (P<0.0001). The number of pain episodes in group D patients was significantly lower than in group B (P +/- 0.0078).

CONCLUSIONS

Doxazosin treatment proved to be safe and effective for distal-ureteral stones, as determined by earlier expulsion, decreased colic frequency, and absence of side effects. The efficacy of doxazosin was significantly higher for 5-to 10-mm stones than for smaller ones.

Emergency ureteroscopic management of ureteral stones: why not?

OBJECTIVES

To describe a single-center experience in the emergency ureteroscopic management of ureteral stones.

METHODS

We retrospectively considered the data from 144 patients (mean age 49.6 years, range 23 to 82) who had had obstructive ureteral stones and had undergone emergency ureteroscopy with stone retrieval. Intracorporeal pneumatic lithotripsy was performed when necessary. At the end of the procedure, a ureteral catheter was systematically left in place in 100 patients (69.4%) and removed within 24 hours. In the remaining 44 patients, a double-J stent was preferred and was removed within 30 days, depending on the clinical course. Stone-free status was defined as the complete absence of fragments at 1 month of follow-up.

RESULTS

The calculi were more frequently localized in the distal ureter than in the proximal one (90.3% versus 9.7%, respectively). The overall mean stone diameter was 9.1 mm (range 5 to 20). The overall stone-free rate was 92.4%. A greater stone-free rate was obtained in those with stones less than 10 mm (95.8%) than in those with stones larger than 10 mm (89%, P = 0.002). Similarly, a significantly better outcome occurred for those with stones located in the distal ureter (94.6%) than for those with stones in the proximal one (71.4%, P = 0.004). The overall complication rate was 4.2%. The mean hospital stay was 2.5 days (range 1 to 7).

CONCLUSIONS

In our experience, emergency ureteroscopy in cases of obstructive ureteral stones proved to be safe and effective. It has the main advantage of offering both immediate relief from pain and stone fragmentation. Additional extensive studies are warranted to corroborate these findings.

Medical therapy to facilitate urinary stone passage: a meta-analysis

BACKGROUND

Medical therapies to ease urinary-stone passage have been reported, but are not generally used. If effective, such therapies would increase the options for treatment of urinary stones. To assess efficacy, we sought to identify and summarise all randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat urinary stone disease.

METHODS

We searched MEDLINE, Pre-MEDLINE, CINAHL, and EMBASE, as well as scientific meeting abstracts, up to July, 2005. All randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat ureteral stones were eligible for inclusion in our analysis. Data from nine trials (number of patients=693) were pooled. The main outcome was the proportion of patients who passed stones. We calculated the summary estimate of effect associated with medical therapy use using random-effects and fixed-effects models.

FINDINGS

Patients given calcium-channel blockers or alpha blockers had a 65% (absolute risk reduction=0.31 95% CI 0.25-0.38) greater likelihood of stone passage than those not given such treatment (pooled risk ratio 1.65; 95% CI 1.45-1.88). The pooled risk ratio for alpha blockers was 1.54 (1.29-1.85) and for calcium-channel blockers with steroids was 1.90 (1.51-2.40). The proportion of heterogeneity not explained by chance alone was 28%. The number needed to treat was 4.

INTERPRETATION

Although a high-quality randomised trial is necessary to confirm its efficacy, our findings suggest that medical therapy is an option for facilitation of urinary-stone passage for patients amenable to conservative management, potentially obviating the need for surgery.

Corticosteroids and Tamsulosin in the Medical Expulsive Therapy for Symptomatic Distal Ureter Stones: Single Drug or Association?

OBJECTIVES

To assess the clinical role of corticosteroids in the medical expulsive therapy of symptomatic distal ureteral stones.

METHODS

Between January 2004 and September 2005, 114 patients with symptomatic distal ureteral stones with a >/=5mm diameter were enrolled in this prospective study and divided into four groups based on the urologist (of four) who treated them in the emergency unit. Group A (33 patients) received tamsulosin (0.4mg daily), group B (24 patients) received deflazacort (30mg daily), group C (33 patients) received both (0.4mg tamsulosin+30mg deflazacort daily), and control group D (24 patients) received only analgesics. The treatment duration was 10 d to prevent the side-effects of prolonged corticosteroid therapy. The end points were the expulsion rate, analgesic consumption, number of ureteroscopies, and safety.

RESULTS

The groups were comparable in terms of age, sex, and stone location. The stone diameter was 5.96+/-0.33mm for group A, 5.83+/-0.4mm for group B, 5.88+/-0.23mm for group C, and 5.71+/-0.5mm (p>0.05) for group D. The rates of expulsion for the four groups were 60%, 37.5%, 84.8%, and 33.3%, respectively. There was a significant difference between group C and the other groups (p<0.001). The mean analgesic consumption was 42.5+/-0.4mg for group A, 50+/-0.3mg for group B, 27.3+/-0.5mg for group C, and 81+/-0.33mg for group D, with a significant difference between group C and the other groups (p<0.001). During the treatment period, only two cases of drug side-effects related to tamsulosin (without any drop-outs) were recorded.

CONCLUSION

When the medical expulsive therapy for symptomatic distal ureteral stones is considered, the use of steroids (deflazacort) proves efficient only when administered together with alpha(1)-blockers (tamsulosin). In addition, tamsulosin used on its own as a medical expulsive therapy can be considered as an alternative treatment for those patients who are not suitable for steroid therapy, as it is generally efficient.