The use of standard imaging techniques and their diagnostic value in the workup of renal colic in the setting of intractable flank pain

Is extracorporeal shock wave lithotripsy a current treatment for urolithiasis? A systematic review

INTRODUCTION

Technological advances have prompted a change in the management of urolithiasis. Endourological techniques are gaining importance because they are highly effective treatments. The aim of this study was to answer the question of whether extracorporeal shock wave lithotripsy (ESWL) is still a competitive alternative compared with other therapeutic modalities.

ACQUISITION OF EVIDENCE

We conducted a literature search of articles published in the past 5 years. We identified 12 randomized and comparative studies and assessed the methodology and results of the study variables. We performed a narrative synthesis of the included studies. To summarise the variables, we used the mean and standard deviation for continuous variables and absolute numbers and percentages for the qualitative variables.

ANALYSIS OF THE EVIDENCE

Of the studies reviewed, 7 evaluated the various treatments for nephrolithiasis and 5 evaluated the treatments for ureteral lithiasis. At the renal level, a stone-free rate of 33.33-91.5% at 3 months was reached with ESWL, while a rate of 90.4-100% was achieved with the other endourological techniques, without finding statistically significant differences in the studies. At the ureteral level, a stone-free rate of 73.5-82.2% at 3 months was reached with ESWL, while a rate of 79-94.1% was achieved with the other endourological techniques, without finding statistically significant differences in the studies.

CONCLUSION

There is a lack of homogeneity among the published studies. ESWL is a minimally invasive treatment that with an appropriate technique and patient selection achieves high effectiveness, thus maintaining an important role at this time.

Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment

PURPOSE

This technology assessment addresses the optimal use of imaging in the evaluation and treatment of patients with suspected or documented ureteral stones.

MATERIALS AND METHODS

A comprehensive literature search addressing 4 guiding questions was performed for full text in English articles published between January 1990 and July 2011. The search focused on major subtopics associated with the imaging of ureteral calculi, and included specific imaging modalities used in the diagnosis and management of ureteral calculous disease such as unenhanced (noncontrast) computerized tomography, conventional radiography, ultrasound, excretory urography, magnetic resonance imaging and nuclear medicine studies. Protocols (in the form of decision tree algorithms) were developed based on this literature review and in some instances on panel opinion. The 4 questions addressed were 1) What imaging study should be performed for suspected ureteral calculous disease? 2) What information should be obtained? 3) After diagnosis of a ureteral calculus, what followup imaging should be used? 4) After treatment of a ureteral calculus, what followup imaging studies should be obtained?

RESULTS

Based on these protocols, noncontrast computerized tomography is recommended to establish the diagnosis in most cases, with a low energy protocol advocated if body habitus is favorable. Conventional radiography and ultrasound are endorsed for monitoring the passage of most radiopaque stones as well as for most patients undergoing stone removal. Other studies may be indicated based on imaging findings, and patient, stone and clinical factors.

CONCLUSIONS

The protocols generated assist the clinician in establishing the diagnosis of ureteral calculous disease, monitoring stone passage and following patients after treatment. The protocols take into account not only clinical effectiveness but also cost-effectiveness and risk/harm associated with the various imaging modalities.

Abdominal plain film in patients admitted with clinical suspicion of renal colic: should it be replaced by low-dose computed tomography?

OBJECTIVES

To evaluate a low-dose abdominal computed tomography (LDCT) protocol, delivering a radiation dose close to that delivered by an abdominal plain film (APF), in patients with a clinical suspicion of renal colic.

METHODS

A total of 139 patients for whom an APF was requested for suspicion of renal colic were randomized into two groups. The patients in group 1 (n = 68) underwent an admission LDCT scan delivering a 2.1-mSv radiation dose to women and 1.6 mSv to men, instead of the APF. Patients in group 2 (n = 71) underwent an APF. Clinical and radiologic follow-up data were obtained for each patient. The number of additional abdominal ultrasound and CT scans performed to reach a confident final diagnosis and determine the proper treatment was compared between the two groups. A mean effective radiation dose was obtained in each group.

RESULTS

Of the 68 patients in group 1 (LDCT), 10 (15%) underwent ultrasonography, 9 (13%) conventional abdominal CT, and 2 (3%) both. In group 2 (APF), the corresponding percentages were 27% (19 of 71), 28% (20 of 71), and 23% (16 of 71). Of the 68 patients in group 1, 47 (69%) did not require any additional examinations compared with 16 (23%) of the 71 patients in group 2 (P < 0.0001). The mean effective dose was 3.5 and 6.9 mSv in groups 1 and 2, respectively (P < 0.0001).

CONCLUSIONS

In patients with suspicion of renal colic, replacing the admission APF with our LDCT protocol will significantly reduce the need for additional CT or ultrasonography. Also, our LDCT protocol decreases by almost 50% the mean radiation dose per patient.

Comparison of cizolirtine citrate and metamizol sodium in the treatment of adult acute renal colic: a randomized, double-blind, clinical pilot study

BACKGROUND

Renal colic causes excruciating pain that provides a good clinical model of acute pain for the development of new analgesics.

OBJECTIVE

The purpose of the study was to compare the analgesic efficacy and tolerability of cizolirtine citrate and metamizol sodium in adult acute renal colic.

METHODS

This Phase II, randomized, double-blind, clinical pilot study was conducted in the emergency departments of 6 general hospitals in the Czech Republic between October 2000 and February 2001. Male and female patients aged 18 to 65 years and presenting with hematuria and moderate to severe pain due to suspected renal colic starting within the 24 hours before presentation were eligible. Patients were randomized to receive a single IV dose of cizolirtine 350 mg or metamizol 2,500 mg, administered by slow infusion over 15 minutes. Both doses were maximal for the respective drugs to attain adequate analgesia. Use of rescue medication with butorphanol was allowed 30 minutes after study drug administration. Pain intensity was assessed at various time points during the following 360 minutes using a 100-mm visual analog scale (VAS) and a verbal categoric scale. In addition, a specific verbal categoric scale was used to rank pain relief. Physical examinations, laboratory tests, and questioning for adverse events addressed drug tolerability.

RESULTS

Sixty-four patients (50 men, 14 women; mean [SD] age, 44.21 [12.29] years; mean [SD] body mass index, 25.97 [3.38] kg/m(2)) were enrolled. Physical examination findings and mean VAS pain intensity scores at baseline (mean [SD], 79.42 [7.89] mm and 82.59 [10.50] mm in the cizolirtine and metamizol groups, respectively) were similar in both groups. After 30 minutes, the mean (SD) scores were 33.84 (25.15) mm and 25.41 (24.51) mm, respectively. This difference was not statistically significant, and the noninferiority of cizolirtine with respect to the comparator could not be established. However, the proportion of patients that showed satisfactory pain relief (ie, decrease of > or = 50% in VAS pain intensity score compared with baseline) at 30 minutes in the cizolirtine group was fairly high (64.5%), which means relevant analgesic activity. Both treatments were well tolerated; 6 adverse events were reported in 5 patients (7.8%), and all were considered as not treatment related.

CONCLUSIONS

Although this limited pilot study did not include an internal measure of sensitivity, relevant pain reduction was shown in the population of patients with suspected renal colic undergoing treatment with cizolirtine, suggesting the presence of analgesic activity. However, the efficacy of cizolirtine was found to be similar to that of metamizol. Treatments were well tolerated.

[Significance of simple radiography of the abdomen in nephritic colic]

BASIS

The utility of the abdominal plain film in the emergency department to evaluate urolithiasis is questionable. Between another things, there are influence of the different formation of distinct examinators.

METHODS

A retrospective study in 65 patients referrals to urology in 1997 and 1998 by suspicion of renal colic was carried out. The radiography of abdomen took in the emergency room the day of the income is reviewed with a protocol, by a resident of Familiar and Community Medicine and by the urologist, separately and without information of the medical records.

RESULTS

We have excluded three patients. At last, we diagnose 49 patients as renal colic with certainty, 6 patients with doubtful diagnosis and 7 patients with distinct diagnosis. The urologist achieved the most adequate reading in 11 cases; in 7 was best the resident, to equal in 31, and in 13 the differences were not important. The resident obtained of radiography a sensitivity of the 67% and a specificity of the 42% and the urologist 71% and 57% respectively.

CONCLUSIONS

There are few differences of reading, at least when the resident dispose a protocol of interpretation. Despite to the almost null diagnostic utility of the radiography, supply additional ation, and permit to value the evolution with a few aggressive technique.