Nonsurgical Management of Urolithiasis: An Overview of Expulsive Therapy

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

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

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

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

Efficacy of Obcordata A from Aspidopterys obcordata on Kidney Stones by Inhibiting NOX4 Expression

Obcordata A (OA) is a polyoxypregnane glycoside derived from the Dai medicine Aspidopterys obcordata vines. This study aims to investigate the efficacy of OA on renal tubular epithelial cells exposed to calcium oxalate crystals. We incubated renal tubular cells with 28 μg·cm2 calcium oxalate crystals for 24 h with and without OA, GKT137831, phorbol-12-myristate-13-acetate (PMA), and tocopherol. The MTT [3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay, microscopic examination, flow cytometry, and immunofluorescence staining revealed that calcium oxalate crystals decreased cell viability and elevated reactive oxygen species (ROS) levels. OA, GKT137831, and tocopherol protected cells and decreased ROS levels. However, OA did not exhibit direct DPPH scavenging ability. In addition, immunoblotting illustrated that OA inhibited the NOX4 (nicotinamide adenine dinucleotide phosphate oxidases 4) expression and downregulated the protein expression in the NOX4/ROS/p38 MAPK (p38 mitogen-activated protein kinase) pathway. The findings suggest that the cytoprotective and antioxidant effects of OA can be blocked by the NOX4 agonist PMA. In conclusion, OA could be used as a NOX4 inhibitor to prevent kidney stones.

Comparison of Two Treatment Methods "One Shot" and "Sequential" on Reduction the Level of Hemoglobin in Patients with Percutaneous Nephrolithotripsy in Al Zahra Hospital in 2012-2013

BACKGROUND

Access dilation is the most important part of percutaneous nephrolithotripsy (PCNL) that is done by different methods, especially metal telescoping and one shot. In this study, two different methods of access dilation one shot and telescoping were compared.

MATERIALS AND METHODS

In observational cross-sectional study, 240 patients who were a candidate for PCNL were selected and randomly divided into two groups. The first group was undergone one-shot method and the second group was undergone telescoping method. The decrease in hemoglobin (Hb), duration of hospitalization and the time of radiation exposure during access dilation was compared in two groups by SPSS software version 21, (SPSS Inc., Chicago, IL, USA).

RESULTS

The decrease of Hb level after intervention in one-shot group was 1.08 ± 1.23 g/dl and in telescoping, group was 1.51 ± 1.08 g/dl with no difference statistically (P = 0.37). The mean duration of hospitalization in one shot and telescoping group were 2.36 ± 0.67 and 2.28 ± 0.61 days, respectively. According to t-test, there was no significant difference between the two groups (P = 0.37). Average radiation exposure in one shot group was 7.13 s and in telescoping, group was 35.75 s, and there was a significant difference between the two groups (P < 0.001).

CONCLUSION

One-shot method is superior to telescoping method due to less time for radiation exposure and no more blood loss and other complications during PCNL.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[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.

Mechanical function and gene expression of alpha(1)-adrenoceptor subtypes in dog intravesical ureter

OBJECTIVES

To characterize the contractile functions and gene expression of the alpha(1)-adrenoceptor (AR) subtypes present in the dog intravesical ureter.

METHODS

In a functional study, alpha(1)-AR antagonists were evaluated against phenylephrine (alpha(1)-AR agonist)-induced contractions in dog isolated intravesical ureteral preparations. The quantitative expression of alpha(1)-AR subtype mRNA in this tissue was determined using real-time quantitative reverse transcriptase-polymerase chain reaction.

RESULTS

In the isolated intravesical ureter, prazosin (nonselective alpha(1)-AR antagonist), silodosin (selective alpha(1A)-AR antagonist), naftopidil (selective alpha(1D)-AR antagonist), and BMY-7378 (selective alpha(1D)-AR antagonist) all shifted the concentration-contractile response curve for phenylephrine to the right. The rank order of potencies (pK(B) value) was silodosin (9.45 +/- 0.14), prazosin (8.16 +/- 0.08), naftopidil (7.39 +/- 0.19), and BMY-7378 (6.78 +/- 0.20). The alpha(1A)-AR antagonist silodosin was much more potent than the 2 alpha(1D)-AR antagonists. The rank order of mRNA expression levels among the alpha(1)-AR subtypes was alpha(1d) (72.68%), alpha(1a) (24.14%), and alpha(1b) (3.18%).

CONCLUSIONS

In the dog intravesical ureter, alpha(1A)-AR plays a major role in contraction, despite the prevalence of alpha(1D)-AR.

The role of extracorporeal shockwave lithotripsy in an asymptomatic special patient group with small renal calculi

BACKGROUND AND PURPOSE

Data concerning extracorporeal shock wave lithotripsy (SWL) management of small (< or = 5 mm) asymptomatic renal caliceal stones are lacking in the literature. In this study, we aimed to determine the effectiveness of SWL in a special group of patients who had very small (< or = 5 mm) asymptomatic renal caliceal stones. The group of patients consisted of pilots, gendarmes, and soldiers, such as commandos, for whom treatment was obligatory and who had to be stone free because of their military duties.

PATIENTS AND METHODS

We retrospectively examined SWL data and retrieved information for 84 patients with small asymptomatic renal caliceal stones. The SWL sessions were performed with a Siemens Lithostar lithotriptor. The mean age of the patients was 34 +/- 13 years. The mean stone size was 4.8 +/- 0.4 mm. The mean numbers of shockwaves and energy used were 2707 +/- 1742 and 18 +/- 2 kV, respectively. The location of stones were: 11 right upper calix, 10 right middle calix, 17 right lower calix, 13 left upper calix, 16 left middle calyx, and 17 left lower calix. Eighty-four patients underwent 101 SWL sessions. Only eight patients had second and three patients had third SWL treatments. SWL was performed five times for only one patient. All mean values were realized with an SPSS 10.0 statistical program.

RESULTS

After the first, second, and third SWL sessions, the stone-free rate was calculated as 87%, 93% and 94%, respectively. Only five patients with lower renal caliceal stones were not stone free. The reported complications were macroscopic hematuria necessitating medical attention in four patients, skin ecchymosis in seven patients, severe colic pain in two patients, and urinary-tract infection in one patient. There was no need for hospitalization for these complications.

CONCLUSION

SWL is effective and safe in patients with very small (< or = 5 mm) asymptomatic renal caliceal stones in all locations.

Cost-Effectiveness of Medical Expulsive Therapy Using Alpha-Blockers for the Treatment of Distal Ureteral Stones

OBJECTIVE

Medical expulsive therapy (MET) has recently emerged as an efficacious and safe option for the initial management of ureteral stones. The objective of this study was to assess the cost-effectiveness of MET compared with conservative therapy for the treatment of ureteral stones using international cost data from the United States and four European countries.

MATERIAL AND METHODS

A decision analysis model was built with the use of TreeAge Pro 2004 software with linear success rate assumptions. The likelihood of spontaneous passage of ureteral stones according to their size and location was estimated with the use of data derived from a published meta-analysis. The estimated cost of ureteroscopy (URS) in the United States ($4973) was based on the mean cost of 121 consecutive cases performed at a large metropolitan hospital. URS costs for other countries were obtained from a published international survey. The cost of tamsulosin ($2.08 per day), currently the most commonly used medical expulsive agent, was estimated as a mean of the costs obtained from two national pharmacy chains. MET and conservative therapies were compared with the use of one-way and two-way sensitivity analyses.

RESULTS

In the United States, MET using tamsulosin resulted in a $1132 cost advantage over observation. MET maintained its cost advantage even in countries where the cost of URS is much lower than in the United States. Two-way sensitivity analysis showed that MET remained cost-effective even with very low rates of spontaneous passage, minimal benefit of MET, or low cost of URS.

CONCLUSION

MET is a cost-effective strategy for the management of distal ureteral stones--even those with a low rate of spontaneous passage--providing another incentive for initial "facilitated observation" before embarking on surgical intervention.

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.

Efficacy of alpha-blockers for the treatment of ureteral stones

PURPOSE

We determined if alpha-blocker therapy promotes expulsion of ureteral stones.

MATERIALS AND METHODS

Meta-analysis was performed of randomized clinical trials of alpha-blockers for the treatment of ureteral stones. The primary outcome was overall stone expulsion rate. Risk ratios and risk differences were estimated using DerSimonian and Laird random effects models.

RESULTS

Eleven trials (911 participants) met inclusion criteria for this study. Pooled analysis demonstrated significantly increased rates of stone expulsion with alpha-blocker therapy. Compared to patients receiving conservative therapy only, patients receiving conservative therapy plus alpha-blockers were 44% more likely to spontaneously expel the stones (RR 1.44, 95% CI 1.31 to 1.59, p<0.001), and stone expulsion incidence increased significantly (RD 0.28, 95% CI 0.22 to 0.34, p<0.001). Sensitivity and subgroup analyses categorized by specific alpha-blocker, prior use of shock wave lithotripsy and stone size produced similar effect estimates, but were generally less precise due to smaller sample sizes. The largest subgroup of trials (664 participants) studied tamsulosin without prior shock wave lithotripsy (RR 1.44, 95% CI 1.32 to 1.58; RD 0.29, 95% CI 0.23 to 0.35).

CONCLUSIONS

alpha-Blocker therapy is associated with significantly increased rates of distal ureteral stone expulsion.

Medical Therapy of Urolithiasis

Nephrolithiasis treatment has become easier and less invasive with the development of extracorporeal shockwave lithotripsy (SWL) and endourologic techniques. However, medical therapy represents a well-established and complementary approach that can improve the efficacy of SWL and endourology. During recent decades, pharmacologic intervention has become more effective in stone disease: drugs can control the pain of renal colic, interfere at various levels in lithogenesis, and contribute to the expulsion of stones. It is well known that lithogenesis is a multifactorial process influenced by environmental-nutritional factors (low urinary volume, diet rich in animal protein, etc) and metabolic alterations; i.e., hypercalciuria, hyperuricosuria, and deficiency of stone-inhibiting factors (citrate, magnesium, glycosaminoglycans [GAGs]). Specific drugs such as citrate, allopurinol, and thiazide represent highly effective treatments for the promoting factors. Furthermore, recent findings suggest an interesting role for a phytotherapeutic agent, Phillantus niruri, and its inhibitory action on calcium oxalate crystallization related to the higher incorporation of GAGs into the calculi. Another step forward in medical management of stone disease is expulsive therapy. Many studies have proven the efficacy of medical expulsive therapy with nifedipine and alpha-blockers: their specific action on ureteral smooth muscle in association with anti-edema drugs accounts for their efficacy in expelling ureteral stones. In this paper, we provide an update on the medical treatment of stone disease, focusing our attention on what is known and what is new in renal colic and litholithic and expulsive medical therapy.