Tadalafil Facilitates the Distal Ureteral Stone Expulsion: A Meta-Analysis

Drugs to affect the smooth musculature of the human ureter - an update with integrated information from basic science to the use in medical expulsion therapy (MET)

PURPOSE

Urolithiasis and symptomatic ureterolithiasis represent diseases known to be on the increase in most westernized countries. The present article aims to give an overview on some drug principles assumed to target signalling systems involved in modulating ureter smooth muscle contractility and to present background to their potential use or prospects in ureter stone disease.

METHODS

The article reviews drugs that have been evaluated over the last decades in vitro, in vivo and/or in clinical settings with regard to their properties to achieve spontaneous passage of (distal) ureteral stones and relieve colic pain. Among these drugs are alpha- and beta-adrenoceptor antagonists, calcium channel blocking agents, Rho kinase inhibitors, nitric oxide (NO) donor drugs, selective inhibitors of cyclic nucleotide phosphodiesterase enzymes (PDEs), as well as potassium channel openers.

RESULTS

Based on the recent scientific information on agents targeting different pathways, antagonists of alpha 1-adrenoceptors, inhibitors of the PDE isoenzymes PDE4 and PDE5 (affecting cyclic AMP- or NO/cyclic GMP-mediated signals that facilitate relaxation of ureter smooth muscle), as well as the combination of certain drugs (for example, PDE5/PDE4 inhibitor plus alpha 1-AR antagonist) seem to be intriguing pharmacological approaches to medical expulsion therapy (MET) in the overall population of patients.

CONCLUSION

While NO donors, calcium channel antagonists and potassium channel openers may be limited for further development for medical expulsion therapy (MET) due to their systemic effects and a lack of effect on stone clearance, Rho kinase inhibitors should be explored further as a future pharmacological principle in ureteral stone disease.

Efficacy of sexual stimulation in the treatment of distal ureteral stones: A meta-analysis

Introduction

This study aimed to compare the clinical efficacy of sexual stimulation with that of placebo in the treatment of distal ureteral stones.

Methods

We searched PubMed, Web of Science, Cochrane Library, and Google Scholar from January 1, 2000 to December 31, 2022 for studies comparing the efficacy of sexual stimulus with that of placebo for the treatment of distal ureteral stones. RevMan 5.3 software was used to pool the data. The study protocol was registered on PROSPERO (Registration Number: CRD42023432408).

Results

A total of six randomized controlled trials comprising 535 cases of distal ureteral stones were included in this study. Among these, 273 cases were associated with sexual intercourse or masturbation 3-4 times a week, while 262 cases only received symptomatic treatment. The pooled results showed that the 2-week [risk ratios (RR) = 1.77, 95 % confidence interval (CI): 1.34, 2.33] and 4-week [RR = 1.48, 95 % CI: 1.29, 1.69] ureteral stone expulsion rates of the sexually stimulated group were significantly higher than those of the placebo group (ps < 0.01). Additionally, sexual stimulation was associated with a shorter ureteral stone expulsion time [weighted mean differences (WMD) = -3.74, 95 % CI: -6.27, -1.22, p < 0.01] and a decreased prevalence of renal colic attacks [WMD = -0.61, 95 % CI: -1.01, -0.22, p < 0.01] compared with those of the placebo group.

Conclusion

Appropriate sexual stimulation can enhance the spontaneous expulsion of distal ureteral stones in patients presenting with tolerable pain.

Obstructive uropathy: Overview of the pathogenesis, etiology and management of a prevalent cause of acute kidney injury

Obstructive uropathy is defined as the structural or functional interruption of urinary outflow at any level in the urinary tract. It is regarded as one of the most prevalent causes of acute kidney injury (AKI), accounting for 5%-10% of cases. Acute severe obstruction of the urinary tract is a potentially threatening situation for the kidneys and therefore requires prompt identification and management to relieve obstruction. The aim of the present article is to review and synthesize available evidence on obstructive uropathy, providing a clinical guideline for clinicians. A literature review on obstructive uropathy in the context of AKI was performed, focusing on the least clarified aspects regarding diagnosis and management. Recent literature searching was conducted in English and top-level evidence articles including systematic reviews, metanalyses and large series were prioritized. Acute obstruction of the urinary tract is a diagnostic and therapeutical challenge that may lead to important clinical complications together with direct structural and hemodynamic damage to the kidney. Early recognition of the leading cause and its exact location is essential to ensure prompt urinary drainage together with the most suitable drainage technique selection. A multidisciplinary approach, including urologists, nephrologists, and other medical specialties, is best suited to correctly manage concomitant hemodynamic changes, fluid and electrolyte imbalances, and other related issues. Obstructive uropathy is one of the leading causes of AKI. Recognition of patients suitable for early diversion and feasibility or adequate selection of the indicated technique is sometimes challenging. A thorough understanding of the physiopathology behind the development of urinary obstruction is vital for correct diagnosis and management.

Pooled-analysis of tadalafil and tamsulosin for ureteral calculi

Objective

Urolithiasis is a common urological diseases and affects the daily life of patients. Medical expulsive therapy has become acceptable for many parents. We conducted a meta-analysis to determine the efficacy and safety of tadalafil compared with tamsulosin for treating distal ureteral stones less than 10 mm in length.

Methods

Related studies were identified via searches of the PubMed, Embase, and Cochrane Library databases. All the articles that described the use of tadalafil and tamsulosin for treating distal ureteral stones were collected.

Results

A total of 14 studies were included in our meta-analysis. Our results revealed that tadalafil enhanced expulsion rate [odds ratio (OR) = 0.68, 95% confidence interval (CI): 0.47 to 0.98, p = 0.04]; reduced expulsion time [mean difference (MD) = 1.22, 95% CI (0.13, 2.30), p = 0.03]; lowered analgesia use [MD = 38.66, 95% CI (7.56, 69.77), p = 0.01] and hospital visits [MD = 0.14, 95% CI (0.06, 0.22), p = 0.0006]. According to our subgroup analysis, either tadalafil 5 mg or 10 mg did not promote expulsion rate and accelerate expulsion time compared with tamsulosin. But patients receiving 5 mg tadalafil decreased analgesia usage [MD = 101.04, 95% CI (67.56, 134.01), p < 0.00001].

Conclusion

Compared with tamsulosin, tadalafil demonstrates a higher expulsion rate and less expulsion time for patients with distal ureteral stones less than 10 mm with a favorable safety profile.

Mirabegron for medical expulsive therapy of ureteral stones: a systematic review and meta-analysis

Objective

To systematically review and quantitively evaluate the efficacy and safety of mirabegron as a medical expulsive therapy for ureteral stones.

Methods

We performed an extensive search of the EMBASE and PubMed databases for studies examining the use of mirabegron as a medical expulsive therapy for ureteral stones. The primary outcome measure assessed was the stone expulsion rate (SER), while the secondary outcomes evaluated were the stone expulsion interval (SEI) and the occurrence of pain episodes during follow-up. Risk ratios (RRs) and mean differences (MDs) with their respective 95% CIs were calculated.

Results

We included a total of seven studies involving 728 participants. Our analysis revealed a significant increase in the stone expulsion rate (SER) with mirabegron (RR = 1.40; 95% CI = 1.17-1.67; p < 0.001) and a reduction in the frequency of pain episodes (MD = -0.80; 95% CI = -0.39 to -0.21; p = 0.008) compared to the control group. No significant difference was found in SEI between the two groups (MD = -3.04; 95% CI = -6.33 to 0.25; p = 0.07). Subgroup analysis revealed that the increased SER was significant for distal ureteral stones, but not for proximal and middle ureter stones. Compared to tamsulosin or silodosin, mirabegron showed no significant difference in SER, SEI, or pain episode frequency. The adverse effects of mirabegron were relatively rare and mild.

Conclusion

Mirabegron appears to be a promising candidate for the MET of distal ureteral stones rather than proximal and middle ureteral stones, as it significantly increases SER and reduces pain episode frequency. Further well-designed randomised controlled trials are needed to validate and affirm these findings.

Systematic Review Registration

PROSPERO (CRD42022341603).

The Saudi urological association guidelines on urolithiasis

Aims

The Saudi Urolithiasis Guidelines are a set of recommendations for diagnosing, evaluating, and treating urolithiasis in the Saudi population. These guidelines are based on the latest evidence and expert consensus to improve patient outcomes and optimize care delivery. They cover the various aspects of urolithiasis, including risk factors, diagnosis, medical and surgical treatments, and prevention strategies. By following these guidelines, health-care professionals can improve care quality for individuals with urolithiasis in Saudi Arabia.

Panel

The Saudi Urolithiasis Guidelines Panel consists of urologists specialized in endourology with expertise in urolithiasis and consultation with a guideline methodologist. All panelists involved in this document have submitted statements disclosing any potential conflicts of interest.

Methods

The Saudi Guidelines on Urolithiasis were developed by relying primarily on established international guidelines to adopt or adapt the most appropriate guidance for the Saudi context. When necessary, the panel modified the phrasing of recommendations from different sources to ensure consistency within the document. To address areas less well covered in existing guidelines, the panel conducted a directed literature search for high quality evidence published in English, including meta analyses, randomized controlled trials, and prospective nonrandomized comparative studies. The panel also searched for locally relevant studies containing information unique to the Saudi Arabian population. The recommendations are formulated with a direction and strength of recommendation based on GRADE terminology and interpretation while relying on existing summaries of evidence from the existing guidelines.

Efficacy of mirabegron for ureteral stones: a systematic review with meta-analysis of randomized controlled trials

Background: Medical expulsive therapy demonstrates efficacy in managing ureteral stones in patients amenable to conservative interventions. This meta-analysis aims to evaluate the effectiveness of mirabegron in the treatment of ureteral stones. Methods: From conception to November 2023, we examined PubMed databases, the Cochrane Library, Embase, Ovid, Scopus, and trial registries for this systematic review and meta-analysis. We chose relevant randomized controlled trials (RCTs) evaluating the efficacy of mirabegron as an expulsive treatment for ureteral stones. The Cochrane risk of bias method was used to assess the quality of the evidence. Outcome measures, which included the stone expulsion rate (SER), expulsion time, and pain episodes, were analyzed using RevMan 5.4 and Stata 17. Results: Seven RCTs (N = 701) had enough information and were ultimately included. In patients with ureteral stones, mirabegron-treated patients had a substantially higher SER [odds ratio (OR) = 2.57, 95% confidence interval (CI) = 1.41-4.68, p = 0.002] than placebo-treated patients. Subgroup analysis revealed that mirabegron was superior to placebo in patients with small ureteral stones (OR = 2.26, 95% CI = 1.05-4.87, p = 0.04), with no heterogeneity between studies (p = 0.54; I2 = 0%). Mirabegron patients had a higher SER than the control group for distal ureteral stones (DUSs) (OR = 2.48, 95% CI = 1.31-4.68, p = 0.005). However, there was no difference in stone ejection time or pain episodes between groups. Conclusion: Mirabegron considerably improves SER in patients with ureteral stones, and the effect appears to be more pronounced for small and DUSs. Nevertheless, mirabegron treatment was not associated with improved stone expulsion time or pain management.

Tamsulosin vs. Tadalafil as medical expulsive therapy for distal ureteral stones: a systematic review and meta-analysis

PURPOSE

Medical expulsive therapy (MET) is recommended for distal ureteral stones from 5 to 10 mm. The best drug for MET is still uncertain. In this review, we aim to compare the effectiveness of tadalafil and tamsulosin for distal ureteral stones from 5 to 10 mm in terms of stone expulsion rate (SER), stone expulsion time (SET) and the side effect profile.

MATERIALS AND METHODS

A comprehensive literature search was conducted on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science, from inception until April 2023. Only randomized controlled trials were included in the analysis.

RESULTS

Eleven publications with 1,330 patients were included. We observed that tadalafil has a higher SER (OR 0.55, CI 95% 0.38;0.80, p=0.02, I2=52%) and the same efficacy in SET (MD 1.07, CI 95% -0.25; 2.39, p=0.11, I2=84%). No differences were found when comparing side effects as headache, backache, dizziness, and orthostatic hypotension.

CONCLUSION

Tadalafil has a higher stone expulsion rate than tamsulosin as a medical expulsive therapy for patients with distal stones from 5 to 10 mm without differences in side effects.

Comparative study between Tamsulosin, Silodosin and Tadalafil as a medical expulsive therapy for lower ureteral stones

OBJECTIVE

To compare the efficacy of Tamsulosin, Silodosin and Tadalafil as a medical expulsive therapy for treatment of distal ureteral calculi.

PATIENTS AND METHODS

Over a period of 6 months (January 2022 to June 2022) this prospective randomized study was conducted on 170 patients with distal ureteric stone ≤ 10 mm. Patients were randomly divided into three groups. Patients in group A received Tamsulosin 0.4mg, in group B received Silodosin, and in group C receive Tadalafil 5 mg. Therapy was given for a maximum of 4 weeks. The rate and time of stone expulsion, the analgesic use, attacks of colic and hospital visits for pain, and adverse effects of drugs were recorded.

RESULTS

Among 170 patients who were enrolled in study, 20 were lost to follow-up (7, 8, 5 in group A, B, And C respective-ly). There was a significant higher stone passage rate in group C than group A and B (90% vs. 70% and 76% respectively; p-value = 0.043) and shorter expulsion time in group C (8.7 ± 3.3 days) vs. group A (12.5 ± 5.2 days) and group B (11.3 ± 4.2 days) with (p-value = 0.001)(highly statistically significant with p-value < 0.001) and increased amount of analgesics required in group A (225 ± 115.7 mg) and group B (163 ± 77.5 mg) when compared with group C (120 ± 55.3 mg).

CONCLUSION

Tadalafil is more effective than Tamsulosin and Silodosin in treatment of patients with distal ureteric stones ≤ 10 mm as regard stone expulsion rate, expulsion time with decreased number of colicky episodes and side effects.

Silodosin versus Tamsulosin for Medical Expulsive Therapy of Ureteral Stones: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: This systematic review and meta-analysis of randomized controlled trials was performed to compare the therapeutic effects and safety profiles of silodosin and tamsulosin for medical expulsive therapy (MET) of ureteral stones. Materials and Methods: We searched PubMed, EMBASE, the Cochrane Library, and Web of Science to identify articles published before July 2022 that described randomized controlled trials comparing silodosin and tamsulosin for MET of ureteral stones. Endpoints were stone expulsion rate, stone expulsion time, and total complication rate. Results: In total, 14 studies were included in our analysis. The size of ureteral stones was <1 cm. Compared with tamsulosin, silodosin resulted in a significantly higher stone expulsion rate (p < 0.01, odds ratio (OR) = 2.42, 95% confidence interval (CI) = 1.91 to 3.06, I2 = 0%) and significantly shorter stone expulsion time (p < 0.01, mean difference = −3.04, 95% CI = −4.46 to −1.63, I2 = 89%). The total complication rate did not significantly differ between silodosin and tamsulosin (p = 0.33, OR = 1.15, 95% CI = 0.87 to 1.52, I2 = 7%). Conclusions: Compared with tamsulosin, silodosin resulted in significantly better expulsion of ureteral stones <1 cm. The total complication rate did not significantly differ between silodosin and tamsulosin. Thus, silodosin may be superior to tamsulosin for MET of ureter stones <1 cm.

Development of prediction models of spontaneous ureteral stone passage through machine learning: Comparison with conventional statistical analysis

Objectives

To develop a prediction model of spontaneous ureteral stone passage (SSP) using machine learning and logistic regression and compare the performance of the two models. Indications for management of ureteral stones are unclear, and the clinician determines whether to wait for SSP or perform active treatment, especially in well-controlled patients, to avoid unwanted complications. Therefore, suggesting the possibility of SSP would help make a clinical decision regarding ureteral stones.

Methods

Patients diagnosed with unilateral ureteral stones at our emergency department between August 2014 and September 2018 were included and underwent non-contrast-enhanced computed tomography 4 weeks from the first stone episode. Predictors of SSP were applied to build and validate the prediction model using multilayer perceptron (MLP) with the Keras framework.

Results

Of 833 patients, SSP was observed in 606 (72.7%). SSP rates were 68.2% and 75.6% for stone sizes 5–10 mm and <5 mm, respectively. Stone opacity, location, and whether it was the first ureteral stone episode were significant predictors of SSP. Areas under the curve (AUCs) for receiver operating characteristic (ROC) curves for MLP, and logistic regression were 0.859 and 0.847, respectively, for stones <5 mm, and 0.881 and 0.817, respectively, for 5–10 mm stones.

Conclusion

SSP prediction models were developed in patients with well-controlled unilateral ureteral stones; the performance of the models was good, especially in identifying SSP for 5–10-mm ureteral stones without definite treatment guidelines. To further improve the performance of these models, future studies should focus on using machine learning techniques in image analysis.

[Renal colic: How to calm and optimize the stone expulsion? Which treatment for pregnant women and children?]

INTRODUCTION

The aims of this narrative review was to report on the contemporary data of renal colic (RC) in terms of epidemiology and pressure on emergency structures and also to describe the latest therapeutic developments about uncomplicated RC, depending on the pediatric, adult and pregnancy population.

MATERIAL AND METHODS

A request to the health surveillance network for emergencies and deaths (SurSaUD®, Santé Publique France) revealed original data on the contemporary epidemiology of renal colic. A narrative synthesis of the articles (French, English) available on the Pubmed database was produced in June 2021.

RESULTS

Renal colic represents 1.1% of the annual total of emergency room visits. The mean age at admission was 45 years and 62% of patients were men. NSAIDs and Paracetamol are the most effective analgesic treatments and should be given priority over opioids. Non-drug analgesic treatments by tactile stimulation probably have a place in the CN management, particularly in case of contraindications. Among the validated treatments, alphablockers allow better expulsion when the stone is located in the pelvic ureter and if its size is between 5 and 10mm in diameter. In pregnant women, the predominant problem is to confirm the diagnostic. If there is a strong suspicion, MRI or a low-dose CT scan is possible. Ureteroscopy is feasible in particular in the first part of pregnancy to avoid iterative ureteral catheter changes. The care for children is now based on that of adults.

CONCLUSION

The renal colic care pathway in 2021 can benefit from various optimizations in the field of expulsion and analgesic treatments. Good knowledge of the specific situations in pregnant women and children allowing to improve the quality of care.

Comparison of efficacy of various drugs used for medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis

OBJECTIVES

Medical expulsive therapy has been found to be effective for distal ureteric stones; however, which drug is most efficacious in terms of stone expulsion rate (SER) and stone expulsion time (SET) is not known. With this review we aimed to compare the efficacy of various drug treatments for distal ureter stones used as medical expulsive therapy in terms of SER and SET.

METHODS

Systematic literature search was conducted to include all the randomised study comparing various drug interventions for lower ureter stones. Standard preferred reporting items for systematic review and meta-analysis for network meta-analysis (PRISMA-NMA) were pursued.

RESULTS

In this review, 50 randomised studies with 12,382 patients were included. For stone expulsion rate (SER), compared with placebo all the treatment groups were more effective except nifedipine and sildenafil. According to the SUCRA values obtained, naftopidil plus steroid was the highest rank and nifedipine lowest. For stone expulsion time (SET), compared with placebo only tadalafil plus silodosin, nifedipine plus steroid, alfuzosin, silodosin, tadalafil and tamsulosin were more effective. SUCRA values were highest for tadalafil plus silodosin and least for naftopidil plus steroid. From subgroup analysis with individual drugs for SER, SUCRA values were highest for naftopidil followed by silodosin and SET was highest for silodosin and least for naftopidil.

CONCLUSION

For lower ureter stone, tadalafil plus silodosin is the best combination and silodosin best individual drug considering the SET and SER. Nifedipine as monotherapy is no more effective than control group.

Mediators of human ureteral smooth muscle contraction-a role for erythropoietin, tamsulosin and Gli effectors

Background

Ureteral contractility is a poorly understood process. Contractions have been demonstrated to occur in the smooth muscle layers of the ureter. Previous work suggests the involvement of Gli family proteins and erythropoietin (EPO) in regulating mammalian ureteral smooth muscle contraction. We sought to devise a method by which the effects of these proteins and tamsulosin on distal human ureteral tissue contractility could be investigated to better understand mechanisms regulating human ureteral function.

Methods

IRB approval was obtained to procure portions of extraneous distal ureteral tissue from living donor renal transplants. Contractility was measured by placing the tissue in Krebs buffer and stimulating via a uniform electric current. Contractile force was recorded with each stimulation with and without the presence of a Gli inhibitor (GANT61) or EPO. Each ureteral specimen was subsequently fixed and tested by immunohistochemistry to determine Gli, EPO and alpha-adrenergic receptor activity.

Results

Electrical field stimulation successfully elicited contractions in the ureteral tissue. Administering tamsulosin decreased force and duration of ureteral contractions. Inhibiting Gli signaling decreased contractility and EPO decreased ureteral contractile forces within 5 minutes of administration versus untreated controls. Staining confirmed Gli1 protein and α-adrenergic receptor expression in ureteral smooth muscle and epithelial tissue with EPO receptor expression confined to the epithelial layer.

Conclusions

Distal ureteral contractile forces are decreased by inhibition of Gli family proteins and the α-adrenergic receptor. EPO acts within five minutes, suggesting ion channel involvement instead of changes in gene expression. Continuing work will elucidate the role of these proteins in coordinating ureteral contractions. This has implications for the use of pharmacologic methods to address ureteral contractility and dysfunctional peristalsis during stone passage, ureteroscopy, in transplant patients and potentially to reduce symptoms from ureteral stents.

Comparison of the efficacy of silodosin and a terpene combination in the medical expulsive therapy of distal ureteral stones

OBJECTIVE

We aimed to compare the efficacy of silodosin and a terpene combination in the treatment of distal ureteral stones.

METHODOLOGY

The data of the patients admitted to the urology policlinic with renal colic, diagnosed with distal ureteral stones, and followed up with medical expulsive therapy between December 2017 and June 2018 were retrospectively reviewed. The patients were divided into two groups: Group 1 comprised 72 patients that received 8 mg/day silodosin and Group 2 consisted of 51 patients that were given three capsules of a terpene combination daily. The groups were compared in terms of the patients' demographic characteristics, medical history, localisation of the present stone, renal collecting system status, daily fluid intake, number of emergency service visits, number of additional analgesic applications needed, number of pain attacks, number of days off work, stone expulsion rate and time to stone expulsion.

RESULTS

Of the total 123 patients, 98 (79.7%) were stone-free. The stone-free rate was 75.0% in Group 1 and 86.3% in Group 2, with no statistical difference between the two groups. However, the number of visits to the emergency service because of pain, number of additional analgesic applications required, number of days off work, and time to stone expulsion were statistically significantly lower in Group 2 than in Group 1.

CONCLUSIONS

The treatment of distal ureteral stones with silodosin is as effective as the terpene combination. However, the terpene combination is more effective than silodosin in managing pain and accelerating stone expulsion.

Comparison of efficacy of three commonly used alpha-blockers as medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis

Introduction:

The efficacy of alpha-blockers as medical expulsive therapy (MET) is well established. However, it is not known which of the three most commonly used alpha-blockers (tamsulosin, alfuzosin and silodosin) is the most efficacious. With this study we aimed to assess the efficacy of the three commonly used alpha-blockers as MET for distal ureter stones.

Materials and Methods:

For this review, we searched multiple databases such as PubMed/Medline, Scopus, Embase, OviD SP, CINAHL, and web of science to identify all the relevant randomized studies comparing the efficacy of tamsulosin, alfuzosin, and silodosin. Preferred reporting items for systematic reviews for network meta-analysis (PRISMA-NMA) were followed while conducting this review and the study protocol was registered with PROSPERO (CRD42020175706).

Results:

In this review, 31 studies with 7077 patients were included. Compared to placebo all the treatment groups were more effective for both stone expulsion rate (SER) and stone expulsion time (SET). For both SER and SET, silodosin had the highest SUCRA (94.8 and 90.4) values followed by alfuzosin (58.8 and 64.9) and tamsulosin (46.2 and 44.5). The incidence of postural hypotension was similar with all the drugs, whereas, the incidence of retrograde ejaculation was significantly higher for silodosin. Overall confidence for each comparison group in this review ranged from “very low” to “moderate” according to the CINeMA approach.

Conclusion:

Among the three commonly used alpha-blockers silodosin is the most efficacious drug as MET for lower ureter stones followed by alfuzosin and tamsulosin.

Efficacy of Tamsulosin plus Tadalafil versus Tamsulosin as Medical Expulsive Therapy for Lower Ureteric Stones: A Randomized Controlled Trial

Introduction

Urolithiasis is one of the common disorder with which about 1/5^th is found in the ureter, of which 2/3^rd is seen in the lower ureter. Medical expulsive therapy is one of the routine modalities of treatment which uses various drugs acting on the ureter smooth muscle by different mechanism. We aim to compare the efficacy of combination vs. single drug.

Methods

This randomized controlled trial was done in 176 consecutive patients over a period of six months (March 2019 to August 2019) in Department of Urology and Kidney Transplant Surgery, Tribhuvan University Teaching. Participants were divided into two groups (Group A, tamsulosin plus tadalafil, and Group B, tamsulosin) from computer-generated random numbers. Therapy was continued for a maximum of 3 weeks. Stone expulsion rate, time to stone expulsion, analgesic use, number of colic and emergency room visits for pain, early intervention, and adverse effects of drugs were recorded.

Results

Among 176 patients who were enrolled in study, 7 were lost to follow-up, and 5 people required immediate intervention. There was a significant higher stone passage rate in group A than group B (64 vs. 50; P=0.025) and shorter expulsion time (1.66 vs. 2.32 weeks P=0.001) and less number of emergency room visits and colic episodes. No significant side effects were noted during study.

Conclusion

Tamsulosin plus Tadalafil is more effective than tamsulosin with early passage of stone and decreased number of colic episodes and emergency visits without significant side effects for lower ureteric calculi of 5 mm to 10 mm.

The evaluation of the effectiveness of Gilaburu (Viburnum opulus L.) extract in the medical expulsive treatment of distal ureteral stones

OBJECTIVE

Medical expulsive therapy is an important non-invasive treatment modality that facilitates the passage of ureteral stones. The aim of the present study was to evaluate the efficacy of Gilaburu (Viburnum opulus) extract in the treatment of distal ureteral stones <10 mm.

MATERIAL AND METHODS

Data of 103 patients were retrospectively analyzed. Patients were divided into two groups: those given V. opulus 1000 mg peroral 3×2 and diclofenac 50 mg peroral on-demand (n=53) and those given only diclofenac sodium 50 mg peroral on-demand (n=50). Comparisons of stone expulsion rates and the elapsed time until the expulsion between the groups were determined as primary outcome measures. The comparison of the need for additional treatment [ureteroscopy (URS) or extracorporeal shock wave lithotripsy (ESWL)], the need for emergency admission, analgesic requirement, and the complication rates in additional treatment were determined as secondary outcome measures.

RESULTS

The mean age of the patients was 45.8±14.5 years. The rate of stone expulsion was significantly higher (82% vs. 66%, p=0.026), and elapsed time to stone expulsion was significantly shorter (9±1.8 vs. 14±2.3 day, p=0.018) in the V. opulus group. The need for additional treatment (URS and ESWL) and analgesic requirement was less in the V. opulus group (9.4% vs. 20%, p=0.038 and 24.5% vs. 44%, p=0.042, respectively).

CONCLUSION

V. opulus is an herbal treatment alternative that facilitates the passage of ureteral stones <10 mm. Prospective, randomized studies are needed to support these results.

Efficacy and safety of phosphodiesterase type 5 inhibitors for the treatment of distal ureteral calculi of 5 to 10 mm in size: A systematic review and network meta-analysis

To evaluate the Efficacy and safety of phosphodiesterase type 5 inhibitors as a medical therapy for distal ureteral calculi by means of a systematic review and network meta-analysis (NMA). We searched the Embase, Medline, and the Cochrane Central Register of Controlled Trials for randomised controlled trials (RCTs) published before May, 2017. Stone passage rate as the primary outcome. We used random effects model for pairwise meta-analyses and Bayesian random effects model for NMA. We evaluated the quality of evidence by the GRADE framework for each network estimate. Five RCTs (861 patients) comparing four different interventions. The results of NMA showed that compared with tamsulosin alone, tamsulosin combined with tadalafil group was associated with significantly higher stone passage rate (odds radio [OR] 2.55, 95% credible intervals [Crl] 1.11 to 5.89). When considering stone expulsion rate, compared with tamsulosin, silodosin was ranked best (OR 3.58, 95% Crl 1.13 to 11.91), followed by tamsulosin combined with tadalafil (OR 2.55, 95% Crl 1.11 to 5.89) and tadalafil alone (OR 1.86, 95% Crl 0.95 to 4.25). No significant difference was found considering safety profiles between any interventions. This meta-analysis indicates that tamsulosin combined with tadalafil is an effective treatment option for ureteral stones with a low occurrence of side effects. Clinicians should take all known safety and compliance of patients into account when choosing an optimal strategy. Since sample size of included studies, further RCTs are strongly encouraged to address the clinical question.

Comparing tamsulosin, silodosin versus silodosin plus tadalafil as medical expulsive therapy for lower ureteric stones: A randomised trial

Objective

To compare the efficacy of tamsulosin, silodosin, and silodosin plus tadalafil as medical expulsive therapy (MET) for distal ureteric calculi.

Methods

In all, 120 patients who met the inclusion criteria were randomised into one of three treatment arms: tamsulosin (Group A), silodosin (Group B), and silodosin plus tadalafil (Group C). The drugs were given for a maximum of 4 weeks. The primary endpoint was the stone expulsion rate and secondary endpoints were stone expulsion time, number of pain episodes, and side-effects associated with MET. The follow-up period was for 4 weeks, after which ureteroscopic lithotripsy was done to remove any stones that were not expelled.

Results

There was a statistically significantly higher stone expulsion rate in Group C (90%) as compared to groups A (57.5%) and B (77.5%) with a shorter mean time to stone expulsion. Also, there were statistically fewer pain episodes in Group C as compared to groups A and B. There were no serious side-effects.

Conclusion

The present study concludes that the combination of silodosin and tadalafil increases the ureteric stone expulsion rate and decreases the expulsion time significantly. This combination provided significantly better control of pain without any serious side-effects.