Efficacy of Tamsulosin, Oxybutynin, and their combination in the control of double-j stent-related lower urinary tract symptoms

Comparison of the efficacy and complications of tolterodine and α-adrenergic receptor blockers in improving ureteral stent-related symptoms: A systematic review and meta-analysis

OBJECTIVE

We conducted a systematic evaluation of the therapeutic efficacy and complications of tolterodine and α-adrenergic receptor blockers in alleviating ureteral stent-related symptoms.

METHODS

Until August 2023, we conducted a comprehensive literature search on PubMed, Embase, Web of Science, and Cochrane Library to identify randomized controlled trials evaluating the efficacy and complications of tolterodine and α-adrenergic receptor blockers in treating ureteral stent-related symptoms. Two reviewers independently screened studies and extracted data. The scores from various domains of the Ureteral Stent Symptom Questionnaire (USSQ) were summarized and compared, and statistical analysis was performed using RevMan 5.4.0 software.

RESULTS

A total of 8 studies met the inclusion criteria for our analysis. These studies were conducted at different centers. All studies were randomized controlled trials, involving a total of 487 patients, with 244 patients receiving α-adrenergic receptor blockers and 243 patients receiving tolterodine. The results showed that tolterodine demonstrated significantly better improvement in body pain (MD, 1.56; 95% CI [0.46, 2.66]; p = 0.005) (MD, 0.46; 95% CI [0.12, 0.80]; p = 0.008) (MD, 3.21; 95% CI [1.89, 4.52]; p = 0.00001) among patients after ureteral stent placement compared to α-adrenergic receptor blockers at different time points. Additionally, at 4 weeks, tolterodine showed superior improvement in general health (MD, 0.15; 95% CI [0.03, 0.27]; p = 0.01) and urinary symptoms (MD, 1.62; 95% CI [0.59, 2.66]; p = 0.002) compared to α-adrenergic receptor blockers, while at 6 weeks, tolterodine showed better improvement in work performance (MD, -1.60; 95% CI [-2.73, -0.48]; p = 0.005) compared to α-adrenergic receptor blockers. Additionally, the incidence of dry mouth (RR, 4.21; 95% CI [1.38, 12.87]; p = 0.01) is higher with the use of tolterodine compared to α-adrenergic receptor blockers. However, there were no significant statistical differences between the two drugs in other outcomes.

CONCLUSION

This meta-analysis suggests that tolterodine is superior to α-adrenergic receptor blockers in improving physical pain symptoms after ureteral stent placement, while α-adrenergic receptor blockers are more effective than tolterodine in enhancing work performance. Additionally, the incidence of dry mouth is higher with the use of tolterodine compared to α-adrenergic receptor blockers. However, higher-quality randomized controlled trials are needed to further investigate this issue.

Efficacy and safety of pelvic floor magnetic stimulation combined with mirabegron in female patients with refractory overactive bladder: a prospective study

Objective

To observe the efficacy and safety of pelvic floor magnetic stimulation (PFMS) combined with mirabegron in female patients with refractory overactive bladder (OAB) symptoms.

Patients and methods

A total of 160 female patients with refractory OAB symptoms were prospectively randomized into two groups. Eighty cases in the combination group accepted PFMS and mirabegron therapy and 80 cases as control only accepted mirabegron therapy (The clinical trial registry number: ChiCTR2200070171). The lower urinary tract symptoms, OAB questionnaire (OAB-q) health-related quality of life (HRQol), symptom bother score and OABSS between two groups were compared at the 1st, 2nd and 4th week ends.

Results

All of 160 patients were randomly assigned to two groups, of which 80 patients were included in the combination group and 80 in the mirabegron group. The incidences of LUTS, including urgency, frequent urination, and incontinence episodes, in the 2nd week and the 4th week after combination treatment were significantly lower than those in the mirabegron group (p < 0.05). The incidence of drug-related adverse events between two groups was similar, and there was no statistically significant difference (p > 0.05). With respect to secondary variables, the OAB-q HRQol score in the combination group was statistically superior in comparison with that in the mirabegron group between the 2nd week and the 4th week (p < 0.05). This was consistent with the primary outcome. Meanwhile, from the second to fourth week, the OAB-q symptom bother score and OABSS in the combination group were both lower than in the mirabegron group (p < 0.05).

Conclusion

Combination therapy of PFMS and mirabegron demonstrated significant improvements over mirabegron monotherapy in reducing refractory OAB symptoms for female patients, and providing a higher quality of life without increasing bothersome adverse effects.

Clinical Trial Registration

https://www.chictr.org.cn/, ChiCTR-INR-22013524.

Tamsulosin Versus Mirabegron in Relieving Ureteric Stent-Related Symptoms: A Prospective, Double-Blinded, Randomized Controlled Trial

Introduction Alpha-adrenergic blockers like tamsulosin are widely used in the treatment of stent-related symptoms due to ureteric stents. Recently, mirabegron has emerged as a potential alternative. So, our study aimed to compare the effect of mirabegron and tamsulosin on ureteric stent-related morbidity. Methods In this randomized controlled study, 80 patients undergoing uncomplicated ureteroscopic lithotripsy with double J stenting for ureteric stones were enrolled. They were divided into two groups: Group A (n=40) received mirabegron (25mg) and Group B (n=40) received tamsulosin (0.4mg). Outcomes were assessed using the Ureteral Stent Symptom Questionnaire (USSQ), International Prostate Symptoms Score (IPSS), and the visual analog pain scale. The t-test and the Chi-square test were utilized to study the efficacy of the interventions across both groups. Results The USSQ urinary symptom score (25.5 vs 33.45; p < 0.001) and body pain score (16.15 vs 26.02; P < 0.001) were significantly lower in the mirabegron group. However, the general health score (17.0 vs 17.28; p = 0.62) and work performance score (7.6 vs 8.0; p = 0.28) did not show a significant difference. The storage symptom score was significantly lower in the mirabegron group (3.98 vs 5.1; p = 0.001). Furthermore, the mirabegron group reported a better quality of life score (2.18 vs 3; p < 0.001). Conclusion Mirabegron has been shown to reduce urinary symptoms associated with ureteric stents and also results in a better quality of life when compared with tamsulosin. However, large-scale, prospective, multicentric studies are further required to holistically evaluate and comprehend the beneficial effects of mirabegron on stent-related morbidity.

Open Label, Pilot Evaluation of the Safety and Efficacy of Intravesical Sustained Release System of Lidocaine and Oxybutynin (TRG-100) for Patients With Interstitial Cystitis/Bladder Pain Syndrome, Overactive Bladder and Patients With Retained Ureteral Stents Following Endourological Interventions

BACKGROUND

Intravesical instillation of analgesic and anticholinergic drugs have shown efficacy in the treatment of pain and voiding symptoms. Unfortunately, drug loss with urination and dilution in the bladder limit their durability and clinical usefulness. We have recently developed and tested in vitro, a sustained delivery system (TRG-100) of fixed-dose combination of lidocaine and oxybutynin designed to allow for a longer exposure of the urinary bladder to the drugs.

OBJECTIVE

To asses the safety and efficacy of TRG-100 in Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS), overactive bladder (OAB), and endourological intervention stented (EUI) patients in an open-label, prospective study.

METHODS

Thirty-six patients were enrolled: 10 IC/BPS, 10 OAB, and 16 EUI. EUI patients received a once-weekly installation until stent removal, OAB and IC/BPS patient received weekly installations for 4 consecutive weeks. Treatment effect was assessed by visual analog scale (VAS) score for the EUI group, voiding diaries for OAB group and VAS score, voiding diaries and O'Leary Sant Questionnaires for the IC/BPS group.

RESULTS

The EUI group showed a mean 4-point improvement in their VAS score. The OAB group showed 33.54% reduction in frequency of urination and IC/PBS group showed a mean of 3.2-point improvement in their VAS score, 25.43% reduction in frequency of urination, and a mean 8.1-point reduction in O'Leary Sant Questionnaires score. All changes were statistically significant.

CONCLUSION

Intravesical instillation of TRG-100 was found to be safe and efficient in reducing pain and irritative bladder symptoms in our study population. TRG-100 efficacy and safety should be further assessed in a large, randomized control trial.

Efficacy and safety of combination of mirabegron and solifenacin in patients with double-J stent related overactive bladder: a prospective study

To observe the efficacy and safety of solifenacin and/or mirabegron as a medical expulsive therapy (MET) in patients with double-J stent-related overactive bladder (OAB) symptoms. A total of 219 patients with double-J stent-related OAB symptoms were prospectively randomized into two groups. One-hundred and nine cases in the combination group accepted mirabegron and solifenacin therapy and 110 cases as control only accepted solifenacin therapy. The lower urinary tract symptoms and overactive bladder questionnaire (OAB-q) health-related quality of life (HRQol) and symptom bother score between two groups were compared at the 1st, 2nd and 4th week ends. All of 219 patients were randomly assigned to two groups, of which 109 patients were included in the combination group and 110 in the solifenacin group. The incidences of LUTS, including urgency, frequent urination, and incontinence episodes, in the 2nd week (44.9% vs. 64.5%, P = 0.028; 48.6% vs. 62.7%, P = 0.036; and 40.4% vs. 56.4%, P = 0.018) and the 4th week (14.7% vs. 30.9%, P = 0.004; 16.5% vs. 33.6%, P = 0.003; and 11.9% vs. 26.4%, P = 0.007) after combination treatment were significantly lower than those in the solifenacin group. The incidence of drug-related adverse events in the solifenacin group was higher than that in the combination group, but there was no statistically significant difference (P > 0.05). In terms of secondary variables, the OAB-q HRQol score in the combination group was statistically superior in comparison with that in the solifenacin group between the second and fourth week (77.9 vs. 76.4, P = 0.020; and 87.9 vs. 85.6, P = 0.001). The OAB-q symptom bother score was higher in the solifenacin group than in the combination group (37.6 vs. 36.4, P = 0.016; and 26.2 vs. 24.8, P = 0.003). Combination therapy of solifenacin and mirabegron demonstrated significant improvements over solifenacin monotherapy in reducing OAB symptoms associated with double-J stents, and providing a higher quality of life without increasing bothersome adverse effects.

Mirabegron as effective as oxybutynin for ureteral stent symptoms

OBJECTIVE

Ureteral stents usually cause pain and lower urinary tract discomfort. This study aimed to compare the effect of mirabegron with oxybutynin in relieving ureteral stent-related symptoms over time.

METHODS

A prospective, longitudinal, randomized, single-blinded study was conducted. Patients who had a ureteral stent inserted after urolithiasis treatment were classified into two groups and received either oxybutynin 5 mg/day (Group O) or mirabegron 50 mg/day (Group M). The Ureteral Stent Symptoms Questionnaire (USSQ) was applied on the 3rd, 6th, and 15th postoperative days. Group domain scores were compared, and a mixed linear model was used to better assess score differences.

RESULTS

Ureteral Stent Symptoms Questionnaire scores were similar in both groups during all three postoperative days (p>0.05). A longitudinal analysis showed that global quality of life and general health improved over time, independently of the use of any of the medications (p<0.05), while urinary symptoms and body pain scores were lower over time in participants receiving oxybutynin.

CONCLUSION

Both mirabegron and oxybutynin are equivalent in relieving ureteral stent symptoms. Moreover, some stent symptoms seem to decrease over time despite the use of medication.

Are All Stent Bearers Equal? Ureteral Stent Symptoms in Kidney Transplant Patients: A Case-Control Prospective Study

Purpose: The aim of this study is to conduct a prospective, controlled single-center study to determine the prevalence and types of ureteral stent symptoms in kidney transplant (KTx) recipients and compare them with nontransplant subjects. Materials and Methods: From December 2012 to June 2019, a total of 102 patients having undergone a KTx and Double-J stent (DJS) placement and 88 patients having undergone endourological lithotripsy and DJS placement were enrolled. The Ureteral Stent Symptom Questionnaire (USSQ) was administered to patients with a median of 25 (KTx) and 31 (urolithiasis) days after stent placement. USSQ scores were used to compare symptoms between the two groups. Results: Of the 190 patients enrolled, 88 belonged to the lithotripsy group (control group) and 102 to the KTx recipients' group. Mean score for urinary symptoms was 21.42 for KTx patients vs 27.53 for control patients with statistical significance (p < 0.001, CI -7.792 to -4.433). The visual analog scale, overall bother, pain at voiding, flank pain at voiding, and frequency of painkiller use scores were significantly higher for control patients than for KTx patients (p = 0.024, <0.001, <0.001, <0.001, and 0.014, respectively). Frequency of rest, changes in work duration, work domain score, suspicion of urinary tract infection (UTI), and need for professional assistance scores were significantly lower for KTx patients than the control. There were no significant differences in general health and sexual domains between groups. Conclusions: KTx recipients have significantly fewer urinary symptoms, pain, work-related disturbances, suspected UTIs, and hospitalizations associated with stent placement than urolithiasis patients.

Postoperative opioid-free ureteroscopy discharge: A quality initiative pilot protocol

BACKGROUND

Opioids are commonly prescribed after ureteroscopy. With an increasing adoption of ureteroscopy for management of urolithiasis, this subset of patients is at high risk for opioid dependence. We sought to pilot an opioid-free discharge protocol for patients undergoing ureteroscopy for urolithiasis.

MATERIALS AND METHODS

A prospective cohort study was performed of all patients undergoing ureteroscopy for urolithiasis and compared them to a historical control group. An opioid-free discharge protocol was initiated targeting all areas of surgical care from June 20th, 2019 to September 20th, 2019 as part of an institutional quality improvement initiative. Demographic and surgical data were collected as were morphine equivalent doses (MEDs) prescribed at discharge, postoperative measures including phone calls, clinic visits, and emergency room visits for pain.

RESULTS

Between October 1st, 2017 and February 1st, 2018, a total of 54 patients who underwent ureteroscopy were identified and comprised the historical control cohort while 54 prospective patients met the inclusion criteria since institution of the quality improvement initiative. There were no statistically significant differences in baseline patient demographics or surgical characteristics between the 2 patient groups. Total 37% of the intervention group had a preexisting opioid prescription versus 42.6% of the control group with no difference in preoperative MED (p = 0.55). The intervention group had a mean MED of 12.03 at discharge versus 110.5 in the control cohort (p ≤ 0.001). At discharge 3.7% of the intervention group received an opioid prescription versus 88.9% of the control group (p < 0.001). Overall, there was no difference in postoperative pain related phone calls (p = 1.0) or emergency room visits (p = 1.0).

CONCLUSIONS

An opioid-free discharge protocol can dramatically reduce opioid prescription at discharge following ureteroscopy for urinary calculi without affecting postoperative measures such as phone calls, clinic visits, or subsequent prescriptions.

Effects of mirabegron on JJ stent-related symptoms: A multicentric study

AIMS OF THE STUDY

To investigate the effect of mirabegron 50 mg/daily for JJ stent-related symptoms after ureteroscopic stone surgery.

METHODS

Medical records of 145 patients who were given a single daily oral dose of 50 mg of mirabegron for relieving stent-related symptoms were retrospectively analysed. Demographic and clinical data and stone parameters were recorded. All participants completed the Turkish version of the Ureter Symptom Score Questionnaire (USSQ-T) on the postoperative 7th day, and again after at least 3 weeks, before JJ stent removal. The severity of stent-related symptoms was statistically compared before and after the mirabegron treatment.

RESULTS

The mean urinary symptoms score decreased significantly from 30.87 ± 9.43 to 22.61 ± 6.78 (P < .0001), mean body pain score decreased significantly from 21.82 ± 11.22 to 14.03 ± 7.52 (P < .0001), mean work performance score decreased from 10.50 ± 8.61 to 7.02 ± 6.51 (P < .0001) and mean general health score decreased significantly from 15.43 ± 6.50 to 11.12 ± 3.70 (P < .0001). The mean sexual matters score significantly decreased from 3.88 ± 3.40 to 2.48 ± 2.03 (P < .0001), the additional problem score decreased from 9.31 ± 4.61 to 6.51 ± 2.83 (P < .0001) and the overall quality of life (QoL) score decreased from 5.18 ± 1.94 to 4.23 ± 1.71 after mirabegron use (P < .0001).

CONCLUSION

Daily use of 50 g of mirabegron significantly improved stent-related symptoms, sexual matters and quality of life.

Strategies to Improve Patient Outcomes and QOL: Current Complications of the Design and Placements of Ureteric Stents

Ureteric stents have played a vital role in relieving urinary obstruction in many urological conditions. Although they are extremely successful, stents have been associated with complications and reduced patients' health-related quality of life (HRQoL). There are many factors that may affect the quality and longevity of stents. In this review, we have highlighted the journey and innovation of ureteric stents through the modern day. A literature review was conducted to identify relevant articles over the last 20 years. There is a plethora of evidence with various indications for the use of ureteral stents and how they affect QoL. There is still ongoing research to develop the ideal stent with reduced encrustation, one that resists infection and is also comfortable for the patients. Stents made from metal alloys, polymers and biodegradable materials have unique properties in their own right but also have certain deficiencies. These have been discussed along with an overview of newly developed stents. Certain pharmacological adjuncts have also been highlighted that may be useful to improve patient's tolerance to stents. In summary, this paper describes the features of the different types of stents and the problems that are frequently encountered, including effect on patients' HRQoL and financial burden to healthcare providers.

Ureteric stenting vs not stenting following uncomplicated ureteroscopic lithotripsy: A prospective randomised trial

Objective

To compare three groups of patients who underwent uncomplicated ureteroscopic lithotripsy (URSL) and to evaluate whether stenting could be eliminated after the procedure, as there is no consensus about whether a ureteric stent should be placed after uncomplicated ureteroscopy for stone retrieval.

Patients and methods

In this randomised clinical trial (NCT04145063) 105 patients underwent uncomplicated URSL for ureteric stones. They were prospectively randomised into three groups: Group 1 (34 patients) with a double pigtail ureteric stent, Group 2 (35 patients) with a double pigtail ureteric stent with extraction string, and Group 3 (36 patients) with no ureteric stent placed after the procedure. The outcomes measured were: postoperative visual analogue scale (VAS) score for flank pain and dysuria score, urgency, frequency, suprapubic pain, haematuria, analgesia requirement, operative time, re-hospitalisation, and return to normal physical activity.

Results

The mean (SD) operative time was significantly longer in groups 1 and 2 compared to Group 3, at 22.2 (9.1), 20.2 (6) and 15.1 (7.1) min, respectively (P < 0.001). The results of the VAS for flank pain and dysuria scores, urgency, frequency, haematuria, and suprapubic pain showed a significant difference at all time-points of follow-up, being significantly higher in groups 1 and 2 compared to Group 3 (all P < 0.001). Further analysis showed that measured outcomes, and analgesia need for groups 1 and 2 were similar, at all time-points except at week 1 and 1 month where Group 2 patients’ had less symptoms (P < 0.001).

Conclusion

Double pigtail ureteric stent placement appears to be unnecessary in procedures considered ‘uncomplicated’ by operating urologists during surgery. The advantages of the double pigtail ureteric stent with extraction string over the double pigtail ureteric stent only include earlier and easier removal with earlier relief of symptoms, and less analgesia requirements.

Abbreviations

KUB: plain abdominal radiograph of the kidneys, ureters and bladder; URSL: ureteroscopic lithotripsy; VAS: visual analogue scale

Ureteric stents: Overview of current clinical applications and economic implications

Ureteric stents are one of the most crucial tools used for various clinical conditions in the urological field. Placement of a ureteric stent, for short- or long-term use, remains one of the commonest urological interventional procedures. In the past few decades, ureteral stents have undergone notable technological advancements. However, an ideal stent without significant side-effects is yet to be engineered. Indwelling ureteric stents are often accompanied by physical distress to the patient and clinical complications, such as bacterial adhesion, encrustation, malpositioning, stent fracture and forgotten stent syndrome, that influence patients' health-related quality of life. In the market, different stent types are available, designed to reduce infections, and improve patient symptoms and tolerance. In this review, we have emphasized the recent developments that have taken place in stent design, size, materials and coating. This overview looks at current practices and problems related to stents, along with clinical and economic considerations. Few trial studies have been enumerated in the context of utilization of a ureteral stent symptom questionnaire and various stent models to compare their effects in patients.

Opiate Exposure and Predictors of Increased Opiate Use After Ureteroscopy

Objective: Kidney stone formers are at risk for opioid dependence. The aim of this study is to describe opiate exposure and determine predictors of prolonged opiate use among kidney stone formers after surgery. Materials and Methods: A retrospective review was performed among patients who underwent ureteroscopy for upper tract stone disease. Prescription data were ascertained from a statewide prescribing database. Demographic data and surgical factors were collected from the electronic medical record. Predictors of additional postsurgery prescriptions filled within 30 days and persistent opiate use 60 days after ureteroscopy were determined. Results: Among 208 patients, 127 (61%) had received preoperative opiate prescriptions within 30 days before surgery. Overall, 12% (n = 25) of patients required an additional opiate prescription within 30 days after ureteroscopy, and 7% (n = 14) of patients continued to use opiate medications more than 60 days postoperatively. Patients continuing to use opiates long-term were not chronic opiate users. For both outcomes, preoperative opiate exposure, including number of prescriptions, days prescribed, and unique providers had significant associations (all p < 0.05). Additionally, younger age (p = 0.049) was associated with obtaining an additional opiate prescription within 30 days. Lower BMI (p = 0.02) and higher ASA score (p = 0.03) were predictors of continued opiate use more than 60 days after ureteroscopy. Conclusions: The majority of stone formers have had opiate exposure before surgery, often from multiple providers. Approximately 1 in 8 stone formers who undergo ureteroscopy require additional opiate prescriptions within 30 days. A small but significant population receive opiates beyond the immediate postoperative period.

Comparison of safety and efficacy of silodosin, solifenacin, tadalafil and their combinations in the treatment of double-J stent- related lower urinary system symptoms: A prospective randomized trial

OBJECTIVE

To evaluate the efficacy and safety of silodosin, solifenacin, tadalafil and their combinations in reducing double J (DJ) stent-related symptoms (SRS).

MATERIAL AND METHODS

A total of 335 patients who underwent DJ stenting and develop SRS at 1^st week were randomized into eight groups. Ureteral stent symptom questionnaire (USSQ) and Quality of life (QOL) scores were noted in each group: Group A-Silodosin (8 mg OD)+ Solifenacin (10 mg OD)+ Tadalafil (5 mg OD), B - Silodosin 8 mg OD, C - Solifenacin 10 mg OD, D- Tadalafil 5 mg OD, E- Silodosin (8 mg OD) + Solifenacin (10 mg OD), F- Silodosin (8 mg 0D)+ Tadalafil (5 mg OD), G- Solifenacin (10 mg OD)+ Tadalafil (5 mg OD) and H-placebo. Analgesic (diclofenac 50 mg) was given as per requirement. All groups received the drugs for 14 days and again USSQ, QOL score with analgesic requirement were noted in each group.

RESULTS

USSQ score was similar in all groups at 1^st week but all groups (Groups A-G) led to significant decrease in USSQ score at 3^rd week as compared to Group H with less requirement of analgesic. However when we compared groups with each other we found that mean USSQ score and analgesic requirement was favoring Group E as compared to other groups. Quality of life score was also best in Group E (mean 1.5) (p<0.05).

CONCLUSION

Combination therapy with silodosin and solifenacin (group E) was effective for relieving SRS with improved quality of life and less requirement of analgesic than any other groups and should be considered in patients who develop SRS.