Time to stone passage for observed ureteral calculi: a guide for patient education

RANDOMIZED TRIAL OF THE EFFICACY OF TAMSULOSIN, NIFEDIPINE AND PHLOROGLUCINOL IN MEDICAL EXPULSIVE THERAPY FOR DISTAL URETERAL CALCULI

PURPOSE

Recent studies show the interesting efficacy of different drug combinations for the spontaneous expulsion of distal ureteral stones. We performed a randomized, prospective study to assess and compare the efficacy of 3 drugs as medical expulsive therapy for distal ureteral calculi.

MATERIALS AND METHODS

A total of 210 symptomatic patients with distal ureteral calculi greater than 4 mm were randomly allocated to home treatment with phloroglucinol, tamsulosin or nifedipine (groups 1 to 3, respectively). Each group was given a corticosteroid drug and antibiotic prophylaxis with an injectable nonsteroidal anti-inflammatory drug was also used on demand. The primary end point was the expulsion rate and the secondary end points were expulsion time, analgesic use, need for hospitalization and endoscopic treatment as well as the number of workdays lost, quality of life and drug side effects

RESULTS

The expulsion rate was significantly higher in group 2 (97.1%) than in groups 1 (64.3%, p <0.0001) or 3 (77.1%, p <0.0001). Group 2 significantly achieved stone passage in a shorter time than the other 2 groups and showed a significantly decreased number of hospitalizations as well as a better decrease in endoscopic procedures performed to remove the stone. The control of renal colic pain was significantly superior in group 2 compared with the other groups, resulting in fewer workdays lost. Group 3 showed lower analgesic use and decreased workdays lost compared with group 1. No difference in side effects was observed among the groups.

CONCLUSIONS

Medical expulsive therapy should be considered for distal ureterolithiasis without complications before ureteroscopy or extracorporeal lithotripsy. The use of tamsulosin in this treatment regimen produced stone expulsion in almost all cases in a short time, allowing complete home patient treatment.

THE COMPARISON AND EFFICACY OF 3 DIFFERENT α1-ADRENERGIC BLOCKERS FOR DISTAL URETERAL STONES

PURPOSE

alpha1-Adrenergic blockers have recently been shown to increase the rate of spontaneous passage of distal ureteral stones. We compared efficacy of 3 different alpha1-adrenergic blockers for this purpose.

MATERIALS AND METHODS

A total of 114 patients between 18 and 65 years old who had lower ureteral stones were included in the study. Patients were randomly divided into 4 groups. Group 1 consisted of 28 patients and acted as the control group. Group 2 comprised 29 patients who received tamsulosin, group 3 was 28 patients receiving terazosin and group 4 was 29 patients receiving doxazosin. These agents were given for up to a month and hydration was also recommended simultaneously. Every week patients were controlled with x-rays of the kidneys, ureters, bladder and urinary ultrasonography. Meanwhile the number of pain episodes, analgesic dosage and the number of days for spontaneous passage of the calculi through the ureter were also recorded.

RESULTS

There were no differences between the groups with respect to age, weight, height, sex and stone size. The calculi passed through the ureter spontaneously in 15 patients in group 1 (53.57%), in 23 patients in group 2 (79.31%), in 22 patients in group 3 (78.57%), and in 22 patients in group 4 (75.86%). In groups 2 to 4 the number of pain episodes, expulsion time and analgesic dosage were found to be lower compared with those in group 1.

CONCLUSIONS

alpha1-Adrenergic blockers increase the frequency of spontaneous passage of the distal ureteral calculi. All 3 agents tested were equally efficacious.

Does tamsulosin enhance lower ureteral stone clearance with or without shock wave lithotripsy?

OBJECTIVES

To evaluate whether alpha1-blockers have any impact on stone clearance in patients with lower ureteral stones who underwent either shock wave lithotripsy (SWL) or were followed up with standard hydration, analgesics, and anti-inflammatory treatment.

METHODS

A total of 78 patients (56 men and 22 women) who had lower ureteral stones located at the distal 5 cm of the ureter were divided into four groups. The first group consisted of 30 patients (38.5%) with stones less than 5 mm (range 3 to 5) who were randomly divided into two subgroups. Group 1 consisted of 15 patients (19.2%) who were followed up with oral hydration and diclofenac sodium. Group 2 consisted of 15 patients (19.2%) who received tamsulosin 0.4 mg daily in addition to the standard regimens. The second two groups consisted of 48 patients (61.5%) with stones greater than 5 mm (range 6 to 15) who underwent SWL. These patients were also randomly divided between those who did not (group 3, n = 24) and those who did (group 4, n = 24) receive tamsulosin 0.4 mg daily. All patients were re-evaluated with plain abdominal x-rays and helical computed tomography 15 days after the beginning of treatment.

RESULTS

Of the 78 patients, 36 (46.2%) became stone free. The stone-free rate was 20%, 53.3%, 33.3%, and 70.8% for group 1, 2, 3, and 4, respectively. The best results were achieved in those who underwent SWL plus tamsulosin treatment (group 4). The differences between the stone-free rates for groups 3 versus 4 (P = 0.019) and the tamsulosin versus control groups (P = 0.0015) were statistically significant.

CONCLUSIONS

The addition of tamsulosin to conventional treatment seemed beneficial in terms of stone clearance of lower ureteral stones, and this effect was more evident for larger stones, especially when combined with SWL.

Management of ureteric stones

The contemporary management of ureteric stones is reviewed and evidence based recommendations about treatment are made. Stones measuring less than 4mm in diameter have a high chance of spontaneous passage and the main debate for optimum treatment of larger stones centres around the choice of shock wave lithotripsy or endoscopic management combined with laser fragmentation. Treatment recommendations should be based on patient preference, published evidence, local audit (surgeon expertise and availability of equipment) and cost. Artificial Neural Networks could become a useful tool for prediction of treatment outcome for ureteric stones, and further research is needed to clarify this potential. ESWL is less effective than ureteroscopy but it may prevent the need for more invasive treatment in a substantial proportion of patients. It should only be considered as initial treatment in patients with stones less than 10mm in size. The routine use of stents should be avoided as both fragmentation and stone free rates are noticeably lower. For larger stones, initial laser ureteroscopy serves better both for proximal or distal calculi and is more cost-efficient. Provided that no contraindications for general anaesthesia exist, laser ureterolithotripsy should be regarded as an excellent first line treatment modality for ureteric stone especially in greater stone burden. In the best hands, the outcome for endoscopic management of ureteric stone in all sites is better than ESWL and is cheaper, although equipment, expertise and experience are all required to achieve this superior outcome.

Nifedipine versus tamsulosin for the management of lower ureteral stones

PURPOSE

We evaluate and compare the effectiveness of 2 different medical therapies during watchful waiting in patients with lower ureteral stones.

MATERIALS AND METHODS

A total of 86 patients with stones less than 1 cm located in the lower ureter (juxtavesical or intramural tract) were enrolled in the study and were randomly divided into 3 groups. Group 1 (30) and 2 (28) patients received daily oral treatment of 30 mg deflazacort, (maximum 10 days). In addition group 1 patients received 30 mg nifedipine slow-release (maximum 28 days) and group 2 received 1 daily oral therapy of 0.4 mg tamsulosin (maximum 28 days), Group 3 patients (28) were used as controls. Statistical analyses were performed using Student's test, ANOVA test, chi-square test and Fisher's exact test.

RESULTS

The average stone size for groups 1 to 3 was 4.7, 5.42 and 5.35 mm, respectively, which was not statistically significant. Expulsion was observed in 24 of 30 patients in group 1 (80%), 24 of 28 in group 2 (85%) and 12 of 28 in group 3 (43%). The difference in groups 1 and 2 with respect to group 3 was significant. Average expulsion time for groups 1 to 3 was 9.3, 7.7 and 12 days, respectively. A statistically significant difference was noted between groups 2 and 3. Mean sodium diclofenac dosage per patient in groups 1 to 3 was 19.5, 26, and 105 mg, respectively. A statistical significant difference was observed between groups 1 and 2 with respect to group 3.

CONCLUSIONS

Medical treatments with nifedipine and tamsulosin proved to be safe and effective as demonstrated by the increased stone expulsion rate and reduced need for analgesic therapy. Moreover medical therapy, particularly in regard to tamsulosin, reduced expulsion time.

A COMPUTER MODEL TO PREDICT THE OUTCOME AND DURATION OF URETERAL OR RENAL CALCULOUS PASSAGE

PURPOSE

We developed a computer model to predict the outcome and the duration until passage of ureteral/renal calculi.

MATERIALS AND METHODS

A retrospective, randomized study was performed of the outcome in 301 patients presenting to the emergency room for renal colic. Presenting characteristics of those diagnosed with a single calculus by computerized tomography were recorded for analysis. Predictors of stone passage and passage duration were identified and then used to create a logistic regression model. The algorithm was trained on 141 randomly selected patients and then tested on a separate 160 patients. Model accuracy was compared to predictions from 10 experienced urologists and 9 urology residents in 77 randomly selected patients. The model was tested further in 30 randomly selected patients at a private hospital to assess its general applicability.

RESULTS

The model prediction accuracy in 160 patients was 86.3% for passage and 87.3% for duration (less or greater than 2 weeks). In the comparison group the model, the 10 experienced urologists and the 9 urology residents had an overall prediction accuracy of 88.3%, 70.5% (p = 0.006) and 72% (p = 0.007) for passage, and 87.1%, 71.6% (p = 0.007) and 81% (p = 0.075) for duration, respectively. Prediction accuracy was 93.3% for passage and 90.3% for duration when tested at a private hospital.

CONCLUSIONS

Our model provides outcome and duration of passage predictions for patients presenting acutely in the emergency room with a single ureteral/renal calculus. It performs better than experienced urologists and urology residents. It can be applied to a private practice setting with equal accuracy.

Extracorporeal Shockwave Lithotripsy For Solitary Distal Ureteral Stones: Does the Degree of Urinary Obstruction Affect Success?

BACKGROUND AND PURPOSE

Extracorporeal shockwave lithotripsy (SWL) is a safe and effective way to treat stones in the distal ureter, but the impact of urinary obstruction on outcome is not clear. We investigated the relation between the degree of stone-induced urinary obstruction and the outcome of SWL treatment in patients with solitary distal ureteral stones.

PATIENTS AND METHODS

A series of 165 consecutive patients with solitary distal ureteral stones underwent SWL (Multimed 9200 Lithotriptor, Elmed Medical Systems, Turkey) between October 2002 and September 2003 at two separate centers. Distal ureteral stones were defined as those located below the lower border of the sacroiliac joint. Patients were divided into four groups according to the degree of stone-induced urinary obstruction: group I (N = 62) had no urinary system dilation; group II (N = 40) had mild dilation, group III (N = 35) moderate dilation, and group IV (N = 28) severe dilation. In addition to degree of obstruction, stone size, average fluoroscopy time, total number of shockwaves applied, number of sessions required to achieve stone-free status, and stone clearance time were recorded. Treatment failure was defined as persistence of fragments after three SWL sessions.

RESULTS

Overall, 152 (92.1%) of the patients became stone free after SWL. There were no statistically significant differences among the groups with respect to any of the factors studied.

CONCLUSION

In cases where there is a solitary calculus in the distal ureter, the degree of urinary obstruction caused by the stone does not affect the success of stone clearance with SWL.

Efficacy of Tamsulosin in the Medical Management of Juxtavesical Ureteral Stones

PURPOSE

We evaluated the efficacy of the alpha1-adrenergic antagonist tamsulosin for conservative expulsive therapy in patients with ureteral colic due to juxtavesical stones.

MATERIALS AND METHODS

A total of 60 consecutive symptomatic patients with stones located in the juxtavesical tract of the ureter were randomly divided into group 1--30 who received oral floroglucine-trimetossibenzene 3 times daily and group 2--30 who received 0.4 mg tamsulosin daily. The 2 groups received 30 mg deflazacort daily for 10 days plus cotrimoxazole 2 times daily for 8 days and 75 mg diclofenac injected intramuscularly on demand. Ultrasound followup and medical visits were performed weekly for 4 weeks. Stone passage rate and time, analgesic use, hospitalization and endoscopical intervention were evaluated. Statistical analysis was performed using the Student t test.

RESULTS

The stone expulsion rate was 70% for group 1 and 100% for group 2. Mean stone size was 5.8 and 6.7 mm, respectively (p = 0.001). Mean expulsion time was 111.1 hours for group 1 and 65.7 hours for group 2 (p = 0.020). The mean number of diclofenac injections was 2.83 for group 1 and 0.13 for group 2 (p <0.0001). Ten group 1 patients were hospitalized, of whom 9 underwent ureteroscopy, compared with none in group 2 (p <0.0001 and 0.001, respectively).

CONCLUSIONS

Tamsulosin used as a spasmolytic drug during renal colic due to juxtavesical calculi increased the stone expulsion rate and decreased expulsion time, the need for hospitalization and endoscopic procedures, and provided particularly good control of colic pain.

Clinical characteristics of ureteral calculi detected by nonenhanced computerized tomography after unclear results of plain radiography and ultrasonography

PURPOSE

Prospective non-enhanced computerized tomography (CT) was performed for patients presenting with renal colic and showing negative or equivocal results on plain x-ray of the kidneys, ureters and bladder (KUB) as well as ultrasonography (US) to evaluate the usefulness of plain CT. We also evaluated the clinical characteristics of urinary calculi detected under such conditions.

MATERIALS AND METHODS

Between January 2000 and June 2002, 560 patients presented with acute unilateral renal colic. Of these patients 238 negative or equivocal for ureteral calculus on KUB and US underwent non-enhanced CT. The diagnostic value of plain CT in patients with negative or equivocal KUB and US was determined, and results and other clinical findings were compared. Clinical characteristics of ureteral stones detected by plain CT were compared with those of stones diagnosed by KUB and US.

RESULTS

By plain CT 143 (60.1%) and 6 (2.5%) cases of pain were determined to have been caused by ureteral stones and other pathogeneses, respectively. No definitive diagnosis was obtained in 89 (37.4%). Stone size detected by plain CT was significantly smaller than controls (3.77 vs 6.37 mm, p <0.0001) and tended to be located in the middle or lower ureter (76.2% or 109 of 143 vs 52.2% or 168 of 322, p <0.0001). Symptoms spontaneously improved in 137 (95.8%) after conservative therapy while 6 underwent intervention, a rate significantly lower (p <0.0001) than controls (32.9% or 106 of 322).

CONCLUSIONS

Non-enhanced CT is a useful modality for diagnosis of patients presenting with acute renal colic but whose results are negative or equivocal on KUB and US. Excretory urography is rarely needed because stones undetected on KUB and US tend to be small and in the middle or lower ureter, and spontaneous passage is expected.

Urinary tract stones--Part II: current status of treatment

The majority of renal and ureteric stones are now managed by minimally invasive techniques, for example nephrostomy, ureteral stents, extracorporeal shockwave lithotripsy or percutaneous nephrolithotomy. A multi-disciplinary approach is necessary, and this review examines the status of modern stone therapy and the contribution of the radiology department.

Resolution of ephedrine stones with dissolution therapy

A patient with a history of ingesting large quantities of an over-the-counter stimulant developed renal calculi that on further analysis, after stone passage, revealed increased amounts of ephedrine. Over the course of 7 months, all of the patient's ephedrine stones were managed successfully by alkalinization. Similar to previously reported ephedrine calculi, these stones were radiolucent on x-ray imaging, but their course was monitored on serial nonenhanced computed tomography scans. We believe this to be the first reported use of alkaline therapy for the dissolution of renal stones containing ephedrine.

Comparison of stone size and response to analgesic treatment in predicting outcome of patients with renal colic

The aim of this study was to compare the prognostic value of stone size and response to analgesic treatment in patients with renal colic. We reviewed the charts of patients treated for renal colic in our Emergency Department. The eligibility criteria were a radiological examination demonstrating direct or indirect signs of ureteral obstruction and/or a stone. The primary endpoint was the requirement for surgical treatment. The parameters considered as prognostic factors were pain relief with ketorolac (K) or ketorolac plus opiate treatment (KO), and stone size (>or= or <6 mm). Ninety-five patients were considered for analysis. Of these, 49 (52%) had a stone demonstrated radiologically. Four out of 27 patients (15%) in the KO group and six out of 68 patients (8.8%) in the K group required a surgical procedure to relieve the obstruction (NS). Four out of five patients (80%) with a stone >or=6 mm required a surgical procedure, compared with one out of 44 (2.2%) who had a stone smaller than 6 mm (P<0.001). In conclusion, stone size is a better prognostic factor than the response to analgesic treatment in predicting the clinical outcome of patients with renal colic. A stone >or=6 mm in patients with renal colic should alert the emergency physician that urological complications requiring surgical intervention may occur and that urological management may be warranted.

[Endoscopic treatment of ureteral lithiasis. Our experience with 360 retrograde uretero-renal endoscopies in the last ten years]

Presentation of results and complications obtained in 360 procedures of transuretral ureterorenoscopy (URS) in ureteral lithiasis performed in our unit from january 1990 to august 2000 in 354 patients: 55% female and 45% male. A rigid ureteroscopy Storz 10.5 Ch. was used and intracorporeal lithotripsy was necessary in 17.31% of cases. URS indications were always treatment of ureteral lithiasis, pelvic ureter localization in most cases (70.33%) being 93.05% the percentage of overall success and with a significant decrease when the calculus was located in the upper third of the ureter. Serious complications were only 3.05% of cases and endoscopic surgery was necessary in three cases of ureteral stenosis. In our experience, URS is our technique of choice for treatment of lower and medium third of the ureter where the percentage of success we have obtained were 98.99% and 95.83% respectively.

[Ureteral lithiasis, what treatment?]

Extracorporeal shock wave lithotripsy and ureteroscopy are minimal invasive techniques, both of which have definitively become essential for the treatment of ureteral stones resistant to conservative treatment. At the time of evidence-based medicine, no study makes it possible to recommend one of these methods rather than the other. For stones of identical size and location, this review of the literature shows that extracorporeal shock wave lithotripsy and ureteroscopy prove of comparable effectiveness and innocuousness. The urologist thus has two alternatives of which the technical control, the availability of the endoscopes or lithotriptors as well as the desire and comfort of the patients are the factors which condition his choice of the method for the treatment of ureteral stones.

Use of glyceryl trinitrate patches in patients with ureteral stones: a randomized, double-blind, placebo-controlled study

OBJECTIVES

To report a randomized, double-blind, placebo-controlled trial of glyceryl trinitrate (GTN) patches. The primary outcome measure was stone passage at 6 weeks. GTN is a potent smooth muscle relaxant that may offer benefit by both reducing pain and facilitating ureteral stone passage.

METHODS

Fifty consecutive patients, with a single radiopaque calculus less than 10 mm, were randomized to receive a 6-week course of patches containing either 5 mg GTN or placebo. Patients used a diary to record pain episodes during the 6-week study period and were reviewed weekly with x-ray imaging. Analysis was by intention to treat.

RESULTS

Twenty-six patients were randomized to the GTN group and 24 to the placebo group. Seven patients in the GTN group discontinued therapy because of headaches. One patient in the placebo group discontinued because of a skin reaction to the patches. No serious adverse events were recorded. No difference was observed in the stone-free rate at 6 weeks (18 patients in each group), interval to stone passage (median GTN 11.5 days versus placebo 13 days), or interventions performed (5 patients each). Although the GTN group reported fewer pain episodes (median 3.5 versus 6.0), this did not achieve statistical significance.

CONCLUSIONS

Our preliminary results did not demonstrate a significant advantage in using GTN compared with placebo, with regard to the stone-free rate at 6 weeks, interval to stone passage, or number of episodes of pain experienced.

New concepts in the treatment of ureteral calculi

The management of patients with ureteral stones remains under debate in several areas. The ability to predict spontaneous passage has improved but remains imprecise, whilst the range of therapeutic options continues to widen. Excellent results can be obtained by both shockwave lithotripsy and ureteroscopic methods, with relatively minimal complications. Routine ureteral stenting is not warranted whichever treatment is chosen. In future, directly comparative studies should be designed to incorporate quality-of-life parameters rather than just stone-free status, to improve our understanding of the effect of treatment decisions on patients.

Effectiveness of nifedipine and deflazacort in the management of distal ureter stones

OBJECTIVES

To evaluate the effectiveness of medical therapy during watchful waiting in patients with distal ureter stones.

METHODS

Ninety-six patients with radiopaque stones located in the distal tract of the ureter and with stone sizes of 1 cm or smaller were involved in the study. The patients were randomly divided into two groups. Group A (n = 48) received oral treatment with 30 mg of deflazacort daily (maximum 10 days) plus 30 mg of slow-release nifedipine daily (maximum 4 weeks). Group B (n = 48) underwent a wait-and-watch approach. Both groups of patients were allowed to use diclofenac on demand. Statistical analyses were carried out using Student's t test, the chi-square test, and Fisher's exact test.

RESULTS

The average stone size was 5.8 +/- 1.8 mm for group A and 5. 5 +/- 1.4 mm for group B. No statistically significant difference was found in stone size. Stone expulsion was observed in 38 (79%) of 48 patients in group A and in 17 (35%) of 48 patients in group B. The average expulsion time was 7 days (range 2 to 10) for group A and 20 days (range 10 to 28) for group B. A statistically significant difference was observed in both the expulsion rate and the expulsion time (P <0.05). The mean amount of sodium diclofenac used was 15 mg per patient for group A and 105 mg per patient for group B (P <0.05).

CONCLUSIONS

The medical treatment proved to be effective and safe, as demonstrated by the increased stone expulsion rate, decreased expulsion time, and reduced need for analgesic therapy.