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Brain E, Geraghty RM, Tzelves L, Mourmouris P, Chatzikrachtis N, Karavitakis M, Skolarikos A, Somani BK. Outcomes of alpha-blockers as medical expulsive therapy following shockwave lithotripsy: a systematic review and meta-analysis. BJU Int 2023; 131:424-433. [PMID: 36156845 DOI: 10.1111/bju.15901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine stone-free rate following shockwave lithotripsy (SWL) with/without alpha-blockers as well as complication rates (individual and classified using the Clavien-Dindo system). MATERIALS AND METHODS We performed a systematic review of all randomized controlled trials that included more than 20 patients (age > 18 years) and examined the use of alpha-blockers after SWL. Meta-analysis was performed using 'metafor' in R. We report risk ratios (RRs) with 95% confidence intervals (95% CIs). The PROSPERO ID for the trial was: CRD42021248108. RESULTS We assessed 158 full-text articles and included a total of 21 studies in our review. There were 1445 patients receiving alpha-blockers and 1478 control patients. Those receiving alpha-blockers were significantly more likely to be stone-free (RR 1.12, 95% CI 1.07-1.16; P < 0.001). This effect was robust to 'trim-and-fill' adjustment. In those taking alpha-blockers there was a significant reduction in Clavien III-V complications and, on trim-and-fill adjustment, a significant reduction in Clavien I-II complications. There were also significant reduction in rates of steinstrasse, pain and requirement for auxiliary procedures. There was no significant difference in retreatment rates. These effects were robust to trim-and-fill adjustment. CONCLUSIONS There is a modest increase in stone-free rates in those receiving alpha-blockers following SWL, with a reciprocal modest risk reduction for steinstrasse, pain and auxiliary procedures. However, alpha-blockers do not reduce the risk of requiring retreatment.
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Affiliation(s)
- Eleanor Brain
- Newcastle Medical School, Newcastle University, Newcastle-upon-Tyne, UK
| | - Robert M Geraghty
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Lazaros Tzelves
- Department of Urology, National and Kapodistrian University of Athens, Sismanogleio Hospital, Athens, Greece
| | - Panagiotis Mourmouris
- Department of Urology, National and Kapodistrian University of Athens, Sismanogleio Hospital, Athens, Greece
| | - Nikolaos Chatzikrachtis
- Department of Urology, National and Kapodistrian University of Athens, Sismanogleio Hospital, Athens, Greece
| | - Markos Karavitakis
- Department of Urology, National and Kapodistrian University of Athens, Sismanogleio Hospital, Athens, Greece
| | - Andreas Skolarikos
- Department of Urology, National and Kapodistrian University of Athens, Sismanogleio Hospital, Athens, Greece
| | - Bhaskar K Somani
- Department of Urology, University Hospital Southampton, Southampton, UK
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Lee JY, Andonian S, Bhojani N, Bjazevic J, Chew BH, De S, Elmansy H, Lantz-Powers AG, Pace KT, Schuler TD, Singal RK, Wang P, Ordon M. Canadian Urological Association guideline: Management of ureteral calculi - Abridged version. Can Urol Assoc J 2021; 15:383-393. [PMID: 34847343 PMCID: PMC8631858 DOI: 10.5489/cuaj.7652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jason Y. Lee
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sero Andonian
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Naeem Bhojani
- Department of Urology, Université de Montréal, Montreal, QC, Canada
| | - Jennifer Bjazevic
- Division of Urology, Department of Surgery, Western University, London, ON, Canada
| | - Ben H. Chew
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Shubha De
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Hazem Elmansy
- Urology, Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | | | - Kenneth T. Pace
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Trevor D. Schuler
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Rajiv K. Singal
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Peter Wang
- London Health Sciences Centre, Western University, London, ON, Canada
| | - Michael Ordon
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Jayawardene MD, Balagobi B, Ambegoda ALAMC, Vidanapathirana S, Wijayagunawardane GWASK, Senthan V, Ranasinghe DD, Abeygunasekera AM. Outcome of uncomplicated ureteric calculi managed with medical expulsive therapy in the outpatient clinic of a urology unit in Sri Lanka. BMC Res Notes 2017; 10:636. [PMID: 29183356 PMCID: PMC5704535 DOI: 10.1186/s13104-017-2974-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 11/22/2017] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Although medical expulsive therapy (MET) is shown to be effective for ureteric calculi, the optimum duration and the stone size suitable for MET are not well established yet. The objectives of the study were to determine the optimum duration and maximum stone size suitable for MET. RESULTS All patients with radiologically confirmed uncomplicated ureteric calculi treated with MET using tamsulosin over a period of 6 months in the outpatient setting were followed up. There were 213 patients. 165 were men. Mean age was 42 years. At presentation 42 stones were in upper ureter (19.7%), 51 in mid ureter (23.9%), 120 in lower ureter (56.3%). The majority (82.7%) of stones were less than 10 mm. Seven stones (3.3%) were over 15 mm. Ninety-two (43.2%) patients had spontaneous passage of stones within 6-weeks of MET. Another 38.9% passed the stone within the next 6-weeks. Thirty-eight patients (17.8%) required surgery. Uncomplicated ureteric stones up to 10 mm can be given a trial of MET using tamsulosin which can be extended up to 12-weeks with a success rate over 92%. This may have substantial clinical and fiscal benefits by reducing the number of interventional procedures especially in resource-poor settings.
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Affiliation(s)
| | - Balasingam Balagobi
- Department of Urology, Colombo South Teaching Hospital, Kalubowila, Sri Lanka
| | - A L A M C Ambegoda
- Department of Urology, Colombo South Teaching Hospital, Kalubowila, Sri Lanka
| | | | | | - V Senthan
- Department of Urology, Colombo South Teaching Hospital, Kalubowila, Sri Lanka
| | - D D Ranasinghe
- Department of Radiology, Colombo South Teaching Hospital, Kalubowila, Sri Lanka
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Drake T, Grivas N, Dabestani S, Knoll T, Lam T, Maclennan S, Petrik A, Skolarikos A, Straub M, Tuerk C, Yuan CY, Sarica K. What are the Benefits and Harms of Ureteroscopy Compared with Shock-wave Lithotripsy in the Treatment of Upper Ureteral Stones? A Systematic Review. Eur Urol 2017; 72:772-786. [DOI: 10.1016/j.eururo.2017.04.016] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 04/12/2017] [Indexed: 12/23/2022]
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A network meta-analysis on the beneficial effect of medical expulsive therapy after extracorporeal shock wave lithotripsy. Sci Rep 2017; 7:14429. [PMID: 29089544 PMCID: PMC5663967 DOI: 10.1038/s41598-017-14862-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 10/12/2017] [Indexed: 02/05/2023] Open
Abstract
We applied a newly introduced method, network meta-analysis, to re-evaluate the expulsion effect of drugs including tamsulosin, doxazosin, nifedipine, terazosin and rowatinex after extracorporeal shock wave lithotripsy (ESWL) as described in the literature. A systematic search was performed in Medline, Embase and Cochrane Library for articles published before March 2016. Twenty-six studies with 2775 patients were included. The primary outcome was the number of patients with successful stone expulsion. The data were subdivided into three groups according to duration of follow-up. A standard network model was established in each subgroup. In 15-day follow-up results, SUCRA outcome showed the ranking of effects was: doxazosin > tamsulosin > rowatinex > nifedipine > terazosin (88.6, 77.4, 58.6, 32.2 and 30.4, respectively). In 45-day follow-up results, SUCRA ranking was: tamsulosin > nifedipine > rowatinex (69.4, 67.2 and 62.6, respectively). In 90-day follow-up results, SUCRA ranking was: doxazosin > rowatinex > tamsulosin (84.1, 68.1 and 49.1, respectively). In conclusion, doxazosin and tamsulosin have potential to be the first choice for pharmacological therapy to promote the expulsion of urinary stone fragments after ESWL, with this doxazosin can improve the SFR in the long term, while tamsulosin may result more in accelerating the process of expulsion.
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Sridharan K, Sivaramakrishnan G. Medical expulsive therapy in urolithiasis: a mixed treatment comparison network meta-analysis of randomized controlled clinical trials. Expert Opin Pharmacother 2017; 18:1421-1431. [DOI: 10.1080/14656566.2017.1362393] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Kannan Sridharan
- School of Health Sciences, Fiji National University, Suva, Fiji Islands
| | - Gowri Sivaramakrishnan
- School of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji Islands
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POSSIBILITIES TO IMPROVE THE THERAPY OF THE PATIENTS WITH URETERAL CONCRETIONS. EUREKA: HEALTH SCIENCES 2017. [DOI: 10.21303/2504-5679.2017.00387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim of the given study was to improve the results of treatment of patients with concretions of the upper third of the ureter.
Materials and methods. The clinical trial was carried out as a non-interventional open, controlled, in two groups of patients with baseline control. The inclusion criteria concerned the patients with concretions of the upper third of the ureter 0.7-0.9 mm in size, which had one session of an extracorporeal shock-wave lithotripsy (ESWL), and after the procedure the size of the concretions fragments was up to3 mm. The study involved 60 patients, all patients in the main group (n = 30) were treated using phytotherapy, within 1 month starting with basic therapy under hospital conditions and continuing with preventative treatment in an outpatient setting. The control group (n = 30) received baseline therapy (up to 10 days) at the stationary stage.
Results and discussion. In patients of the main group, fragments of concretions came out significantly faster, namely: in the main group, the fragments came out in 21 patients (70.0 %), while in the control group in 15 patients (50.0 %) (p1- p2, p <0.05) to the 7th day, and in the main group, the fragments came out in one patient more than 14 days, and in the control group – in 5 patients, p <0.05. The "stone path" in the bottom third of the ureter was in 1 patient (3.3 %) of the main group and in 3 patients (10.0 %) in the control group (p1-p2, p <0.05). The "stone path" departure time in patients of the main group was 2 days, and in patients of the control group it was 4.1 days from the time of its formation (p1-p2, p <0.05). Bacteriuria was observed in the main group on the 10th day 6.6 % less relative to the control group.
Conclusion. At comparing the obtained results in patients of both groups in 1 month it was noted that high efficacy of the treatment was registered in 6 (20 %) patients of the main group and in 3 patients (10 %) of the control group (p <0.05), moderate efficiency was registered in 23 (76.7 %) patients of the main group and in 22 (73.3 %) patients of the control group respectively, low efficacy was registered in 1 (3.33 %) patient in the main group and 5 (16.7 %) patients of the control group (p <0,05), which points to the effectiveness of Urolesan capsules use in complex therapy of patients with concretions of the one third of ureter.
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Medical Expulsive Therapy in Urolithiasis: A Review of the Quality of the Current Evidence. Eur Urol Focus 2017; 3:27-45. [DOI: 10.1016/j.euf.2017.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 01/30/2023]
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Abstract
Objective: TO evaluate the role of nifedipine and the α1-adrenoreceptor antagonists tamsulosin, terazosin, and doxazosin in the expulsive treatment of ureteral calculi. Data Sources: Literature was searched via MEDLINE (1966–February 2006) with subsequent bibliographic review. MeSH headings included ureteral calculi, nifedipine, doxazosin, and adrenergic α-antagonists. Key terms were ureteral calculi, nifedipine, tamsulosin, terazosin, and doxazosin. Study Selection and Data Extraction: Trials evaluating nifedipine, tamsulosin, terazosin, and doxazosin for expulsion of ureteral stones were reviewed. All were published in English-language, peer-reviewed journals. Data Synthesis: Several trials have evaluated the effects of nifedipine and tamsulosin on ureteral stone passage rates and mean time to stone passage in stones no larger than 15 mm. In 28 day trials, the rates of ureteral stone passage were 35–70% in the control groups compared with 77.1–80% in patients treated with nifedipine and 79.3–100% in patients treated with tamsulosin. Average number of days to stone passage in the control groups was 4.6–20, and the time to stone passage was only 5–9.3 days in patients receiving nifedipine and 2.7–7.9 days in those receiving tamsulosin. The stone passage rates and time to stone passage appeared to be similar in one trial that compared tamsulosin with terazosin and doxazosin. Limited data suggest that these agents may have a role as adjuncts to shock wave lithotripsy. Adverse drug reactions were uncommon. Conclusions: Nifedipine, tamsulosin, terazosin, and doxazosin are safe and effective options in enhancing ureteral stone expulsion in selected patients with uncomplicated presentations.
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Ordon M, Andonian S, Blew B, Schuler T, Chew B, Pace KT. CUA Guideline: Management of ureteral calculi. Can Urol Assoc J 2015; 9:E837-51. [PMID: 26788233 DOI: 10.5489/cuaj.3483] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The focus of this guideline is the management of ureteral stones. Specifically, the topics covered include: conservative management, medical expulsive therapy, active intervention with either shockwave lithotripsy (SWL) or ureteroscopy (URS), factors affecting SWL treatment success, optimizing success, and special considerations (e.g., pregnancy, urinary diversion). By performing extensive literature reviews for each topic evaluated, we have generated an evidence-based consensus on the management of ureteral stones. The objective of this guideline is to help standardize the treatment of ureteral stones to optimize treatment outcomes.
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Affiliation(s)
- Michael Ordon
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Sero Andonian
- Division of Urology, Department of Surgery, McGill University, Montreal, QC
| | - Brian Blew
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa, ON
| | - Trevor Schuler
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB
| | - Ben Chew
- Department of Urology, University of British Columbia, Vancouver, BC
| | - Kenneth T Pace
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
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Skolarikos A, Grivas N, Kallidonis P, Mourmouris P, Rountos T, Fiamegos A, Stavrou S, Venetis C. The Efficacy of Medical Expulsive Therapy (MET) in Improving Stone-free Rate and Stone Expulsion Time, After Extracorporeal Shock Wave Lithotripsy (SWL) for Upper Urinary Stones: A Systematic Review and Meta-analysis. Urology 2015; 86:1057-64. [PMID: 26383613 DOI: 10.1016/j.urology.2015.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 08/31/2015] [Accepted: 09/01/2015] [Indexed: 10/23/2022]
Abstract
In this meta-analysis, we included randomized studies on medical expulsive therapy implemented following shock wave lithotripsy for renal and ureteral stones. Pooled results demonstrated the efficacy of α-blockers, nifedipine, Rowatinex, and Uriston in increasing stone clearance. In addition, the time to stone elimination, the intensity of pain, the formation of steinstrasse, and the need for auxiliary procedures were reduced mainly with α-blockers. Expulsion rate was not correlated with the type of α-blocker, the diameter, and the location of stone. Our results show that medical expulsive therapy for residual fragments after shock wave lithotripsy should be implemented in clinical practice.
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Affiliation(s)
- Andreas Skolarikos
- Second Department of Urology, Athens Medical School, Sismanogleio General Hospital, Athens, Greece
| | - Nikolaos Grivas
- Department of Urology, G. Hatzikosta General Hospital, Ioannina, Greece.
| | | | - Panagiotis Mourmouris
- Second Department of Urology, Athens Medical School, Sismanogleio General Hospital, Athens, Greece
| | - Thomas Rountos
- Department of Urology, Ippokrateio General Hospital, Thessaloniki, Greece
| | - Alexandros Fiamegos
- Second Department of Urology, Athens Medical School, Sismanogleio General Hospital, Athens, Greece
| | | | - Chris Venetis
- First Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Janane A, Hamdoun A, Hajji F, Dakkak Y, Ghadouane M, Ameur A, Abbar M. Usefulness of adjunctive alpha1-adrenergic antagonists after single extracorporeal shock wave lithotripsy session in ureteral stone expulsion. Can Urol Assoc J 2014; 8:E8-E11. [PMID: 24454608 DOI: 10.5489/cuaj.1261] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We evaluate the efficiency of α-adrenergic antagonists on stone clearance after extracorporeal shock wave lithotripsy (ESWL) in patients with lower ureteral stones. METHODS A total of 356 patients with solitary lower ureteral stones who underwent single ESWL sessions were divided into 2 groups. Group 1 received our standard medical therapy, and Group 2 was treated with 0.4 mg/day tamsulosin for a maximum of 2 weeks. All patients were re-evaluated with plain film radiography and ultrasound each week during the treatment period. A computed tomography scan was systematically performed 3 months after ESWL. RESULTS In total, 82 of the 170 patients in Group 1 (48.2%) and 144 of the 186 patients in Group 2 (77.4%) (p = 0.002) were stone-free. Among the patients with stones 10 to 15 mm in diameter, the stone-free rate was 38.4% in Group 1 and 77.1% in Group 2 (p = 0.003). Average stone expulsion time was 10.6 days and 8.4 days in Groups 1 and 2, respectively. Ureteral colic occurred in 40 patients (23.5%) in Group 1, but only in 10 patients (5.3%) in Group 2 (p = 0.043). The only side effect of tamsulosin was slight dizziness in 5 of the 186 patients in Group 2 (2.6%). CONCLUSION Adjunctive therapy with α1-adrenergic antagonists after ESWL is more efficient than, and equally as safe as, lithotripsy alone to manage patients with lower ureteral stones. The adding of α-blockers is more reliable and helpful for stones with a large dimension, and can also decrease stone elimination time and episodes of ureteral colic.
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Affiliation(s)
- Abdellatif Janane
- Department of Urology, University Military Hospital Mohammed V. Rabat, Morocco
| | - Abdelaziz Hamdoun
- Department of Urology, University Military Hospital Mohammed V. Rabat, Morocco
| | - Fouad Hajji
- Department of Urology, University Military Hospital Mohammed V. Rabat, Morocco
| | - Youssef Dakkak
- Department of Urology, University Military Hospital Mohammed V. Rabat, Morocco
| | - Mohamed Ghadouane
- Department of Urology, University Military Hospital Mohammed V. Rabat, Morocco
| | - Ahmed Ameur
- Department of Urology, University Military Hospital Mohammed V. Rabat, Morocco
| | - Mohamed Abbar
- Department of Urology, University Military Hospital Mohammed V. Rabat, Morocco
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The effect of tamsulosin on pain and clearance according to ureteral stone location after shock wave lithotripsy. Curr Ther Res Clin Exp 2014; 74:33-5. [PMID: 24385155 PMCID: PMC3862193 DOI: 10.1016/j.curtheres.2012.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2012] [Indexed: 11/20/2022] Open
Abstract
Background Medical expulsion therapy has shown encouraging results in facilitating spontaneous clearance of ureteral stones after extracorporeal shock wave lithotripsy. However, no other study has yet determined the benefit of medical expulsion therapy for stones in different ureteral locations. Objective The aim of the study was to evaluate tamsulosin as adjunctive therapy to extracorporeal shock wave lithotripsy (SWL) in terms of pain clearance of stones in the upper, middle, and lower ureter. Methods Between June 2008 and July 2011, patients with a solitary ureteral stone that was ≥6 mm up to 15 mm and located in the upper, middle, or lower ureter undergoing SWL were evaluated. The patients were randomly allocated to a conservative treatment (group 1) and a tamsulosin treatment group (group 2). Administration of the drug was started immediately after SWL and was continued for a maximum of 28 days. Patients were evaluated for stone clearance, time to stone clearance, and number of SWL sessions. The pain intensity was evaluated by visual analog scale. Results There were 64 patients in the control group and 59 in the tamsulosin group. The average stone sizes were 10.70 (3.20) mm and 11.40 (3.01) mm (P = 0.24). Group 1 and group 2 received 2507 (984) and 2759 (775) shock waves (P = 0.86), 1.53 (0.8) and 1.49 (0.75) sessions (P = 0.85), respectively. Mean visual analog scale scores and times to clearance were 3.81 (2.74) and 2.73 (2.28) (P = 0.00) and 12.59 (8.63) days and 8.34 (7.60) days (P = 0.00), respectively, for all stones in groups 1 and 2. Only the clearance time of upper ureteral stones between groups showed statistical significance (13.54 [8.32] days vs 7.10 [6.40] days; P = 0.00). Conclusions Tamsulosin may help in the treatment of all ureteral stones after SWL, particularly stones in the upper ureter, with a shorter time to clearance and less need for analgesic drugs.
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Gandhi HR, Agrawal C. The efficacy of tamsulosin vs. nifedipine for the medical expulsive therapy of distal ureteric stones: A randomised clinical trial. Arab J Urol 2013; 11:405-10. [PMID: 26558112 PMCID: PMC4442985 DOI: 10.1016/j.aju.2013.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 08/11/2013] [Accepted: 08/15/2013] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To assess and compare, in a randomised clinical trial, the efficacy of tamsulosin and nifedipine as medical expulsive therapy for distal ureterolithiasis. PATIENTS AND METHODS In all, 128 symptomatic patients with stones in the juxtavesical tract of the ureter were randomly divided into group 1 (64 patients) receiving oral nifedipine sustained-release 30 mg/day, and group 2 (64 patients) receiving tamsulosin 0.4 mg/day. Both groups received oral prednisolone 30 mg/day for 10 days and diclofenac 75 mg intramuscularly on demand. Patients were assessed by weekly ultrasonography with or with no abdominal computed tomography, during a follow-up of 4 weeks. The stone passage rate and time, analgesic use, hospitalisation and endoscopic interventions were evaluated. The results were analysed statistically using appropriate tests. RESULTS The stone expulsion rate was 55% for group 1 and 80% for group 2 (P = 0.004). The mean stone size was 8.59 and 8.85 mm in groups 1 and 2, respectively. The mean expulsion time was 23 days for group 1 and 9 days for group 2 (P < 0.001). The mean number of diclofenac injections was 1.19 for group 1 and 0.42 for group 2 (P < 0.001). Eleven patients in group 1 vs. two in group 2 were hospitalised (P = 0.001). Twenty-six patients in group 1 and 13 in group 2 underwent ureteroscopy (P < 0.001). CONCLUSIONS Medical expulsive therapy with tamsulosin should be considered as a first-line treatment for index cases of distal ureterolithiasis with no complications. The use of tamsulosin provides better stone expulsion than does nifedipine.
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Affiliation(s)
- Himesh R. Gandhi
- Amrita Institute of Medical Sciences, Ponekkera, Kochi, Kerela, India
| | - Chandrasekhar Agrawal
- Department of General Surgery, BP Koirala Institute of Health Sciences, Dharan, Nepal
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Lipkin ME, Preminger GM. Shock Wave Lithotripsy: Present Indications and Future Prospects. Urolithiasis 2012. [DOI: 10.1007/978-1-4471-4387-1_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Vicentini FC, Mazzucchi E, Brito AH, Chedid Neto EA, Danilovic A, Srougi M. Adjuvant Tamsulosin or Nifedipine After Extracorporeal Shock Wave Lithotripsy for Renal Stones: A Double Blind, Randomized, Placebo-controlled Trial. Urology 2011; 78:1016-21. [DOI: 10.1016/j.urology.2011.04.062] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/12/2011] [Accepted: 04/16/2011] [Indexed: 11/25/2022]
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Kallidonis P, Liourdi D, Liatsikos E. Medical Treatment for Renal Colic and Stone Expulsion. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.eursup.2011.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Seitz C. Medical Expulsive Therapy of Ureteral Calculi and Supportive Therapy After Extracorporeal Shock Wave Lithotripsy. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.eursup.2010.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Urinary tract stone disease is one of the most common urologic conditions in the US, with a lifetime prevalence of about 13% for men and 7% for women. In this article we review the management of urinary tract stones and discuss when to seek urologic consultation. We cover epidemiologic data, stone types, presenting symptoms, imaging, metabolic evaluation and risk factors, and medical management strategies. We also discuss the indications for surgical intervention and the common operative procedures currently available.
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Affiliation(s)
- George R Schade
- Department of Urology, University of Michigan Medical School, A. Alfred Taubman Health Care Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Zheng S, Liu LR, Yuan HC, Wei Q. Tamsulosin as adjunctive treatment after shockwave lithotripsy in patients with upper urinary tract stones: A systematic review and meta-analysis. ACTA ACUST UNITED AC 2010; 44:425-32. [PMID: 21080841 DOI: 10.3109/00365599.2010.523014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Shuo Zheng
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Liang Ren Liu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Hai Chao Yuan
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Qiang Wei
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
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21
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Sas DJ, Hulsey TC, Shatat IF, Orak JK. Increasing incidence of kidney stones in children evaluated in the emergency department. J Pediatr 2010; 157:132-7. [PMID: 20362300 DOI: 10.1016/j.jpeds.2010.02.004] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 12/28/2009] [Accepted: 02/03/2010] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To test the hypothesis that there is an increase in the incidence of childhood nephrolithiasis in the state of South Carolina. STUDY DESIGN We analyzed demographic data from a statewide database on incidence of kidney stones from emergency department data and financial charges. Data were compared with population data from the US Census to control for population growth. RESULTS There was a significant increase in the incidence of kidney stones in children between 1996 and 2007. The greatest rate of increase was seen in adolescents, pre-adolescents, and Caucasian children. Infants, toddlers, and African-American children did not show significantly increased incidence in the period. Girls show a growing predominance in our population. The amount of money charged for care of children with kidney stones has gone up >4-fold in our state. CONCLUSION The incidence of kidney stone disease has risen dramatically in the state of South Carolina since 1996. Further studies investigating potential contributing factors are needed to prevent this costly and painful condition.
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Affiliation(s)
- David J Sas
- Division of Pediatric Nephrology, Medical University of South Carolina Children's Hospital, Charleston, SC 29425-6080, USA.
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22
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Steinberg PL, Williams S, Hoenig DM. Adjuncts to improve outcomes of shock wave lithotripsy. Curr Urol Rep 2010; 11:93-7. [PMID: 20425096 DOI: 10.1007/s11934-010-0094-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Shock wave lithotripsy (SWL) has been a major tool in the treatment of urinary stones for nearly three decades. In recent years, SWL technology has been less effective at fragmenting stones than earlier devices; thus, adjunctive maneuvers to improve stone-free rates after SWL have been required. This article summarizes several of these adjuncts, such as slower shock wave rate, the use of percussion therapy to clear fragments, medications to hasten expulsion of fragments, and appropriate selection and positioning of patients for SWL.
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Affiliation(s)
- Peter L Steinberg
- Department of Urology, Montefiore Medical Center and Albert Einstein School of Medicine, 3400 Bainbridge Avenue, 5th Floor, Bronx, NY, 10467, USA
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23
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Abstract
The pyeloureteral function is to transport urine from the kidneys into the ureter toward the urinary bladder for storage until micturition. A set of mechanisms collaborates to achieve this purpose: the basic process regulating ureteral peristalsis is myogenic, initiated by active pacemaker cells located in the renal pelvis. Great emphasis has been given to hydrodynamic factors, such as urine flow rate in determining the size and pattern of urine boluses which, in turn, affect the mechanical aspects of peristaltic rhythm, rate, amplitude, and baseline pressure. Neurogenic contribution is thought to be limited to play a modulatory role in ureteral peristalsis. The myogenic theory of ureteral peristalsis can be traced back to Engelmann (1) who was able to localize the peristaltic pressure wave's origin in the renal pelvis and suggested that the ureteral contraction impulse passes from one ureteral cell to another, the whole ureter working as a functional syncitium. Recent studies of ureteral biomechanics, smooth muscle cell electrophysiology, membrane ionic currents, cytoskeletal components and pharmacophysiology much improved our understanding of the mechanism of how the urine bolus is propelled, how this process is disturbed in pathological states, and what could be done to improve it.
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Affiliation(s)
- F Osman
- Department of Urology and Clinical Experimental Research Department, Semmelweis University, Budapest, Hungary.
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24
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Wang H, Liu K, Ji Z, Li H. Effect of α1-Adrenergic Antagonists on Lower Ureteral Stones With Extracorporeal Shock Wave Lithotripsy. Asian J Surg 2010; 33:37-41. [DOI: 10.1016/s1015-9584(10)60007-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2010] [Indexed: 10/19/2022] Open
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25
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&NA;. Medical expulsive therapy is an effective treatment for small distal ureteral stones. DRUGS & THERAPY PERSPECTIVES 2009. [DOI: 10.2165/11203440-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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26
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Seitz C, Liatsikos E, Porpiglia F, Tiselius HG, Zwergel U. Medical therapy to facilitate the passage of stones: what is the evidence? Eur Urol 2009; 56:455-71. [PMID: 19560860 DOI: 10.1016/j.eururo.2009.06.012] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 06/09/2009] [Indexed: 12/27/2022]
Abstract
CONTEXT Medical expulsive therapy (MET) for urolithiasis has gained increasing attention in the last years. It has been suggested that the administration of alpha-adrenoreceptor antagonists (alpha-blockers) or calcium channel blockers augments stone expulsion rates and reduces colic events. OBJECTIVE To evaluate the efficacy and safety of MET with alpha-blockers and calcium channel blockers for upper urinary tract stones with and without prior extracorporeal shock wave lithotripsy (ESWL). EVIDENCE ACQUISITION A systematic review of the literature was performed in Medline, Embase, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews searched through 31 December 2008 without time limit. Efficacy and safety end points were evaluated in 47 randomised, controlled trials assessing the role of MET. Meta-analysis was conducted using Review Manager (RevMan) v.5.0 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). EVIDENCE SYNTHESIS Pooling of alpha-blocker and calcium channel blocker studies demonstrated a higher and faster expulsion rate compared to a control group (risk ratio [RR]: 1.45 vs 1.49; 95% confidence interval [CI]: 1.34-1.57 vs 1.33-1.66). Similar results have been obtained after ESWL (RR: 1.29 vs 1.57; 95% CI: 1.16-1.43 vs 1.21-2.04). Additionally, lower analgesic requirements, fewer colic episodes, and fewer hospitalisations were observed within treatment groups. CONCLUSIONS Pooled analyses suggest that MET with alpha-blockers or calcium channel blockers augments stone expulsion rates, reduces the time to stone expulsion, and lowers analgesia requirements for ureteral stones with and without ESWL for stones < or = 10 mm. There is some evidence that a combination of alpha-blockers and corticosteroids might be more effective than treatment with alpha-blockers alone. Renal stones after ESWL also seem to profit from MET. The vast majority of randomised studies incorporated into the present systematic review are small, single-centre studies, limiting the strength of our conclusions. Therefore, multicentre, randomised, placebo-controlled trials are needed.
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Affiliation(s)
- Christian Seitz
- Department of Urology, General Hospital of Bolzano, Bolzano, Italy.
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27
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Schuler TD, Shahani R, Honey RJD, Pace KT. Medical Expulsive Therapy as an Adjunct to Improve Shockwave Lithotripsy Outcomes: A Systematic Review and Meta-Analysis. J Endourol 2009; 23:387-93. [DOI: 10.1089/end.2008.0216] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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28
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Kang DI, Cho WY, Kim TH, Chung JM, Park J, Yoon JH, Lee SD. Effect of Tamsulosin 0.2 mg on the Short-Term Treatment of Urinary Stones: Multicenter, Prospective, Randomized Study. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.6.586] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Dong Il Kang
- Department of Urology, Inje University College of Medicine, Busan, Korea
| | - Won Yeol Cho
- Department of Urology, Dong-A University College of Medicine, Busan, Korea
| | - Tae Hyo Kim
- Department of Urology, Dong-A University College of Medicine, Busan, Korea
| | - Jae Min Chung
- Department of Urology, Kosin University College of Medicine, Busan, Korea
| | - Jisung Park
- Department of Urology, Pusan National University School of Medicine, Busan, Korea
| | - Jang Ho Yoon
- Department of Urology, Inje University College of Medicine, Busan, Korea
| | - Sang Don Lee
- Department of Urology, Pusan National University School of Medicine, Busan, Korea
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Ferrandino MN, Monga M, Preminger GM. Adjuvant therapy after surgical stone management. Adv Chronic Kidney Dis 2009; 16:52-9. [PMID: 19095206 DOI: 10.1053/j.ackd.2008.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of this article was to review the most widely researched adjuvant medical therapies for the surgical management of urolithiasis. Articles were identified and reviewed from PubMed and Medline databases with MeSH headings focusing on the various surgical treatments of urolithiasis and adjuvant therapy. Additional articles were retrieved from references and conference proceedings. Surgical treatments reviewed included shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. Adjuvant therapy was considered medical or complementary therapy as an adjunct to these surgical interventions. Adjuvant therapy for the surgical management of urolithiasis has been documented to increase stone-free rates, reduce stone remission rates, prevent renal damage, and decrease postoperative morbidity. A variety of agents have been studied, ranging from antioxidants to alpha-blockers and to alkalinizing agents. Additionally, there is increasing interest in complementary adjuvant therapy (ie, acupuncture). Adjuvant therapy is a fertile area for research in the surgical management of urolithiasis. The optimal agents have yet to be determined and therefore further investigation is warranted and necessary.
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30
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Tzortzis V, Mamoulakis C, Rioja J, Gravas S, Michel MC, de la Rosette JJ. Medical Expulsive Therapy for Distal Ureteral Stones. Drugs 2009; 69:677-92. [DOI: 10.2165/00003495-200969060-00003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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31
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Yoon WY, Jeong TY, Lee SI, Kim DJ. Effect of Tamsulosin and Dichlozid on the Expected Treatment of Ureteral Calculi. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.12.1213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Woon Yong Yoon
- Department of Urology, College of Medicine, Kwandong University, Goyang, Korea
| | - Tae Yoong Jeong
- Department of Urology, College of Medicine, Kwandong University, Goyang, Korea
| | - Sang Ik Lee
- Department of Urology, College of Medicine, Kwandong University, Goyang, Korea
| | - Dong Jun Kim
- Department of Urology, College of Medicine, Kwandong University, Goyang, Korea
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Tamsulosin Facilitates Earlier Clearance of Stone Fragments and Reduces Pain After Shockwave Lithotripsy for Renal Calculi: Results From an Open-Label Randomized Study. Urology 2008; 72:1006-11. [DOI: 10.1016/j.urology.2008.05.035] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Revised: 04/27/2008] [Accepted: 05/03/2008] [Indexed: 11/13/2022]
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33
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Raynal G, Bellan J, Saint F, Tillou X, Petit J. [Ureter drugs]. Prog Urol 2008; 18:152-9. [PMID: 18472067 DOI: 10.1016/j.purol.2008.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2007] [Accepted: 02/15/2008] [Indexed: 11/28/2022]
Abstract
Many improvements have been made recently in the field of the ureteral smooth muscle pharmacology. After a brief summary on physiological basis, we review what is known about effects on ureter of different drugs class. In a second part, we review clinical applications for renal colic analgesia, calculi expulsive medical therapy, ESWL adjuvant treatment and preoperative treatment before retrograde access. There are now sufficient data on NSAID and alpha-blockers. beta-agonists, especially for beta3 selective ones, and topical drugs before retrograde access are interesting and should be further evaluated.
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Affiliation(s)
- G Raynal
- Service d'urologie et transplantation, CHU d'Amiens, hôpital Sud, boulevard Laennec, 80054 Salouel cedex, France.
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34
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Choi NY, Ahn SH, Han JH, Jang IH. The Effect of Tamsulosin and Nifedipine on Expulsion of Ureteral Stones after Extracorporeal Shock Wave Lithotripsy. Korean J Urol 2008. [DOI: 10.4111/kju.2008.49.2.150] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Nak-Young Choi
- Department of Urology, KEPCO Medical Foundation Hanil General Hospital, Seoul, Korea
| | - Seung-Hyun Ahn
- Department of Urology, KEPCO Medical Foundation Hanil General Hospital, Seoul, Korea
| | - Jun-Hyun Han
- Department of Urology, KEPCO Medical Foundation Hanil General Hospital, Seoul, Korea
| | - In-Ho Jang
- Department of Urology, KEPCO Medical Foundation Hanil General Hospital, Seoul, Korea
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35
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Wang CJ, Huang SW, Chang CH. Efficacy of an α1 Blocker in Expulsive Therapy of Lower Ureteral Stones. J Endourol 2008; 22:41-6. [PMID: 18315472 DOI: 10.1089/end.2007.0133] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Chung-Jing Wang
- St. Martin De Porres Hospital, Division of Urology, Department of Surgery, Taiwan, Republic of China
| | - Shi-Wei Huang
- St. Martin De Porres Hospital, Division of Urology, Department of Surgery, Taiwan, Republic of China
| | - Chien-Hsing Chang
- St. Martin De Porres Hospital, Division of Urology, Department of Surgery, Taiwan, Republic of China
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36
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Singh A, Alter HJ, Littlepage A. A systematic review of medical therapy to facilitate passage of ureteral calculi. Ann Emerg Med 2007; 50:552-63. [PMID: 17681643 DOI: 10.1016/j.annemergmed.2007.05.015] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Revised: 05/06/2007] [Accepted: 05/09/2007] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Amandeep Singh
- Department of Emergency Medicine, Alameda County Medical Center-Highland Hospital, Oakland, CA 94602, USA.
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37
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Canda AE, Turna B, Cinar GM, Nazli O. Physiology and pharmacology of the human ureter: basis for current and future treatments. Urol Int 2007; 78:289-98. [PMID: 17495484 DOI: 10.1159/000100830] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This article sets out to be a review regarding agents that affect contraction and relaxation of the ureter in order to establish a basis for current and future treatments for upper urinary tract obstruction. MATERIAL AND METHODS A complete review of the English literature using MEDLINE was performed between 1960 and 2007 on ureter physiology and pharmacology with special emphasis on signal transduction mechanisms involved in the contractile regulation of the human ureter. RESULTS Activation of muscarinic and adrenergic receptors increases the amplitude of ureteral contractions. The sympathetic nerves modulate the contractions by alpha-adrenoceptors and relaxation by beta-adrenoceptors. The purinergic system is important in sensory/motor functions and ATP is an important non-adrenergic non-cholinergic (NANC) agent causing contraction. Nitric oxide (NO) is a major inhibitory NANC neurotransmitter causing relaxation. Serotonin causes contraction. Prostaglandin-F(2)alpha contracts whereas prostaglandin-E(1)/E(2) relaxes the ureter. Phosphodiesterases (PDE) and the Rho-kinase pathway have recently been identified in the human ureter. PDE-IV inhibitors, K(+) channel openers, calcium antagonists, alpha(1)-adrenoceptor antagonists and NO donors seem to be promising drugs in relieving obstruction and facilitating stone passage. CONCLUSIONS Further understanding of the ureteral function and pharmacology may lead to the discovery of promising new drugs that could be useful in relieving ureteral colic, facilitating spontaneous stone passage, preparing the ureter for ureteroscopy as well as acting adjunctive to extracorporeal shock-wave lithotripsy.
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Affiliation(s)
- A Erdem Canda
- Manisa State Hospital, Urology Clinic, Manisa, Turkey
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38
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Bhagat SK, Chacko NK, Kekre NS, Gopalakrishnan G, Antonisamy B, Devasia A. Is There a Role for Tamsulosin in Shock Wave Lithotripsy for Renal and Ureteral Calculi? J Urol 2007; 177:2185-8. [PMID: 17509314 DOI: 10.1016/j.juro.2007.01.160] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Indexed: 11/21/2022]
Abstract
PURPOSE We evaluated the effect of the alpha-blocker tamsulosin on stone clearance, analgesic requirements and steinstrasse in shock wave lithotripsy for solitary renal and ureteral calculus. MATERIALS AND METHODS A prospective, double-blind, randomized placebo controlled study was performed during 1 year involving 60 patients with a solitary renal or ureteral calculus undergoing shock wave lithotripsy. The control group (30) received 0.4 mg tamsulosin and the study group (30) received placebo daily until stone clearance or for a maximum of 30 days. An oral preparation of dextropropoxyphene hydrochloride and acetaminophen was the analgesic used on an on-demand basis. The parameters assessed were stone size, position, clearance time, effect on steinstrasse and analgesic requirement. RESULTS The overall clearance rate was 96.6% (28 of 29) in the study group and 79.3% (23 of 29) in the control group (p = 0.04). With larger stones 11 to 24 mm the difference in the clearance rate was significant (p = 0.03) but not so with the smaller stones 6 to 10 mm (p = 0.35). The average dose of analgesic used was lower with tamsulosin than with controls, without statistical significance. Steinstrasse resolved spontaneously in the tamsulosin group whereas 25% (2 of 8) required intervention in the placebo group. There was no difference between the 2 groups with regard to age, stone size or location. CONCLUSIONS The alpha-blocker tamsulosin seemed to facilitate stone clearance, particularly with larger stones during shock wave lithotripsy for renal and ureteral calculus. It also appeared to improve the outcome of steinstrasse. Tamsulosin may have a potential role in routine shock wave lithotripsy.
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Affiliation(s)
- Suresh K Bhagat
- Departments of Urology and Biostatistics, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu 632004, India
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Micali S, Grande M, Sighinolfi MC, De Stefani S, Bianchi G. Efficacy of expulsive therapy using nifedipine or tamsulosin, both associated with ketoprofene, after shock wave lithotripsy of ureteral stones. ACTA ACUST UNITED AC 2007; 35:133-7. [PMID: 17396251 DOI: 10.1007/s00240-007-0085-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 02/15/2007] [Indexed: 10/23/2022]
Abstract
Extracorporeal shock wave lithotripsy (ESWL) is currently considered one of the main treatments for ureteral stones. Some studies have reported the effectiveness of pharmacologic therapies (calcium antagonists or alpha-blockers) in facilitating ureteral stone expulsion after ESWL. We prospectively evaluated the efficacy, after ESWL, of nifedipine on upper-middle ureteral stones, and tamsulosin on lower ureteral stones, both associated to ketoprofene as anti-edema agent. From January 2003 to March 2005 we prospectively evaluated 113 patients affected by radiopaque or radiolucent ureteral stones. Average stone size was 10.16 +/- 2.00 mm (range 6-14 mm). Thirty-seven stones were located in the upper ureter, 27 in the middle ureter, and 49 in the lower ureter. All patients received a single session of ESWL (mean number of shock waves: 3,500) by means of a Dornier Lithotripter S (mean energy power for each treatment: 84%). Both ultrasound and X-ray were used for stone scanning. After treatment, 63 of 113 patients were submitted to medical therapy to aid stone expulsion: nifedipine 30 mg/day for 14 days administered to 35 patients with upper-middle ureteral stones (group A1) and tamsulosin 0.4 mg/day for 14 days administered to 28 patients with stones located in the distal ureter (group A2). The remaining 50 patients were used as a control group (29 upper-middle ureteral stones-B1-and 21 lower ureteral stones-B2-), receiving only pain-relieving therapy. No significant difference in stone size between the groups defined was observed. Stone clearance was assessed 1 and 2 months after ESWL by means of KUB, ultrasound scan and/or excretory urography. A stone-free condition was defined as complete stone clearance or the presence of residual fragments smaller than 3 mm in diameter. The stone-free rates in the expulsive medical therapy group were 85.7 and 82.1% for the nifedipine (A1) and tamsulosin (A2) groups respectively; stone-free rates in the control groups were 51.7 and 57.1% (B1 and B2, respectively). Five patients (14.3%) in group A1, 5 (17.8%) in group A2, 14 (48.3%) in group B1 and 9 (42.8%) in group B2 were not stone-free after a single ESWL session and required ESWL re-treatment or an endoscopic treatment. Medical therapy following ESWL to facilitate ureteral stone expulsion results in increased 1- and 2-month stone-free rates and in a lower percentage of those needing re-treatment. The efficacy of nifedipine for the upper-mid ureteral tract associated with ketoprofene makes expulsive medical therapy suitable for improving overall outcomes of ESWL treatment for ureteral stones.
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Affiliation(s)
- S Micali
- Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
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40
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Bak CW, Yoon SJ, Chung H. Effects of an α-blocker and Terpene Mixture for Pain Control and Spontaneous Expulsion of Ureter Stone. Korean J Urol 2007. [DOI: 10.4111/kju.2007.48.5.517] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Chong Won Bak
- Department of Urology, Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea
| | - Sang Jin Yoon
- Department of Urology, Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea
| | - Han Chung
- Department of Urology, Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea
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Micali S, Grande M, Sighinolfi MC, De Carne C, De Stefani S, Bianchi G. Medical Therapy of Urolithiasis. J Endourol 2006; 20:841-7. [PMID: 17144848 DOI: 10.1089/end.2006.20.841] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- S Micali
- Department of Urology, University of Modena & Reggio Emilia, Modena, Italy
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Ames CD, Weld KJ, Dryer ST, Hruby G, Minor SD, Yan Y, Figenshau RS, Bhayani S, Landman J, Venkatesh R. First Prize: Pharmacologic Manipulation of the Porcine Ureter: Acute Impact of Topical Drugs on Ureteral Diameter and Peristaltic Activity. J Endourol 2006; 20:943-8. [PMID: 17144869 DOI: 10.1089/end.2006.20.943] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Intraluminal application of pharmacologic agents for acute ureteral dilation may facilitate difficult ureteroscopy. We characterized the in-vivo effects of intraluminal application of verapamil and theophylline on ureteral peristalsis and diameter in a porcine model. MATERIALS AND METHODS Twenty-four female domestic pigs (35-40 kg) were incorporated into the study. We deployed a giant magneto resistive (GMR) sensor and electromagnetic (EMG) electrodes laparoscopically onto the ureteral surface for simultaneous measurement of the mechanical and electrical signals of ureteral peristalsis, respectively. The ureteral-luminal diameter was measured at three levels by digital retrograde pyelography and standardized to a 10-mm laparoscope. The results were calculated as change in peristalsis and ureteral diameter from baseline during the first hour after drug injection. We tested two smooth-muscle relaxants, verapamil (2 mg/kg) and theophylline (70 mg/kg), with saline and dimethylsulfoxide (DMSO; solvent) as controls. Six pigs were studied for each of the four groups. Hydration, anesthesia, and intra-abdominal pressure were standardized. The serum concentrations of the drugs were measured to determine systemic absorption. RESULTS During the first 10 minutes after intraluminal drug injection, theophylline caused a significant decrease in ureteral peristalsis (6.75 waves/10 minutes) compared with the control group (1.00/10 minutes; P = 0.02). This trend persisted for the next hour. However, there were no changes from baseline in ureteral width. Ureteral peristalsis and dilation remained similar after the saline and DMSO injections. Verapamil increased the diameter of the proximal ureter compared with the controls throughout the hour after drug injection. Fifteen minutes after the drug injection, the change in the ureteral diameter with verapamil was 1.38 mm (4.14F), while the control group showed a change of 0.27 mm (P = 0.03). At 1 hour, the width of the proximal ureter in the verapamil group had increased by 1.72 mm (5.16F), while the control group had changed by 0.55 mm (P = 0.03). There were no statistically significant changes in the widths of the mid or distal ureter. No ureteral dilation was observed in the other groups. CONCLUSIONS In the porcine model, intraluminal application of pharmacologic agents produced independent effects on ureteral dilation and peristalsis. Theophylline inhibited ureteral peristalsis, and verapamil produced acute proximal-ureteral dilation. The ability to alter ureteral diameter or peristaltic activity acutely may facilitate ureteroscopy.
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Affiliation(s)
- Caroline D Ames
- Department of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Porpiglia F, Vaccino D, Billia M, Renard J, Cracco C, Ghignone G, Scoffone C, Terrone C, Scarpa RM. Corticosteroids and Tamsulosin in the Medical Expulsive Therapy for Symptomatic Distal Ureter Stones: Single Drug or Association? Eur Urol 2006; 50:339-44. [PMID: 16574310 DOI: 10.1016/j.eururo.2006.02.023] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2005] [Accepted: 02/06/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To assess the clinical role of corticosteroids in the medical expulsive therapy of symptomatic distal ureteral stones. METHODS Between January 2004 and September 2005, 114 patients with symptomatic distal ureteral stones with a >/=5mm diameter were enrolled in this prospective study and divided into four groups based on the urologist (of four) who treated them in the emergency unit. Group A (33 patients) received tamsulosin (0.4mg daily), group B (24 patients) received deflazacort (30mg daily), group C (33 patients) received both (0.4mg tamsulosin+30mg deflazacort daily), and control group D (24 patients) received only analgesics. The treatment duration was 10 d to prevent the side-effects of prolonged corticosteroid therapy. The end points were the expulsion rate, analgesic consumption, number of ureteroscopies, and safety. RESULTS The groups were comparable in terms of age, sex, and stone location. The stone diameter was 5.96+/-0.33mm for group A, 5.83+/-0.4mm for group B, 5.88+/-0.23mm for group C, and 5.71+/-0.5mm (p>0.05) for group D. The rates of expulsion for the four groups were 60%, 37.5%, 84.8%, and 33.3%, respectively. There was a significant difference between group C and the other groups (p<0.001). The mean analgesic consumption was 42.5+/-0.4mg for group A, 50+/-0.3mg for group B, 27.3+/-0.5mg for group C, and 81+/-0.33mg for group D, with a significant difference between group C and the other groups (p<0.001). During the treatment period, only two cases of drug side-effects related to tamsulosin (without any drop-outs) were recorded. CONCLUSION When the medical expulsive therapy for symptomatic distal ureteral stones is considered, the use of steroids (deflazacort) proves efficient only when administered together with alpha(1)-blockers (tamsulosin). In addition, tamsulosin used on its own as a medical expulsive therapy can be considered as an alternative treatment for those patients who are not suitable for steroid therapy, as it is generally efficient.
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Affiliation(s)
- Francesco Porpiglia
- Department of Urology, University of Turin, San Luigi Hospital, Orbassano (TO), Italy.
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Han MC, Park YY, Shim BS. Effect of Tamsulosin on the Expectant Treatment of Lower Ureteral Stones. Korean J Urol 2006. [DOI: 10.4111/kju.2006.47.7.708] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Min Cheol Han
- Department of Urology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Young Yo Park
- Department of Urology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Bong Suk Shim
- Department of Urology, College of Medicine, Ewha Womans University, Seoul, Korea
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Gravina GL, Costa AM, Ronchi P, Galatioto GP, Angelucci A, Castellani D, Narcisi F, Vicentini C. Tamsulosin treatment increases clinical success rate of single extracorporeal shock wave lithotripsy of renal stones. Urology 2005; 66:24-8. [PMID: 15992885 DOI: 10.1016/j.urology.2005.01.013] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2004] [Revised: 12/20/2004] [Accepted: 01/07/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To design a randomized, no-treatment, controlled, prospective study to determine whether the administration of tamsulosin, as adjunctive medical therapy, increases the efficacy of one extracorporeal shock wave lithotripsy (ESWL) session to treat renal stones and decreases the use of analgesic drugs after the procedure. METHODS A total of 130 patients underwent a single ESWL session to treat solitary radiopaque renal stones 4 to 20 mm in diameter. After treatment, all patients were randomly assigned to receive our standard medical therapy alone (controls) or in association with 0.4 mg tamsulosin daily for a maximum of 12 weeks. All 130 patients were followed up for 3 months or until an alternative treatment was given. RESULTS Of the 130 patients, 78.5% of those receiving tamsulosin and 60% of controls had achieved clinical success at 3 months (P = 0.037). When we stratified patients according to stone size, for those with a stone size larger than 10 mm, the success rate was significantly greater in the tamsulosin group (P = 0.028). Renoureteral colic occurred in 76.9% of patients treated with standard therapy but in only 26.1% of those receiving tamsulosin (P < 0.001). The mean cumulative diclofenac dose was 375 mg per patient in the tamsulosin group and 675 mg per patient in the control group (P < 0.001). CONCLUSIONS The results of our study have demonstrated that tamsulosin therapy, as an adjunctive medical therapy after ESWL, is more effective than lithotripsy alone for the treatment of patients with large renal stones and is equally safe. In addition, our results also indicated that adjunctive treatment with tamsulosin could decrease the use of analgesic drugs after ESWL.
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Tombal B, Mawlawi H, Feyaerts A, Wese FX, Opsomer R, Van Cangh PJ. Prospective Randomized Evaluation of Emergency Extracorporeal Shock Wave Lithotripsy (ESWL) on the Short-Time Outcome of Symptomatic Ureteral Stones. Eur Urol 2005; 47:855-9. [PMID: 15925083 DOI: 10.1016/j.eururo.2005.03.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Accepted: 03/03/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Here, we report the results of a randomized controlled trial (RCT) assessing the efficacy of emergency ESWL (eESWL) on the short-term outcome of symptomatic ureteral stones. MATERIAL The trial enrolled 100 patients admitted in emergency room for renal colic caused by a ureteral radioopaque [corrected] stone. Patients were randomized to medical therapy alone or combined with eESWL. eESWL was performed within 6 hours of the onset of renal colic without specific analgesia on a Lithostar lithotripter (Siemens Medical, Munich, Germany). The primary endpoints were the proportion of patients stone free rate after 48 hours (SF-48) and the cumulative proportion of patients discharged from the hospital after 48 and 72 hours. RESULTS Ureteral stone's location was proximal and distal in respectively 46% and 54% of the patients; stone's mean size was 5.5 mm (range 2-10 mm). Median hospital stay was 3 days, ranging from 1 to 14 days. SF-48 in the control group varied from 76% for distal stones <5 mm to 28.6% for proximal stones >5 mm, averaging at 61%. On average, eESWL increased SF-48 by 13% (p: 0.126), the gain strictly depending on stone size and location. SF-48 increase ranged from 40% for proximal stones >5 mm to 1.8% for distal stone <5 mm. On average, eESWL increased the median duration of hospital stay by one day. This mean negative impact results from ESWL increasing significantly the duration of hospital stay in case of distal stone, while slightly shortened it for stones located proximally. CONCLUSION This study demonstrated for the first time that rapidly performed ESWL is a valuable therapeutic option to improve elimination of ureteral stones and shorten duration of hospital stay, proven that the stone is located proximally to the iliac vessels.
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Affiliation(s)
- Bertrand Tombal
- Service d'Urologie, UCL Saint Luc, Avenue Hippocrate, 10, B-1200 Brussels, Belgium.
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Abstract
PURPOSE We quantified the burden of urolithiasis in the United States by identifying trends in the use of health care resources and estimating the economic impact of the disease. MATERIALS AND METHODS The analytical methods used to generate these results have been described previously. RESULTS The rate of national inpatient hospitalizations for a diagnosis of urolithiasis decreased by 15% and hospital length of stay decreased from 2.6 to 2.2 days between 1994 and 2000. Rates of hospitalization were 2.5 to 3-fold higher for Medicare beneficiaries with little change between 1992 and 1998. Almost 2 million outpatient visits for a primary diagnosis of urolithiasis were recorded in 2000. Hospital outpatient visits increased by 40% between 1994 and 2000 and physician office visits increased by 43% between 1992 and 2000. In the Medicare population hospital outpatient and office visits increased by 29% and 41%, respectively, between 1992 and 1998. The distribution of surgical procedures remained relatively stable through the 1990s. Shock wave lithotripsy was the most commonly performed procedure, followed closely by ureteroscopy. Overall the total estimated annual expenditure for individuals with claims for a diagnosis of urolithiasis was almost $2.1 billion in 2000, representing a 50% increase since 1994. CONCLUSIONS The cost of urolithiasis is estimated at almost $2 billion annually and it appears to be increasing with time despite a shift in inpatient to outpatient treatment and the emergence of minimally invasive treatment modalities, perhaps because the prevalence of stone disease is increasing.
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Affiliation(s)
- Margaret S Pearle
- Department of Urology and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA.
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Küpeli B, Irkilata L, Gürocak S, Tunç L, Kiraç M, Karaoğlan U, Bozkirli I. Does tamsulosin enhance lower ureteral stone clearance with or without shock wave lithotripsy? Urology 2004; 64:1111-5. [PMID: 15596181 DOI: 10.1016/j.urology.2004.07.020] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2004] [Accepted: 07/22/2004] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Bora Küpeli
- Department of Urology, Gazi University School of Medicine, Ankara, Turkey
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Literature watch. J Endourol 2003; 17:117-24. [PMID: 12689407 DOI: 10.1089/08927790360587469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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