Management Of Distal Ureteral Calculi Research Articles

Effect of Alpha-Blocker on Distal Ureteric Calculi: A Comparative Study

Introduction Silodosin is a recently introduced selective alpha- blocker in Medical Expulsive Therapy for the management of distal ureteric calculi. The efficacy and safety of silodosin compared to tamsulosin are controversial, however the former is considered to be more effective. The objective of the study is to assess the efficacy and safety of silodosin compared to tamsulosin in the treatment of ureteral stones less than 10mm.  Methods This prospective randomized study was conducted in the Department of General Surgery, Navodaya Medical College, Raichur, Karnataka. Sixty patients were included in the study who presented with abdominal or loin pain and were diagnosed with unilateral solitary distal ureteric stone measuring <10mm with no complications. Participants in Group I received Tablet Silodosin 8mg OD until the passage of stone or up to two weeks, and Group II received Tablet Tamsulosin 0.4mg OD until the passage of stone or up to two weeks. Analgesic Tablet Diclofenac sodium 50mg was given to both patients on demand.  Results A total of 60 patients were included in the study, divided into 30 patients in each group of Silodosin and tamsulosin respectively. In Group I (silodosin), out of 30 patients, 25 patients expelled the calculus, whereas in Group II (tamsulosin), out of 30 patients, 15 patients expelled the calculus. Group I showed a significantly higher rate of expulsion, with a p-value of 0.005. Stone expulsion time was notably shorter in Group I compared to Group II, with averages of 4.73 days versus 6.33 days (p=0.009). Additionally, analgesic use during the medical expulsive therapy was lower in Group I, averaging 8.25 compared to 4.13 (p=0.0001) in the tamsulosin group. Significant differences were observed in the outcomes such as stone expulsion time, and analgesic requirement. However, no significant differences were found when comparing the groups based on age, gender, stone size, and side of the ureter involved. The 20 patients who failed the medical management underwent ureterorenoscopy with 100% clearance. 3 patients in Group II experienced orthostatic hypotension, and zero patients experienced any side effects in Group I. Compared to tamsulosin, silodosin provides significantly higher stone expulsion rates, fewer colic episodes, and shorter stone expulsion duration than tamsulosin.

USING TAMSULOSINE IN THE MANAGEMENT OF LOWER URETERIC CALCULI: OUR EXPERIENCE OF MEDICAL EXPUSIVE THERAPY OF URETERIC CALCULI IN A RANDOMIZED CONTROLLED TRIAL

Background: Lower ureteric calculi can be treated by different modalities. There are many minimally invasive interventional (e.g.,ESWL, ureterorenoscopy, the holmium: YAG laser and basket devices) as well as expectant (watchful waiting) treatments are in practice for the management of distal ureteric calculi. selected method depend on the type of equipment available, location, type and size of stone, needs of the patient and skills of the surgeon. Most of the work on the potency of tamsulosin in lower ureteric calculi expulsion has been done in the developed countries.
 Methods: Our randomized controlled trial in Avicenna Hospital Lahore included 100 patients over 18 years of age with stone Size ≤8mm in distal one third of ureter. Patients were randomly assigned into two groups (A & B). Group A Patients were given Capsule Tamsulosin 0.4 mg, once daily up to four weeks while group B patients were given placebo, one Capsule daily up to four weeks. The final result was the expulsion rate.
 Informed consent was obtained from all the patients. Stone Expulsion time, analgesia requirement, need for
 hospitalization and drug adverse effects were secondary endpoints.
 Results: A total of 49 patients in group A and 48 patients in group B came for follow up, therefore 97 out of 100 patients were evaluated. Mean age of the patients was 36.34 years (range 18–57 years). Mean stone size was 5.78 mm (range 4–8 mm) in largest dimension. A stone expulsion rate of 85.71% (42 patients) was noted in group A and 54.20% (26 patients) in group B. Group A showed a statistically significant advantage in terms of stone expulsion rate (p=0.032). Considering expulsion time in days group A demonstrated statistically significant advantage (p=0.015). Regarding age, sex, stone size and stone lateralization (right/left), there was no remarkable difference between the group A and B. No drug adverse effects were seen in both the groups.
 Conclusion: Tamsulosine can be used as medical expulsion therapy in lower ureteric calculi of size less than or equal to 8mm.

PT049 - Fluoroless ureteroscopy for definitive management of distal ureteral calculi: Randomized controlled trial

PT049 - Fluoroless ureteroscopy for definitive management of distal ureteral calculi: Randomized controlled trial

Tamsulosin in the management of distal ureteric calculi

Introductions: Ureteral stones account for 20% urinary stone. Two third of ureteral stones are seen in lower third of ureter. Medical expulsive therapy is effective for such stones. This study was designed to observe the efficacy of ‘tamsulosin’ a selective alpha-1 adrenoreceptor antagonist in the management of lower ureteric stone.Methods: A cross sectional study of 70 cases of distal ureteral stones of sizes 5 to 10 mm was taken in the Department of Surgery of Shree Birendra Hospital, Nepalese Army Institute of Health Sciences (NAIHS) from January 2011 to 2013. Patients were randomly divided into tamsulosin and analgesic only groups. Stone expulsion at the end of three weeks was confirmed by X-ray or Ultrasonography.Results: Out of 70 patients, stone clearance rate in tamsulosin group was 28 in 35 cases (80%) and 21 in 35 cases (60%) in group II with analgesic only. The mean time of stone expulsion was 8.3 days in group I and 13.5 days in group II.Conclusions: In this study the use of tamsulosin in treatment of lower ureteral stones less than 10 mm was safe and effective.

Supine versus Prone Position during Extracorporeal Shockwave Lithotripsy for Treating Distal Ureteral Calculi: A Systematic Review and Meta-Analysis

Purpose: We aimed at evaluating the efficacy of extracorporeal shockwave lithotripsy (SWL) for treating distal ureteral calculi performed in supine vs. prone position. Materials and Methods: Eligible studies were identified by 2 reviewers using PubMed, Embase, and Web of Science databases. Outcomes included stone-free rate after the first and the final SWL session, the mean number of shocks per SWL session, the mean percentage of power used in the first SWL session, and the mean number of SWL sessions per patient. Results: Pooled data among the 647 included patients showed that supine SWL was associated with a significantly higher stone-free rate than prone SWL. This difference was consistent for both the first SWL session (OR 4.17; 95% CI 2.53-6.87; p < 0.00001) and the final session (OR 3.02; 95% CI 1.96-4.67; p < 0.00001). No differences in the mean number of shocks per SWL session, the mean percentage of power used in the first SWL session, and the mean number of SWL sessions per patient were observed between the positions. SWL complications were infrequent and the incidence was insufficient for further analysis. Conclusion: SWL is safe and effective for the management of distal ureteral calculi, and supine SWL is more effective than prone SWL for achieving a stone-free status.

Outcome of ureteroscopy for the management of distal ureteric calculi: 5-years’ experience

ObjectiveTo review our 5 years’ experience with ureteroscopy treatment of distal ureteric calculi. Patients and methodsWe reviewed the medical records of 136 patients who underwent ureteroscopic procedures for the treatment of distal ureteric calculi from February 2007 to October 2012. Patient and stone characteristics, treatment modality and outcome were assessed. Procedure's duration, status “stone free” and hospital stay were also evaluated. The mean clinical and radiological follow-up period was 31.8 months for 74.2% of eligible patients. ResultsThe stone free rate following an initial ureteroscopy was 79.4. The ultimate success rate for stone removal after “second look” improved to 95.9%. The mean operative duration was 51minutes.The intraoperative complication rate was 8.6%, the postoperative complication rate was 7.5%, and the mean hospital stay was 1.1 days.We could detect one ureteric stricture and one vesico-ureteric reflux (0.9% for each). A significant ureteric perforation was detected in 4.1% and ureteric perforation in 0.7% of the study group.We could find that the longer the operative duration, the greater the complications.Stone impaction and size were also found associated with higher morbidity. ConclusionGrowing skills and experience of ureteroscopy will lead to a significant increase in the success rate and also reducing serious complications.

1985 PREOPERATIVE TAMSULOSIN FACILITATES URETEROSCOPIC MANAGEMENT OF LOWER URETERIC CALCULI: A PROSPECTIVE RANDOMIZED STUDY

INTRODUCTION AND OBJECTIVES: Tamsulosin is proved to promote spontaneous passage of distal ureteral and juxtavesical calculi. Our aim is to prospectively evaluate the role of neoadjuvant tamsulosin during ureteroscopic treatment of lower ureteric stone. METHODS: One hundred thirty-eight adult patients with lower ureteral calculi underwent ureteroscopic management. Stone length varied from 7 to 12 mm. Before treatment, the patients were randomly divided into 2 groups; the study group (n 70) received tamsulosin 0.4 mg once daily for 3-6 weeks and the control group (n 68) received standard analgesia only. Preoperative medications were blinded to the endourologists. The primary endpoint was the need for intraoperative ureteral dilatation. Postoperative complications were recorded for both groups. RESULTS: Of the 120 patients available for follow up, the need for intraoperative ureteral dilatation was 30% in the study group, compared with 86.7% in the control group (p 0.001). Of the control group, 5% had postoperative pyelonephritis episodes, in contrast to only 1.7% of the study group (p 0.619). CONCLUSIONS: Preopertive tamsulosin simplifies ureteroscopic management of lower ureteric calculi. To the best of our knowledge, this is the first study to show the value of neoadjuvant tamsulosin in ureteroscopic management of distal ureteric calculi.

Practice Variation in the Surgical Management of Urinary Lithiasis

Shock wave lithotripsy and ureteroscopy are highly effective treatments for urinary lithiasis. While stone size and location are primary determinants of therapy, little is known about other factors associated with treatment. We identified patient, provider and practice setting characteristics associated with the selection of ureteroscopy or shock wave lithotripsy. We used the Medicare 5% sample to identify beneficiaries with an incident stone encounter from 1997 to 2007. Within this group we identified beneficiaries undergoing shock wave lithotripsy or ureteroscopy for the management of urinary calculi. Multivariable regression models identified factors associated with the use of ureteroscopy. The cohort comprised 9,358 beneficiaries who underwent an initial procedure. Shock wave lithotripsy was used in 5,208 (56%) beneficiaries while ureteroscopy was used in 4,150 (44%). Female patients were less likely than males to undergo ureteroscopy (OR 0.844, p = 0.006). Providers who more recently completed residency training used ureteroscopy more often (p = 0.023). Provider and facility volume were associated with initial procedure selection. The odds of a second procedure following initial shock wave lithotripsy were 1.54 times those of ureteroscopy (p <0.001). Nonclinical factors are associated with the use of ureteroscopy or shock wave lithotripsy for initial stone management, which may reflect provider and/or patient preferences or experience. Further investigation is required to understand the impact of these outcomes on quality and cost of care.

Shock wave lithotripsy is effective and safe for distal ureteral calculi in children

We evaluated the effectiveness of the Siemens Lithostar Modularis lithotriptor for the management of distal ureteric calculi in children. Between 2004 and 2006, 29 children with distal ureteric calculi were treated in our stone center with the Siemens Lithostar Modularis (Siemens Medical Solutions, Inc.) Effectiveness of lithotripsy, retreatment and efficacy quotient rates, and complications were assessed. The series consisted of 18 (62%) boys and 11 (38%) girls with an age range of 1-13 years (average age 7.0 +/- 3.5). Under fluoroscopic guidance, children were treated with a maximum 3,000 shocks at an average of 2.2 +/- 0.3 kV. Mean stone size was 8.2 +/- 3.2 mm (range 4-18). Success was defined as the lack of any visible stone fragments on posttreatment radiological evaluation. The mean number of sessions required was 1.5 +/- 0.8/patient (range 1-4). Complete clearance rate at 3 months was 86.2%. Re-treatment and efficacy quotient rates for distal ureteral stones were 41.4 and 55.6%, respectively. Complications such as urinary tract infection or steinstrasse occurred in 2 (6.9%) patients. Minor complications included petechial skin hemorrhage at the site of entry of shock waves in all patients. Our results show that shock wave lithotripsy for distal ureteral calculi with the Siemens Lithostar Modularis lithotriptor has a high success rate (86.2%) and efficacy quotient (55.6%) with negligible complications in children.

Extracorporeal Shock Wave Lithotripsy for Large Ureteral Stones Using HM3 Lithotriptor

We assessed the efficacy of extracorporeal shock wave lithotripsy for large (more than 10 mm) ureteral calculi with the unmodified Dornier HM3 lithotriptor. A total of 96 consecutive patients with large ureteral stones were treated with shock wave lithotripsy using an unmodified HM3 lithotriptor. Patients, stone characteristics, preliminary treatment before shock wave lithotripsy, additional procedures after shock wave lithotripsy, complications and clinical outcomes were assessed. Between 2000 and 2003 a total of 96 patients (75 males, 21 females, mean age 51 years [range 16 to 81]) with large ureteral stones underwent shock wave lithotripsy. Average stone size was 14 mm (range 10 to 22), 90 stones were calcified, and 66 stones were located in the upper ureter, 20 in the mid ureter and 10 in the distal ureter. A total of 77 (80.2%) patients underwent a single shock wave lithotripsy session, 18 (18.7%) underwent 2 sessions and 1 (1.1%) patient underwent 3 sessions. The overall stone-free rate was 86.5% (83 patients). Complications occurred in 10 (10.4%) patients. Shock wave lithotripsy failed in 13 (13.5%) patients who were successfully treated with ureteroscopy. Our data show that shock wave lithotripsy for large ureteral stones along the entire ureter with the unmodified HM3 lithotriptor has a high success rate with minimal morbidity. We recommend it as first line treatment.

A Comparison of Extracorporeal Shock Wave Lithotripsy and Ureteroscopy Under Intravenous Sedation for the Management of Distal Ureteric Calculi

A Comparison of Extracorporeal Shock Wave Lithotripsy and Ureteroscopy Under Intravenous Sedation for the Management of Distal Ureteric Calculi

Editorial comment

In the current study, the authors have assessed the value of intensive medical management of distal ureteral calculi in an effort to facilitate spontaneous stone passage. During this prospective trial, patients were randomized to receive pain medication (control group) or pain medication plus a calcium-channel blocker and steroids (treatment group). The patients in the treatment group demonstrated a higher incidence of spontaneous stone passage, more rapid stone passage, and an apparent reduction in ureteral colic, as evidenced by a decreased amount of analgesics required during spontaneous stone passage. The authors conclude that medical management of renal calculi with steroids and calcium-channel blocker should be considered to facilitate spontaneous stone passage of distal ureteral calculi.

INTERNET AND POSTAL SURVEY OF ENDOUROLOGIC PRACTICE PATTERNS AMONG AMERICAN UROLOGISTS

We determine endourological practice patterns among American urologists for the management of distal ureteral calculi, ureteropelvic junction obstruction, staghorn calculi and the use of ureteral stents with extracorporeal shock wave lithotripsy (ESWLdagger). Surveys were mailed by the United States postal service to 1,000 American urologists selected randomly from the American Urological Association membership roster. The same survey was sent via the Internet to 3,065 American urologists with an electronic mail address listed in the roster. Responses were received from 1,029 urologists (postal 601, Internet 428). Ureteroscopy was the preferred treatment for all distal ureteral calculi less than or equal to 10 mm. Acucisedouble dagger endopyelotomy was the most frequently selected therapy for adults with ureteropelvic junction obstruction (50.3%, 514 of 1,022). Open pyeloplasty was recommended by a significantly greater percentage of urologists in practice longer than 15 years compared with the remaining survey respondents (166 of 485, 34.2% versus 92 of 427, 21.5%). For patients with renal pelvic stones 10, 15 or 20 mm. who are treated with ESWL routine stent placement was preferred by 25.3% (259 of 1,022), 57.1% (584 of 1,022) and 87.1% (888 of 1, 019) of urologists, respectively. Percutaneous nephrolithotomy was preferred for patients with staghorn calculi by 80.5% (828 of 1,028) of survey respondents. Most urologists follow the American Urological Association practice guidelines for patients with distal ureteral calculi and staghorn stones. There is a significant difference of opinion regarding the use of stents with ESWL. No clear consensus has been reached concerning the management of adults with ureteropelvic junction obstruction. These data may be useful in designing physician education programs and/or future investigations to help define standard treatment practices for urological diseases.

Treatment of distal ureteral calculi with ESWL: experience with more than 100 consecutive cases

Until recently, the indications for extracorporeal shock wave lithotripsy (ESWL) have been limited to renal calculi and ureteral calculi above the pelvic brim. However, the distal ureter can be made available for shock wave treatment as well, by modifying the position of the patient on the support of the Dornier lithotripter HM-3. Using this “sitting position” technique, 133 patients with stones or stone fragments in the lower ureter were treated from January through November 1986. Treatment was successful in 125 patients (94%), 14 of whom required 2 sessions. In 8 patients, treatment failed and stone removal was accomplished using ureteroscopy or open surgery. No complications or adverse side effects were encountered in the entire series. We consider ESWL the treatment of choice in the management of distal ureteral calculi and Steinstrassen.