Medical Expulsive Therapy Research Articles

Comparative Study of Efficacy and Safety of Tamsulosin plus Tadalafil Combination Therapy versus Tamsulosin Monotherapy as Medical Expulsive Therapy of Ureteric Stone

Introduction: If surgical intervention is not indicated, current international guidelines and evidences recommend medical expulsive therapy (MET) involving the administration of drugs to improve spontaneous stone passage. Medical expulsive therapy has now become an established modality of treatment, and employs the use of various drugs that act on the ureter with different mechanisms. It is hypothesised that elevation of cyclic guanosine monophosphate in ureteral smooth muscle by phosphodiesterase type 5 (PDE5) inhibitors may result in ureteral relaxation and increased stone clearance. Aims/ objective: To investigate whether we can achieve better ureteric relaxation and reduction in intramural pressure in order to facilitate stone passage by tamsulosin plus tadalafil combination therapy. Materials and Method: Stone expulsion rate of tamsulosin + tadalafil when compared to tamsulosin was our primary endpoint. (Assessed by subjective response and confirmed by repeat plain X ray abdomen and if needed CT scan abdomen). The efficacy of the individual drugs was analysed and compared with the help of Pearson chi square test. p value <0.05 were considered as statistically significant. Results: 33 patients (66%) receiving tamsulosin and 43 patients (86%) receiving combination therapy showed positive outcome (expulsion of stones). So, tamsulosin plus tadalafil combination therapy had significantly better efficacy. In tamsulosin group 30 patients among 33 (90.9%) expelled the stone in less than 5 days. In tamsulosin plus tadalafil group, 37 patients among 43 (86%) expelled in less than 5 days. But the difference was not statistically significant. Both drugs were well tolerated by the study patients. Conclusion: Tamsulosin plus tadalafil is more efficacious, and well tolerated as medical expulsive therapy for distal ureteric stones compared to tamsulosin. Medical expulsive therapy also doesn’t carry post-operative morbidities as compared to surgical methods.

Paediatric stone management: innovations and standards.

The aim of this study was to discuss current trends and recent developments in the surgical management of paediatric urolithiasis. Medical expulsive therapy (MET) is considered as an option for the treatment of children with ureter stones. Extracorporeal shockwave lithotripsy (SWL) remains as a first option for majority of kidney stones and upper ureter stones. Advances in endourology have led to increased adoption of retrograde intrarenal surgeries (RIRS) and percutaneous nephrolithotomy (PCNL/mini-PCNL/ultra-mini-PCNL/micro-PCNL). Management of paediatric stone disease has developed significantly in the past decade. However, the evidence in the literature remains disproportional to these advances. Well designed multicentric studies are still needed to compare effectiveness and safety of these procedures.

Efficacy of tamsolusin hydrochloride as medical expulsive therapy in lower ureteric calculi < 9mm in adults.

Objectives: To determine the efficacy of Tamsolusin Hydrochloride as medical expulsive therapy in removal of lower ureteric calculi < 9 mm in adults. Study Design: Cross-sectional study. Setting: Naz Memorial Hospital Karachi. Period: July 2019 to December 2019. Material & Methods: Using non-probability convenient sampling technique was conducted for 6 months. After ethical approval patients attending outpatient department with complains of bloody urine, abdominal, flank or groin pain and diagnosed as lower ureteric calculi < 9mm on ultrasonography. Upper ureteric or kidney calculi above 9 mm, patients already on Tamsolusin and lost to follow up or not willing to participate were excluded. Time period of the study was 4 weeks. Patients were started on Tamsolusin 0.4 mg once daily for 30 days. SPSS version 23.0 was used for data analysis. Qualitative data was reported as frequency in percentages. Results: Age range of patients was 18-50 years with mean age of 35.54 ± 10.20 years. 48 (40%) between 6 to 7 mm. After 1 month of follow up, total of 94 (78%) of patients were found to have expulsion of ureteric calculi. From the total of 30 days, the recorded frequency of calculi expulsion was 94 (78%). Among them, 25 (27%) patients were reported to have expulsion of calculi in between 15 to 19 days.32 (34%) patients between 20-24 days, while 37 (39%) patients between 25 to 29 days. Conclusion: Tamsolusin was significantly effective in expulsion of calculi with most calculi reported to be expulsed between 20-29 days of treatment. Patients also reported in significant decrease in pain frequency and were satisfied with treatment with Tamsolusin for lower ureteric calculi < 9mm.

Mirabegron as a Medical Expulsive Therapy for 5-10 mm Distal Ureteral Stones: A Prospective, Randomized, Comparative Study.

The aim of this study was to assess the efficacy and safety of mirabegron as a medical expulsive therapy in patients with distal ureteral stones of 5-10 mm size. A prospective, comparative study included 96 patients with radiopaque distal ure- teral stones of 5-10 mm who were randomly allocated and treated by medical expulsive therapy in 2 groups from January 2019 to December 2020. Patients in group A received only ketorolac 30 mg/day for 5 days, then on demand. Patients in group B received mirabegron 50 mg/day for 4 weeks plus ketorolac 30 mg/day like in group A. The stone expulsion rate was the primary outcome. There were no significant differences regarding age, gender, body mass index, laterality, degree of hydronephrosis, and stone size. After 4 weeks, stone expulsion rate was 52.1% for group A versus 89.6% for group B (P < .001). The median (range) of time to stone expulsion was 14 (13-23) and 7 (3-16) days for groups A and B, respectively (P = .004). The medians (range; interquartile range) of episodes of renal pain (1 (0-2; 1) vs. (0-2; 2); P < .001) and extra analgesic ampoules (1 (0-7; 4) vs. 0 (0-2; 0) vials; P < .001) were significantly higher in group A than those in group B, respectively. In multivariate analysis, only medical expulsive therapy (P <.001) and stone size (P < .001) were independent predictors of stone expulsion rate. Mirabegron is an effective and safe medical expulsive therapy agent in patients with 5-10 mm distal ureteral stones.

Efficacy of medical expulsive therapy using the traditional Japanese medicine (kampo) choreito for the spontaneous passage of proximal ureteric stones: A retrospective analysis

AbstractAimUrolithiasis is a common disorder of the urinary tract. Medical expulsive therapy is recommended for calculi with diameters &lt;10 mm. This study was conducted to determine the effect of choreito, an herbal medication with discharging effects, on the spontaneous passage of urinary calculi.MethodsThis retrospective observational study included 109 adult patients with urinary calculi who were admitted to Hirao Hospital between April 2016 and March 2017. Choreito (7.5 g/day) was administered to 55 participants in the choreito group but not to the 54 participants of the control group. All patients were monitored until the calculi passed naturally. The period of spontaneous passage of the calculi was compared between the choreito and control groups, and the factors associated with this duration were identified using multivariate analysis.ResultsCompared to the control group, the period of spontaneous passage of the proximal ureteric stones was significantly shorter in the choreito group (14 days vs 36 days, p = 0.0262). Calculus diameter (&lt;3 mm) and choreito administration were identified as independent factors associated with a shorter period for spontaneous calculi passage.ConclusionOral administration of choreito may promote the spontaneous passage of proximal ureteric stones without the need for surgical intervention.

A randomized trial of adjuvant tamsulosin as a medical expulsive therapy for renal stones after shock wave lithotripsy.

Adjuvant medical expulsive therapy (MET) for shock wave lithotripsy (SWL) is controversial. With limited use of the computed tomography (CT), the stone free rate (SFR) become overestimated. Herein we evaluate tamsulosin post-SWL for renal stone using the CT to assess SFR. A randomized controlled trial (NCT05032287) was carried out for renal stone patients amenable for SWL. Patients were allocated after 1st session of SWL to receive tamsulosin 0.4 mg or placebo once daily from the 1st day of SWL and for 3-months or becoming stone free. The primary outcome was SFR, defined by presence of residual fragments (RF) ≤ 3 mm (3C-SFR). The 3C-SFR were 73.8% and 59.6% in tamsulosin and placebo groups, respectively (p=0.03). The median (IQR) pain scores were 3 (3, 5) and 5 (3, 6) in tamsulosin and placebo groups, respectively (p=0.04), However, the post-SWL complication and add-on analgesia needed showed no significance differences between groups. The median time for stone free were 30 days (95% CI: 27.29-32.71) in tamsulosin arm, and 36 days (95% CI: 31.01-40.99) in placebo arm, HR= 1.42 (95% CI: 1.02-1.98). Tamsulosin has more reversible adverse effect, compared to placebo (p=0.03). In our study, the use of tamsulosin as MET following SWL facilitates expulsion of retained residual fragments. Tamsulosin shortens time to reach stone free, decreases pain scores. However, tamsulosin does not affect the add-on IV analgesics and have more reversible adverse effect, compared to placebo.

PD05-09 IMPROVED STONE QUALITY OF LIFE IN PATIENTS WITH OBSTRUCTING URETERAL STONE ON ALPHA-BLOCKER MEDICAL EXPULSIVE THERAPY

You have accessJournal of UrologyCME1 May 2022PD05-09 IMPROVED STONE QUALITY OF LIFE IN PATIENTS WITH OBSTRUCTING URETERAL STONE ON ALPHA-BLOCKER MEDICAL EXPULSIVE THERAPY Brijesh Patel, Tarik Phillips, Joshua Palk, Joel Vetter, Mark Biebel, Alexander Chow, Alethea Paradis, Alana Desai, Kenneth Sands, and Ramakrishna Venkatesh Brijesh PatelBrijesh Patel More articles by this author , Tarik PhillipsTarik Phillips More articles by this author , Joshua PalkJoshua Palk More articles by this author , Joel VetterJoel Vetter More articles by this author , Mark BiebelMark Biebel More articles by this author , Alexander ChowAlexander Chow More articles by this author , Alethea ParadisAlethea Paradis More articles by this author , Alana DesaiAlana Desai More articles by this author , Kenneth SandsKenneth Sands More articles by this author , and Ramakrishna VenkateshRamakrishna Venkatesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002524.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Though controversial, alpha blockers continue to be used widely for ureteral stone passage. However, its effects on the patient reported Quality of life (QOL), either positive, negative or no impact, is unknown. We compared the QoL of patients on alpha-blocker medical expulsive therapy (MET) to patients not on MET (noMET) utilizing a validated Wisconsin Stone Quality of Life (WISQOL). METHODS: After IRB approval, we performed a prospective study including patients on either MET or no MET after presenting to a tertiary-care ED with symptomatic, obstructing ureteral stones. Medical treatment type was decided at the point of care by the initial treating physician including medications for analgesia and nausea. Additionally, tamsulosin (0.4mg orally, daily) was prescribed for the MET group. The WISQOL survey was administered at baseline, 7-, 14-, 21- and 28-days following discharge from the ED or until stone expulsion. RESULTS: A total of 197 patients were enrolled, of which 116 (59.2%) completed questionnaires for analysis, 91 in the MET group and 25 in no MET. Average ureteral stone size was 4.7 (STD 1.8) mm and 3.1 (STD 1.0) mm for MET and no MET, respectively. Of completed surveys, 105 (90%) were completed at day 7, 67 (57.6%) at day 14, 53 (45.7%) at day 21, and 40 (34.5%) at day 28. Spontaneous stone passage occurred in 38 (41.8%) while on MET compared to the 7 (28.0%) in no MET (p = 0.21). In total, 8 (6.8%) patients returned to the ED for intractable pain and 11 (9.5%) required surgical intervention. MET was associated with an improved QoL scores across all WISQOL domains compared to no MET (Fig.1). Stone size, age, race, sex, comorbidity score and a prior stone history were not associated with risk of negative effect on QoL (Table 1). CONCLUSIONS: Use of alpha-blocker MET was associated with improved QOL on all WISQOL metrics compared to no MET patients. Larger, randomized controlled trial studies may validate these findings. Alpha-blocker treatment may be an indication to improve stone QOL in patients with ureteral stone colic. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e89 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brijesh Patel More articles by this author Tarik Phillips More articles by this author Joshua Palk More articles by this author Joel Vetter More articles by this author Mark Biebel More articles by this author Alexander Chow More articles by this author Alethea Paradis More articles by this author Alana Desai More articles by this author Kenneth Sands More articles by this author Ramakrishna Venkatesh More articles by this author Expand All Advertisement PDF DownloadLoading ...

Mirabegron attenuates porcine ureteral contractility via α1-adrenoceptor antagonism

The β3-agonist mirabegron is thought to induce relaxation of the detrusor muscle, contributing to the improvement of overactive bladder symptoms. There has been recent interest in purposing mirabegron as a medical expulsive therapy drug to improve the passage of smaller kidney stones by relaxing the ureteral smooth muscles. The aim of this study was to determine the effects of mirabegron on the activity of the ureter. Additionally, we investigated the receptor and mechanisms through which mirabegron exerts these effects. In vitro agonist-induced responses of isolated porcine distal ureteral tissues were measured in the absence and presence of mirabegron in organ bath experiments. The responses were expressed as frequency, area under the curve and maximum amplitude. Mirabegron at concentrations of 100 nM and lower failed to suppress phenylephrine- or 5-HT-induced contractions in the porcine ureteral strip. Mirabegron at 1 μM and 10 μM produced a rightward shift of phenylephrine concentration–response curves in these tissues. This effect of mirabegron (10 μM) was not present in 5-HT concentration–response curves. The mirabegron effect on phenylephrine-induced contractions was also not abolished by β-adrenoceptor antagonist SR 59230A (10 μM), β-adrenoceptor antagonist propranolol (10 μM), α2-adrenoceptor antagonist yohimbine (30 nM), and nitric oxide synthase inhibitor l-NNA (10 μM). The present results show that mirabegron suppresses ureteral contractile responses in the porcine ureter via α1-adrenoceptor antagonism, since their effects were not present when the tissues were contracted with 5-HT. Furthermore, the inhibitory effects by mirabegron were not affected by β3-adrenoceptor antagonists.

Meta-Analysis of the Safety and Efficacy of α-Adrenergic Blockers for Pediatric Urolithiasis in the Distal Ureter.

ObjectivePediatric urolithiasis is a common condition, and medical expulsive therapy has grown to be accepted by many parents. We carried out a meta-analysis to identify the efficacy and safety of α-adrenergic blockers for the treatment of pediatric urolithiasis.MethodsWe identified related articles from the PubMed, Embase, and Cochrane Library databases. All published randomized controlled trials (RCTs) describing the use of α-adrenergic blockers and placebo treatment for pediatric distal urolithiasis were involved. The outcomes included stone expulsion rate, stone expulsion time, pain episodes, need for analgesia, adverse events, and related subgroup analyses.ResultsA total of nine RCTs were involved in our study, including 586 patients. We found that α-adrenergic blockers could significantly increase the rate of stone expulsion [odds ratio (OR), 3.49; 95% confidence interval (CI), 2.38–5.12; p < 0.00001], reduce the stone expulsion time [mean difference (MD), −5.15; 95% CI, −8.51 to −1.80; p = 0.003], and decrease pain episodes (MD, −1.02; 95% CI, −1.33 to −0.72; p < 0.00001) and analgesia demand (MD, −0.92; 95% CI, −1.32 to −0.53; p < 0.00001) but had a higher incidence of side effects (MD, 2.83; 95% CI, 1.55 to 5.15; p = 0.0007). During subgroup analyses, different medications (tamsulosin, doxazosin, and silodosin) also exhibited better efficiencies than placebo, except for doxazosin, which showed no difference in expulsion time (MD, −1.23; 95% CI, −2.98 to 0.51; p = 0.17). The three kinds of α-adrenergic blockers also appeared to be better tolerated, except for tamsulosin with its greater number of adverse events (MD, 2.85; 95% CI, 1.34 to 6.03; p = 0.006). Silodosin led to a better expulsion rate than tamsulosin (OR, 0.42; 95% CI, 0.20 to 0.92; p = 0.03). In addition, α-adrenergic blockers increased the stone expulsion rate regardless of stone size and decreased the expulsion time of stones measuring <5 mm (MD, −1.71; 95% CI, −2.91 to −0.52; p = 0.005), which was not the case for stones measuring >5 mm in expulsion time (MD, −3.61; 95% CI, −10.17 to 2.96; p = 0.28).ConclusionOur review suggests that α-adrenergic blockers are well-tolerated and efficient for treating pediatric distal urolithiasis. We also conclude that silodosin is the best choice of drug, offering a better expulsion rate, but it remains to be evaluated further by future studies.

FREQUENCY OF SPONTANEOUS STONE EXPULSION OF SMALL LOWER URETERIC STONES IN PATIENTS WITH RAISED SERUM CRP(C-REACTIVE PROTEIN)

Objective: To determine the frequency of spontaneous stone expulsion of small lower ureteric stones in patients with raised serum CRP. Materials and Methods: Total of 195 patients with lower ureteric stone size 4mm to 9mm and with raised CRP were analyzed. All patients were subjected to history taking and examination for suspected ureteric stone. Urine R/E, blood investigation, was carried out followed by x-ray KUB and ultrasound of the pelvis and abdomen. CRP was measured only on initial presentation.Results: In our study Spontaneous stone expulsion was recorded in 54.87 % patients while the remaining 45.12% failed to spontaneous stone expulsion. We grouped spontaneous stone expulsion on the basis of age and found 26.56% out of 43.07% of patients were fall in spontaneous stone expulsion criteria in the group of 46-60 Years. Stratification of spontaneous stone expulsion with CRP level was done and that was noted that 54.87% has raised CRP value.Conclusion: The intended concluded that this conservative management with medical expulsive therapy is a successful strategy for managing small ureteric stones in distal ureter and it could be best seen with plasma CRP. Those Patients having raised CRP level have comparatively low stone expulsion rate and therefore should immediately be considered for minimally invasive procedure such as ureteroscopy.

Comparison of the Efficacy of Medical Expulsive Therapy for the Treatment of Distal Ureteric Stones with and without Mirabegron

Comparison of the Efficacy of Medical Expulsive Therapy for the Treatment of Distal Ureteric Stones with and without Mirabegron

The Efficacy of Mirabegron in Medical Expulsive Therapy for Ureteral Stones: A Systematic Review and Meta-Analysis.

Background This study aimed to assess the efficacy of mirabegron (50 mg daily) as a medical expulsive therapy for ureteral stones in adults. Materials and Methods We searched PubMed, Embase, Cochrane Library, and Web of Science from inception to July 2021 to collect the clinical trials. Two reviewers independently screened literature, extracted data, and assessed the risk of bias of included studies by using the Cochrane risk of bias tool. Review Manager 5.3 software was used for the meta-analysis. Results A total of four studies were included, involving 398 patients: 197 patients in mirabegron group and 201 patients in control group. The meta-analysis showed that the stone expulsion rate was higher in the mirabegron group than in the control group (OR: 2.12; 95% CI: 1.33 to 3.40; p=0.002). Subgroup analysis identified that the stone expulsion rate of patients with stone size <5/6 mm was significantly higher than that of patients with stone size ≥5/6 mm (OR: 0.31; 95% CI: 0.13 to 0.72; p=0.006). But no significant difference was identified between the mirabegron group and the control group for the stone expulsion interval (MD: −1.16, 95% CI: −3.56 to 1.24; p=0.35). In terms of pain episodes, the mirabegron group was significantly lower than that of the control group (MD: −0.34, 95% CI: −0.50 to 0.19; p < 0.0001). Conclusions The medical expulsive therapy with mirabegron had a significant effect in improving the stone expulsion rate for patients with ureteral stones, especially in those whose stone size <5/6 mm. Mirabegron had no effect on the stone expulsion interval but did decrease the pain episodes.

Beneficial Extracardiac Effects of Cardiovascular Medications.

Cardiovascular diseases are the most common cause of death worldwide, with cardiovascular medications being amongst the most common medications prescribed. These medications have diverse effects on the heart, vascular system, as well as other tissues and organ systems. The extra cardiovascular effects have been found to be of use in the treatment of non-cardiovascular diseases and pathologies. Minoxidil is used to manage systemic hypertension with its well-known side effect of hirsutism used to treat alopecia and baldness. Sildenafil was originally investigated as a treatment option for systemic hypertension; however, its side effect of penile erection led to it being widely used for erectile dysfunction. Alpha-1 blockers such as terazosin are indicated to treat systemic hypertension but are more commonly used for benign prostatic hyperplasia and post-traumatic stress disorder. Beta blockers are the mainstay treatment for congestive heart failure and systemic hypertension but have been found useful to help in patients with intention tremors as well as prophylaxis of migraines. Similarly, calcium channel blockers are indicated in medical expulsion therapy for ureteric calculi in addition to their cardiovascular indications. Thiazides are commonly used for treating systemic hypertension and as diuretics. Thiazides can cause hypocalciuria and hypercalcemia. This side effect has led to thiazides being used to treat idiopathic hypercalciuria and associated nephrolithiasis. Spironolactone is commonly utilized in treating heart failure and as a diuretic for edema. It's well described anti-androgen side effects have been used for acne vulgaris and hirsutism in polycystic ovarian syndrome. This review article discusses how the various extracardiovascular effects of commonly used cardiovascular medications are put to use in managing non-cardiovascular conditions.

Medical expulsive therapy in ureteric calculi: A prospective study

Ureteric calculus with a colicky pain is a common issue faced by surgeons and urologists in the ER and OPD with a major universal health and financial strain on the health care system. Different studies have shown promising outcomes for ureteric calculus with medical expulsive therapy (MET) in relation to the expulsion rate and mean duration of expulsion, decrease hospital stay and less requirements of analgesics. The aim of this study is to compare the efficacy and safety of Tamsulosin alone or in combination of Deflazacort in medical expulsive therapy of ureteric calculus of less than 10 mm (sub-centric).Effect was studied on two groups. Group-A patient received standard medical treatment plus Tamsulosin. Group-B patients received standard medical treatment and Tamsulosin plus Deflazacort.MET with Tamsulosin and Deflazacort has major advantages, with very mild, reasonable side effects and substantially lower healthcare system costs.Medical therapy with Tamsulosin is effective and have been found to increase and hasten the expulsion of ureteric calculus, but expulsion rate is more, mean expulsion time and duration of hospital stays, and the episodes of pain is less when tamsulosin is combined with Deflazacort.

A0264 - Tamsulosin as medical expulsive therapy after shock wave lithotripsy for renal stones: A randomised controlled trial (NCT05032287)

A0264 - Tamsulosin as medical expulsive therapy after shock wave lithotripsy for renal stones: A randomised controlled trial (NCT05032287)

Comparison Of Emergency And Elective Intervention With Semi-Rigid Ureteroscopic Lithotripsy For Patients With Ureteral Calculi.

Ureteroscopy (URS) is a safe and highly effective treatment option for treatment of ureteral calculi. With the advancement of technology, there is also expansion of its indications including use in early or emergency setting. This study aims to compare safety and efficacy of emergency ureteroscopy (EmURS) versus elective ureteroscopy (ElURS) for ureteral stones. Patients with unilateral single radio-opaque ureteral stone who underwent semi-rigid URS from January 2008 till December 2019 were included. Patients with solitary kidney, uro-sepsis, pregnancy or pre-operative drainage with nephrostomy or JJ stent were excluded. EmURS was defined as URS being performed within 48 hours of presentation, while ElURS was defined as URS performed after failed medical expulsive therapy. Patient, stone and outcome related variables were compared in both groups. Stone free rate was defined as no evidence of stone on plain x-ray KUB after 1 week. We compared 132 patients in EmURS group against 264 in ElURS group. Age, gender, comorbidities, stone location, laterality and mean stone size were comparable in both groups. EmURS had a less median operative time (p=0.05). Stone free rate achieved was 90.2% in EmURS and 87.1% in ElURS, respectively (p=0.38). Double J stent was placed in 44.7% and 46.2% of EmURS and ElURS respectively (p=0.89). Ancillary procedures were performed in 9.8% of EmURS and 11.7% of ElURS (p=0.57). Overall complication rates were reported in 7.6% in EmURS and 11.7% in ElURS (p=0.22) and most were Clavien grade 1. Emergency URS for ureteral stones is a safe and effective one-stage definitive treatment option for patients with acute renal colic not responding to conservative management.

A0252 - Efficacy of mirabegron as medical expulsive therapy for distal ureteral stones: A prospective randomized, double blind, controlled study

A0252 - Efficacy of mirabegron as medical expulsive therapy for distal ureteral stones: A prospective randomized, double blind, controlled study

Barriers in Managing Acute Ureteric Colic Clinical Review and Commentary.

With the global prevalence of urolithiasis increasing, the presentation of acute ureteric colic to emergency departments (ED) poses a significant burden on healthcare systems globally. Management strategies for ureteric colic encompass medical expulsion therapy and various interventional modalities aimed at urinary diversion or definitive stone management. By examining potential or established barriers to managing acute ureteric colic, we can minimise strain on healthcare providers while maintaining patient outcomes. This review aims to assess barriers to the management of acute ureteric colic through a comprehensive overview of the current literature. Acute ureteric colic barriers will be assessed throughout a patient’s disease progression, borrowing a conceptual framework used to assess barriers in cancer care management. Barriers will be discussed in the context of patient-centred access to healthcare, clinical evaluation and diagnosis, and management. Numerous barriers to healthcare have been identified throughout the natural course of acute ureteric colic, both specific and non-specific. Patient-centred barriers typically arise during the initial onset of acute ureteric colic. Originating from patient awareness and access to healthcare, they include barriers founded on race inequalities, cultural beliefs, geographic location, transportation, and the concept of a universal standard of healthcare. Having accessed healthcare, barriers in the management of acute ureteric colic next occur during the clinical evaluation and diagnosis period. These are typically associated with clinical assessment or diagnostic imaging delays, including underutilisation of ultrasound, nurse-led pathways for faster clinical reviews, and general ED delays. The final period during acute ureteric colic management correlates to clinical management. The inherent unpredictable course of ureteral stones leads to poor prognostication and failed initial management modalities. Additionally, this period deals with periprocedural delays and preventative health. Barriers to the management of acute ureteric colic arise during a patient's journey through accessing healthcare. Reviewing barriers allow further research into areas requiring modification to expedite care and improve outcomes.

Efficacy of Mirabegron as Medical Expulsive Therapy for Distal Ureteral Stones: A Prospective, Randomized, Double-Blinded, Controlled Study

Background: Today, medical expulsive therapy (MET) is more effective and commonly used in distal ureteral stones when compared with conservative treatments. Many treatments, namely, alpha-adrenergic blockers and calcium channel blockers, prostaglandin synthesis inhibitors, glyceryl trinitrate, and steroids, have been, therefore, utilized to mitigate such complications and accelerate stone expulsion. Several animal and human studies revealed the presence of β3-receptors in the ureter and bladder, where stimulating these receptors could relax the distal ureteral segment. Objectives: The aim of the study was to evaluate the efficacy of use of mirabegron as MET for distal ureteral stones (intramural and extramural). Methods: This is a prospective randomized controlled study including 90 patients who had distal ureteral stones less than 10 mm and were evaluated between January and June 2020. The patients were classified into 3 groups: group (A) 30 patients: mirabegron 50 mg d−1 + diclofenac Na 100 mg tab (to be taken only during colic episodes), group (B) 30 patients: tamsulosin HCL 0.4 mg cap + diclofenac Na 100 mg tab (to be taken only during colic episodes), and group (C) 30 patients: diclofenac Na 100 mg tab only (to be taken only during colic episodes). Age, sex, stone size, laterality, and grade of ureterohydronephrosis were recorded. Patients were observed for 30 days, and ureteroscopy was completed for those with nonexpulsed stones. Follow-up parameters included number of renal colic episodes, duration of medical therapy, stone expulsion time, and stone expulsion rate (SER). Results: In the group (A), 2 (6.6%) patients were excluded due to nasal congestion, and 1 (3.3%) patient was excluded due to a 20-mm Hg systolic blood pressure increase. Four (13.3%) patients in group (B) were noncompliant on medical treatment. In addition, 2 (6.6%) patients in group (A), 1 (3.3%) patient in group (B), and 5 (16.6%) patients in group (C) who did not attend follow-up examinations were excluded from the study. The SER increased significantly in group (A) and (B) when compared with group (C). The mean time of stone expulsion was about 15, 25, and 12 days for groups A, B, and C, respectively, and there was a significant statistical difference (p value = 0.006) among the 3 groups. The mean number of renal colic episodes of group (A) of patients was 1.8 times, while that of group (B) was 2.6 times and that of group (C) was 2.16 times with no significant statistical difference after comparing the 3 groups (p value = 0.660). Conclusions: Treatment with mirabegron appears to be a safe and effective medical expulsion therapy for distal ureteric stones and is better than tamsulosin.

Comparison between Tamsulosin and Tadalafil Versus Tamsulosin alone to treat Lower Ureteric Stones Through Medical Expulsive Therapy: a comparative study

Aim: To compare between Tamsulosin and Tadalafil versus Tamsulosin alone to treat Lower Ureteric Stones through Medical Expulsive Therapy Study design: Comparative study Place and duration: This study was done at Ghulam Muhammad Mahar Medical college hospital Sukkur, Pakistan from February 2021 to July 2021. Methodology: This study was carried our in our institute for 6 months. Patients that were having stones of 5mm to 10mn were included in the study, because these stones are detected easily through CT scans and ultrasound. Patients were randomly divided into two groups each containing 86 persons. Prescription of tamsulosin of 0.3 mg and tadalafil of 8 mg was given to group A patients and 0.3mg, tamsulosin was prescribed to group B Results: The stone expulsion rate was 78.0% in group A and 61.5% in group B. The stone passage time was 1.55 vs. 2.22 weeks in group B. In 45 patients there was no stone expulsion at the end of 3rd week of treatment. So these patients were treated with laser lithotripsy. A comparison study of two groups showed that group B has more episodes of flatulent pain than group A. The average need for analgesia was more in group B than group A. Conclusion: It is found from this study that tamsulosin alone is less effective than tamsulosin and tadalafil combination therapy and they both give fewer emergency room visits and require less pain killers for the treatment of 5mm and 10mm ureteric stones.