Spontaneous Stone Passage Rate Research Articles

Standardization of the management of pediatric urolithiasis in the emergency department

The incidence of urolithiasis in the pediatric population is rising and medical expulsive therapy (MET) using alpha-adrenergic antagonists has been found to be effective in aiding in the passage of ureteral stones in children. A prior review of patients presenting to our quaternary children's hospital with urolithiasis found only 54% were prescribed MET and these patients had increased rates of spontaneous stone passage. Thus, an ED urolithiasis management protocol was created to standardize evaluation and care of children with suspected urolithiasis. To compare management of children with urolithiasis presenting to the ED before and after urolithiasis management protocol implementation. This is a retrospective review of patients with urolithiasis who presented to our children's ED from 2011 to 2022. The primary outcome was rate of MET prescribing before and after pathway implementation in July 2017, thus the pre-implementation group comprises patients who presented to the ED from July 2011 to July 2017, and the post-protocol group includes those who presented from August 2017 to April 2022. Secondary outcomes included CT utilization in the ED, surgical intervention rate, proportion with spontaneous stone passage, and frequency of urology consultation. Two-sample t-test and Fisher's exact test were used to compare the outcomes of interest before and after protocol implementation. Of 337 patients who presented to the ED after protocol implementation, 120 met inclusion criteria. When comparing outcomes before and after implementation of the protocol, there was significantly decreased use of CT scans (79% vs 50%, p<0.0001) and increased prescribing of MET (54% vs 82%, p<0.0001). There was a significant decrease in opioids prescribed (44% vs 26.7%, p=0.0040), and an increased rate of spontaneous stone passage (34% vs 46%, p=0.0483). Lastly, there was a significant reduction in the rate of surgery for stone management after the implementation of protocol (35% vs 17%, p=0.0020) DISCUSSION: As the ED is the primary site of presentation for many children with urolithiasis, standardization of evaluation and management provides an opportunity to improve outcomes in this population. We found that implementation of an ED urolithiasis management protocol was associated with decreased use of CT scans, decreased opioid prescribing, increased spontaneous stone passage, and decreased rate of surgical management for children with ureteral stones. This study demonstrates the positive impact of standardizing care for children presenting to the ED with urolithiasis.

Is conservative management safe in patients with acute ureterolithiasis and perirenal stranding?

In patients presenting with ureterolithiasis, perirenal stranding is frequently observed in non-contrast computed tomography. Because perirenal stranding may be caused by tears in the collecting system, previous studies have described an increased risk of infectious complications and suggested broad empiric antibiotic therapy and immediate decompressing of the upper urinary tract. We hypothesized that these patients can also be managed conservatively. Therefore, we retrospectively identified patients with ureterolithiasis and perirenal stranding and compared diagnostic and treatment characteristics as well as treatment outcomes between patients undergoing conservative versus interventional management by ureteral stenting, percutaneous drainage or primary ureteroscopic stone removal. We classified perirenal stranding as mild, moderate or severe based on its radiological extent. Of 211 patients, 98 were managed conservatively. Patients in the interventional group had larger ureteral stones, more proximal ureteral stone location, more severe perirenal stranding, higher systemic and urinary infectious parameters, higher creatinine levels, and received more frequent antibiotic therapy. The conservatively managed group experienced a spontaneous stone passage rate of 77%, while 23% required delayed intervention. In the interventional and conservative groups, 4% and 2% of patients, respectively, developed sepsis. None of the patients in either group developed a perirenal abscess. Comparison of perirenal stranding grade between mild, moderate and severe in the conservatively treated group showed no difference in the spontaneous stone passage and infectious complications. In conclusion, conservative management without prophylactic antibiotics for ureterolithiasis and perirenal stranding is a valid treatment option as long as no clinical or laboratory signs of renal failure or infections are observed.

Management of pediatric ureterolithiasis in the emergency room: A single institution review and new management pathway

Urolithiasis is an increasingly common condition seen in children with an annual incidence of 2-3% in children under 18, and up to 10% in adolescents. Treatment of stones varies including observation, IV hydration, pain management, medical expulsive therapy (MET), or surgery. Though well-studied and often used in adults, MET (alpha-adrenergic antagonists to facilitate passage of ureteral stones), is not routinely prescribed in pediatric patients. The goals of this study were to review a quaternary children's hospital's emergency room frequency of MET utilization for ureterolithiasis as well as evaluate the clinical outcomes of children who were prescribed MET compared to those treated with pain control alone. A retrospective review was performed of children 2 months to 18 years with ureterolithiasis who presented to a quaternary children's hospital ED from 2011 to 2017. The primary outcome was the frequency of MET prescribed. Secondary outcomes included the following comparisons in patients who received MET and analgesics with those who received analgesics alone: hospital admission rate, length of hospitalization, emergency room re-presentation rate, surgical intervention, spontaneous stone passage, urology consultation, how the urology consult affected MET utilization, referral to outpatient urology and nephrology clinics, and CT utilization in the ED. Comparisons were performed utilizing Fischer's exact and t-tests. 139 patients were included with a mean age of 14 years (SD 4.14), 42% male. There was no difference between age, gender, stone size, return to the ED, serum creatinine, or length of hospitalization (if admitted) between patients who were and were not placed on MET. The rate of stone passage was significantly higher for those placed on MET (45%) versus not (20%)(p=0.0022). Urology was consulted for 93% of the cases where children were prescribed MET, compared with only 52% of cases where MET was not prescribed (p = <0.0001). In our experience MET was significantly underutilized in patients where urology was not involved. This is similar to a study by Itano etal. which found urology consultation in the ED significantly increased use of tamsulosin for ureterolithiasis in adults. Children with ureterolithiasis placed on MET had a significantly higher rate of stone passage compared to children managed by pain control alone. Given the benefits of MET to increase the rate of spontaneous stone passage it may be considered first line therapy for treatment of children with ureterolithiasis.

The high rate of spontaneous migration of small size common bile duct stones may allow a significant reduction in unnecessary ERCP and related complications: results of a retrospective, multicenter study.

Common bile duct stones (CBDS) can spontaneously migrate through the duodenal papilla. In this case, ERCP could be unnecessary and a significant rate of complications could be avoided. In this study, we aim at retrospectively evaluating the rate of spontaneous stone passage in patients with an imaging diagnosis of CBDS and at analysing the factors associated to spontaneous stone migration. We conducted a retrospective multi-centre analysis of patients undergoing ERCP for CBDS in a 12-month period. 1016 patients with CBDS were analysed. In all patients CBDS was diagnosed with adequate imaging methods performed prior to ERCP. ERCPs with failed biliary cannulation were excluded. Data regarding patients' characteristics, imaging findings and ERCP procedure were analysed. 1016 patients with CBDS undergoing ERCP were analysed (male sex 43.3%; mean age 69.9 ± 16.5years). Diagnosis of CBDS was obtained by EUS in 415 patients (40.8%), MR in 343 (33.8%), CT in 220 (21.7%), and US in 38 (3.7%). No stones were found at ERCP in 179 patients (17.6%), in 14 (6.2%) when ERCP was performed within 6h from imaging study, in 114 (18.5%) between 7h and 7days, in 32 (24.6%) between 8 and 29days, and in 19 (43.2%) after 30days. The rate of unnecessary ERCP occurred significantly more frequently in patients in whom imaging methods demonstrated either sludge or ≤ 5mm CBDS (29.9 vs. 8.3%; p < 0.001). Spontaneous migration of small CBDS is a frequent event, and ≤ 5mm size and a delay in ERCP > 7days represent predictive factors for it. We suggest that CBDS ≤ 5mm should not undergo immediate removal and this fact would allow reducing the rate of unnecessary ERCP with their related complications. Prospective studies are needed to confirm these results and demonstrate the safety of a conservative management in this setting.

MP18-02 EVALUATING SPONTANEOUS STONE PASSAGE RATES DURING THE COVID-19 PANDEMIC

INTRODUCTION AND OBJECTIVE: During the COVID-19 pandemic our institution limited elective surgery including management of kidney stones. Additionally, patients themselves were reluctant to pursue elective surgery. This presented us a unique opportunity to reassess the natural history of symptomatic nephrolithiasis given potentially prolonged periods of conservative management. METHODS: A retrospective review was performed of patients presenting to the emergency room (ER) with flank pain secondary to nephrolithiasis from March to April of 2020 (COVID peak period of elective surgery limitations), and a comparative cohort from March and April 2019. Assessed outcomes included definitive stone treatment at initial presentation to the ER, rate of spontaneous stone passage, and time to elective surgery from initial ER presentation. Chi-square or Mann-Whitney U tests were utilized for dependent binary variables and continuous variables, respectively. A Kaplan Meier analysis was used to demonstrate differences in time to elective surgery between the two eras. RESULTS: Baseline characteristics did not differ between groups (Table). Patients discharged from the ER were more often offered medical expulsive therapy (71.6% vs 55.0%, p=0.026) during the COVID era. The rate of surgical stone management or stent placement at initial presentation did not differ, however, discharged patients waited longer from initial ER presentation to elective surgery (55.3 vs 33.1 days, p=0.02). Spontaneous stone passage rates were similar between groups despite the delay, and similar stone location and stone size between eras. CONCLUSIONS: During the height of the COVID pandemic, ER patients with symptomatic stones had similar characteristics at presentation but were more often offered MET. Spontaneous stone passage during the pandemic was no different than in 2019, despite a significant difference in time to elective surgery from initial presentation to the ER with flank pain .

680 A Virtual Stone Clinic Using an Electronic Database Streamlines the Patient Pathway

IntroductionWe have set up an electronic database to record patients requiring follow-up, which is reviewed in a virtual stone clinic (VSC). A consultant led VSC is held weekly to review the database and follow-up patients virtually.MethodAnalysis of patients added over a 15-month period was performed. Outcomes included spontaneous stone passage rates, intervention rates and time from initial imaging to VSC outcomes.Results615 patients with a median age of 48 years were analysed. Emergency referrals to urology accounted for 85.9% of data. VSC review occurred a median of 5 days after initial imaging. Majority of stones were lower ureteric (64.6%), 28.1% upper ureteric and 7.2% renal stones. Follow up data was available for 557 patients (90.6%). 73.6% of patients passed stones spontaneously.Median time from investigation to imaging was 21 days. 372 patients were discharged following VSC review. 111 patients were listed for surgical intervention. Median time to intervention was 21 days for ESWL, 62 days for ureteroscopy and 202 days for PCNL.ConclusionsVSC leads to shorter waiting times for follow-up imaging and interventions in patients with renal stone disease. This is especially evident in the current Covid-19 pandemic, resulting in higher quality of care.

Role of conservative management of stones.

Urinary tract stone disease is one of the most common pathologies of the modern era with a rising prevalence owing to incidentally detected renal stones from imaging for other reasons. Although there is consensus on active management of symptomatic and asymptomatic stones in high-risk patient groups, conservative management of stones is still controversial. We have reviewed the literature pertaining to conservative management of 3 groups of stones-asymptomatic calyceal stones, staghorn stones, and ureteric stones-and summarized the findings to provide guidance in the conservative management of stones. In the calyceal stone group, our review showed an average spontaneous stone passage rate of 18% (range, 8%-32%) and an average requirement for surgical intervention of 20% (range, 7%-40%), with 62% of patients remaining safely on surveillance over a mean time of 4 years. In the staghorn group, overall disease-specific mortality was noted to be 16% (range, 0%-30%) and chance of renal deterioration was 21% (range, 0%-34.5%), with a mean incidence of infection of 22%. In case of conservatively managed ureteric stones, the rate of spontaneous passage for stones smaller than 5 mm was 75%, compared with 62% for those larger than 5 mm. Based on the position in the ureter, spontaneous passage rates were 49%, 58%, and 68% for proximal, middle, and distal thirds, respectively. Conservative management may be recommended for asymptomatic patients and those who are deemed unfit for any procedures. However, careful patient selection and thorough counseling about the risks of conservative management could make it a suitable option for an appropriate subset of patients.

CT-related parameters and Framingham score as predictors of spontaneous passage of ureteral stones ≤ 10 mm: results from a prospective, observational, multicenter study

To investigate the reliability of newly defined CT-related parameters and cardiovascular risk factors in groups adjusted for stone size and location to predict spontaneous stone passage (SP) of uncomplicated ureteral stones ≤ 10mm. The data of 280 adult patients with solitary unilateral ureteral stones ≤ 10mm in diameter in non-contrast computed tomography were prospectively recorded. All patients undergoing a four-week observation protocol with medical expulsive therapy using tamsulosin were divided into two groups according to SP or no SP. Demographic, clinical and radiological findings of these groups were recorded. Spontaneous stone passage was observed in 176 (62.9%) of the patients, whereas the SP rate was 57.6% for 118 upper ureteral stones and 66.7% for 162 lower ureteral stones. The SP rate was 13.3 times greater with ureteral wall thickness < 1.88mm, 4.4 times greater with a ratio of ureter to stone diameter of < 1.24, 3.4 times greater with Framingham score of < 11.5%, 2 times greater with neutrophil lymphocyte ratio < 1.96, 1.9 times greater with ureteral diameter < 6.33mm and 1.5 times greater with stone volume < 38.54 mm3. Lower levels of ureteral wall thickness, ratio of ureter to stone diameter, Framingham score, neutrophil lymphocyte ratio, ureteral diameter, stone volume and absence of hydronephrosis were found to be more successful predictors. We consider that the success rate can be increased by selection of the proper option (observation or active treatment) according to these predictors.

MP15-05 PERCUTANEOUS NEPHROSTOMY, URETERAL STENT OR PRIMARY URETEROSCOPY WITH STONE REMOVAL FOR THE TREATMENT OF HYDRONEPHROSIS SECONDARY TO URETERIC CALCULI: A PROSPECTIVE EVALUATION OF THE IMPACT ON COMPLICATIONS, STONE MANAGEMENT AND HEALTH-RELATED QUALITY OF LIFE

You have accessJournal of UrologyStone Disease: Surgical Therapy III (MP15)1 Apr 2020MP15-05 PERCUTANEOUS NEPHROSTOMY, URETERAL STENT OR PRIMARY URETEROSCOPY WITH STONE REMOVAL FOR THE TREATMENT OF HYDRONEPHROSIS SECONDARY TO URETERIC CALCULI: A PROSPECTIVE EVALUATION OF THE IMPACT ON COMPLICATIONS, STONE MANAGEMENT AND HEALTH-RELATED QUALITY OF LIFE Ricardo Matos Rodrigues*, Bárbara Silva, Nuno Morais, José Pedro Pereira, Sara Anacleto, Pedro Passos, Torres João, Emanuel Dias, Estêvão Lima, and Paulo Mota Ricardo Matos Rodrigues*Ricardo Matos Rodrigues* More articles by this author , Bárbara SilvaBárbara Silva More articles by this author , Nuno MoraisNuno Morais More articles by this author , José Pedro PereiraJosé Pedro Pereira More articles by this author , Sara AnacletoSara Anacleto More articles by this author , Pedro PassosPedro Passos More articles by this author , Torres JoãoTorres João More articles by this author , Emanuel DiasEmanuel Dias More articles by this author , Estêvão LimaEstêvão Lima More articles by this author , and Paulo MotaPaulo Mota More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000840.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral calculi can be associated with urinary drainage blockage requiring urgent treatment, usually with urinary diversion with percutaneous nephrostomy or retrograde ureteral stent, but primary ureteroscopy with stone removal can be an option. Currently no strong evidence exists to support the superiority of one method over the others. This study proposes to compare these three approaches regarding stone management efficacy, complication rate and its effect on patient's quality of life (QoL). METHODS: A prospective trial was carried out and 94 patients were selected with hydronephrosis secondary to ureteral stones requiring urgent urinary treatment. The patients were divided into three groups according to treatment technique: percutaneous nephrostomy (PCN), retrograde ureteral stent (RUS) or primary ureteroscopy with stone removal (pURS). The stone management efficacy, complications and QoL were evaluated (EQ VAS). RESULTS: A PCN group (n=21), a RUS group (n=53) and a pURS group (n=20) were set. Stone size was higher in RUS (median=9mm) than PCN (median=8mm) and pURS (median=7mm). All pURS successfully removed the stone and the spontaneous stone passage (SSP) after multivariable analysis was higher for PCN than RUS (OR=2,31). A decrease between pre- and post-intervention QoL was found with RUS (p<.001), but not found with PCN (p = .092) and an increase was found with pURS (p=.011). Patients in pURS group experienced less haematuria (p<.001), dysuria (p<.001), urgency (p<.001) (table 1.1), and less need of antibiotics use (p=.005), than RUS and PCN (table 1.2). CONCLUSIONS: pURS shows better chance of higher stone management efficacy than PCN and RUS, moreover PCN was associated with higher rate of spontaneous stone passage than RUS. The QoL improve for pURS patients and decrease for RUS patients. pURS was associated with less symptoms and complications than PCN and RUS, regarding RUS had the higher level of patients with symptoms and complication rate. The pURS appears to be a safe and optimal solution for treatment of patients with ureteral calculi with urinary drainage blockage requiring active treatment. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e205-e206 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ricardo Matos Rodrigues* More articles by this author Bárbara Silva More articles by this author Nuno Morais More articles by this author José Pedro Pereira More articles by this author Sara Anacleto More articles by this author Pedro Passos More articles by this author Torres João More articles by this author Emanuel Dias More articles by this author Estêvão Lima More articles by this author Paulo Mota More articles by this author Expand All Advertisement PDF downloadLoading ...

Identification and local delivery of vasodilators for the reduction of ureteral contractions.

Kidney stones and ureteral stents can cause ureteral colic and pain. By decreasing contractions in the ureter, clinically prescribed oral vasodilators may improve spontaneous stone passage rates and reduce the pain caused by ureteral stenting. We hypothesized that ureteral relaxation can be improved via the local administration of vasodilators and other smooth muscle relaxants. Here, by examining 18 candidate small molecules in an automated screening assay to determine the extent of ureteral relaxation, we show that the calcium channel blocker nifedipine and the Rho-kinase inhibitor ROCKi significantly relax human ureteral smooth muscle cells. We also show, by using ex vivo porcine ureter segments and sedated pigs that, with respect to the administration of a placebo, the local delivery of a clinically deployable formulation of the two drugs reduced ureteral contraction amplitude and frequency by 90% and 50%, respectively. Finally, we show that standard oral vasodilator therapy reduced contraction amplitude by only 50% and had a minimal effect on contraction frequency. Locally delivered ureteral relaxants therefore may improve ureter-related conditions.

Factors associated with spontaneous stone passage in a contemporary cohort of patients presenting with acute ureteric colic: results from the Multi-centre cohort study evaluating the role of Inflammatory Markers In patients presenting with acute ureteric Colic (MIMIC) study.

To assess the relationship of white blood cell count (WBC) and other routinely collected inflammatory and clinical markers including stone size, stone position, and medical expulsive therapy use (MET), with spontaneous stone passage (SSP) in a large contemporary cohort of patients with acute ureteric colic, as there are conflicting data on the role of WBC and other inflammatory markers in SSP in patients with acute ureteric colic. Multicentre retrospective cohort study coordinated by the British Urology Researchers in Surgical Training (BURST) Research Collaborative at 71 secondary care hospitals across four countries (UK, Republic of Ireland, Australia, and New Zealand). In all, 4170 patients presented with acute ureteric colic and a computed tomography confirmed single ureteric stone. Our primary outcome measure was SSP, as defined by the absence of need for intervention to assist stone passage (SP). Multivariable mixed effects logistic regression was used to explore the relationship between key patient factors and SSP. In all, 2518 patients were discharged with conservative management and had further follow-up with a SSP rate of 74% (n=1874/2518). Sepsis after discharge with conservative management was reported in 0.6% (n=16/2518). On multivariable analysis neither WBC, neutrophils count, nor C-reactive protein (CRP) predicted SSP, with an adjusted odds ratio (OR) of 0.97 (95% confidence interval [CI] 0.91-1.04, P=0.38), 1.06 (95% CI 0.99-1.13, P=0.1) and 1.00 (95% CI 0.99-1.00, P=0.17), respectively. MET also did not predict SSP (adjusted OR 1.11, 95% CI 0.76-1.61). However, stone size and stone position were significant predictors. SSP for stones <5mm was 89% (95% CI 87-90) compared to 49% (95% CI 44-53) for stones ≥5-7mm, and 29% (95% CI 23-36) for stones >7mm. For stones in the upper ureter the SSP rate was 52% (95% CI 48-56), middle ureter was 70% (95% CI 64-76), and lower ureter was 83% (95% CI 81-85). In contrast to the previously published literature, we found that in patients with acute ureteric colic who are discharged with initial conservative management neither WBC, neutrophil count, nor CRP, helps determine the likelihood of SSP. We also found no overall benefit from the use of MET. Stone size and position are important predictors and our present findings represent the most comprehensive SP rates for each millimetre increase in stone size from a large contemporary cohort adjusting for key potential confounders. We anticipate that these data will aid clinicians managing patients with acute ureteric colic and help guide management decisions and the need for intervention.

Medical Expulsive Therapy for Symptomatic Distal Ureter Stones: Is the Combination of Bromelain and Tamsulosin More Effective than Tamsulosin Alone? Preliminary Results of a Single-Center Study

Objectives: To assess the safety and efficacy of bromelain plus tamsulosin versus tamsulosin alone as medical expulsive therapy (MET) for promoting spontaneous stone passage (SSP) of symptomatic distal ureter stones. Patients and Methods: One-hundred-fourteen patients with a 4–10 mm distal ureteral stone were enrolled (Group A). Patients self-administered daily bromelain with tamsulosin for 30 days or until SSP or intervention was mandatory. Patients were compared to those from a control group taking tamsulosin as MET (Group B) and matched for the following factors: sex, age ±10%, stone diameter. A logistic regression model evaluated bromelain and the ureteral stone diameter as explanatory variables. Results: SSP rates were 87.7 vs. 75.4% for group A vs. group B respectively (p = 0.016); with no difference observed for the time to self-reported stone expulsion (11.68 vs. 11.57 days; p = 0.91). Considering larger stones (> 5 mm), the SSP rate was 83.3% in group A and 61% in group B (p < 0.01). With each millimeter increment of stone diameter, the probability of SSP decreased by 59.1% (p < 0.0001), while it increased of 3.3 when bromelain was present. Only 3 cases of tamsulosin-related adverse events were recorded. Conclusion: The association of bromelain and tamsulosin as MET increases the probability of SSP of symptomatic distal ureteral stones, with no bromelain-related side effects recorded.

Medical expulsive therapy for ureter stone using naftopidil: A multicenter, randomized, double-blind, and placebo-controlled trial

ObjectivesA prospective, multicenter, randomized, double-blind, placebo-controlled trial evaluated the effects of naftopidil 75 mg for medical expulsive therapy for a single ureter stone.Materials and methodsPatients diagnosed with a ureter stone were prescribed aceclofenac 100 mg or a combined medication of tramadol 37.5 mg and acetaminophen 325 mg. Patients then randomly received either naftopidil 75 mg or placebo. Primary endpoint was the stone passage rate at 14 days after medication.ResultsThe 150 patients enrolled in 6 institutions randomly received either naftopidil (n = 75) or placebo (n = 75). The percentages of ureter stone passed spontaneously 14 days after medication was 60.9% in the naftopidil group and 53.3% in the placebo group. Stone-free rates and the total use of analgesics showed no significant differences between the two groups. Stone-free rates at 14 days after medication were decreased when maximal stone size was increased: 39.4% (≥ 5 mm), 15.5% (≥ 6 mm), and 7.0% (≥ 7 mm).ConclusionsThe use of naftopidil 75 mg once daily was not effective in increasing spontaneous stone passage rates or reducing analgesic use. The maximal stone size < 6 mm and the follow-up for two weeks would be appropriate for applying medical expulsive therapy to patients with a single ureter stone.

Efficacy of Silodosin Dose in Medical Expulsive Therapy for Distal Ureteral Stones: A Retrospective Study.

We aimed to investigate the efficacy of silodosin 4 mg/day and 8 mg/day for medical expulsive therapy(MET) of lower ureteral stones. We retrospectively analyzed the medical records of 161 patients admitted to urologyclinics of Ahi Evran University Medical Faculty and Ankara Training and Research Hospital with distal ureteralstones and treated with MET with different doses of silodosin between January 2013 and August 2015. 81 patientswere treated with silodosin 4mg/day in group-1 and 80 patients with silodosin 8mg/day in group-2. Age, gender,complaints on admission, stone size, the distance between the stone and ureterovesical junction, stone passage rate,duration of stone passage after starting MET, and adverse effects were noted from the charts of the patients, andthe groups were compared. There were 81 patients in group-1, and 80 patients in group-2. Two groups were similar for age (P =.38)and gender (P =.92). Spontaneous stone passage was seen in 41 (50.9%) patients in group-1, and in 59 (73.8%)patients in group 2. The groups were different for spontaneous stone passage rate (P =.002). In group-1, 10 (25%)patients that could not pass their stones spontaneously and were treated with extracorporeal shockwave lithotripsy(SWL), and 30 (75%) of them were treated with ureterolithotripsy. Eight (38%) patients that could not undergoureterolithotripsy and/or anesthesia and were not able to pass their stones were treated with SWL, and 13 (62%)patients were treated with ureterolithotripsy in group-2. All of the patients were stone free at the end of the treatment. A dose of 8 mg/day should be preferred if silodosin is to be preferred for MET in lower ureteral stones.

Preliminary study of the efficacy of the combination of tamsulosin and trospium as a medical expulsive therapy for distal ureteric stones

ObjectivesTo evaluate and compare the efficacy of tamsulosin (0.4mg, once/day) and combinations of it with trospium (20mg, twice/day) in the treatment of single small lower ureteral stones. Patients and methodsA total of 126 patients presenting to urology outpatient clinics from July 2012 to May 2015, with a single 5–10mm sized lower ureteral stone were randomly classified into two treatment groups. Patients in group A (n=62) received an oral dose of 0.4mg tamsulosin once daily and 20mg trospium chloride twice daily. Patients in group B (n=64) received 0.4mg tamsulosin once daily and placebo twice daily. The spontaneous passage of stones, the stone expulsion time, and adverse effects were evaluated. ResultsThere were no significant differences in baseline characteristic of the patients in both groups. Stone expulsion was observed in 47 patients (75.8%), and 58 (90.62%) in groups A and B respectively. The average time to expulsion was 11.65±5.32days in group A and 17.35±6.21days in group B. The spontaneous stone passage rate through the ureter was significantly higher and the stone expulsion time was faster in groups A than in group B (p<0.05). The adverse effects observed in both groups were comparable and were mild. ConclusionsThe combination of 0.4mg tamsulosin and 40mg trospium as MET for single lower ureteral stones <10mm is safe and more effective than 0.4mg tamsulosin as a mono-therapy.

Medical Expulsive Therapy Following Shock Wave Lithotripsy in Ureteral Calculi: An Effective Approach for the Improvement of Health-Related Quality of Life

Objective: To evaluate the possible effects of medical expulsive therapy (MET) on the health-related quality of life (HRQOL) of patients undergoing shock wave lithotripsy (SWL) for ureteric stones. Methods: Eighty patients treated with SWL for ureteric stones were included in this study. Patients were divided into 2 groups; Group 1 received medical therapy only for colic pain and Group 2 received MET in addition to medical therapy. Patients requiring DJ stenting and auxiliary measures after SWL procedure were excluded. The remaining 54 patients were further evaluated (Group 1: n = 26, Group 2: n = 28) and followed up during the 4-week period for analgesic requirement, number of renal colic attacks, emergency department (ED) visits and the HRQOL scores by using EQ-5D index and EQ-5D visual analogue scale (VAS) values. Results: During the 4-week follow-up period, cases undergoing SWL only required significantly higher amount of analgesics. In addition to the lower number of renal colic attacks and ED visits, EQ-5D index and EQ-5D VAS values also demonstrated higher mean values in patients undergoing SWL + MET. Conclusion: In addition to the increased spontaneous stone passage rates, MET following SWL for ureteral calculi could increase the HRQOL scores by lowering the number of both renal colic attacks and ED visits along with decreased analgesic need.

MP22-07 SPONTANEOUS PASSAGE OF URETERAL STONES FOLLOWING STENT PLACEMENT

You have accessJournal of UrologyStone Disease: Surgical Therapy I1 Apr 2016MP22-07 SPONTANEOUS PASSAGE OF URETERAL STONES FOLLOWING STENT PLACEMENT Lee Baumgarten, Anuj Desai, Michel Pontari, Daniel Eun, Jack Mydlo, and Adam Reese Lee BaumgartenLee Baumgarten More articles by this author , Anuj DesaiAnuj Desai More articles by this author , Michel PontariMichel Pontari More articles by this author , Daniel EunDaniel Eun More articles by this author , Jack MydloJack Mydlo More articles by this author , and Adam ReeseAdam Reese More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.695AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteral stents are frequently placed for the initial management of urolithiasis. After stent placement, ureteroscopy is often performed at a later date for definitive stone management. Stones may pass spontaneously after ureteral stent placement, in which case ureteroscopy could be avoided. We aimed to characterize the rate of spontaneous stone passage after ureteral stent placement and to identify factors associated with stone passage after stent placement. METHODS We performed a retrospective review of all ureteroscopic procedures performed for urolithiasis at Temple University Hospital between January 1, 2013 and March 1, 2015. Patients in whom the stone was not visualized at ureteroscopy were deemed to have passed the stone spontaneously. We compared rates of spontaneous stone passage between patients who had previously undergone stent placement vs. those who had not. In patients who were previously stented, univariate and multivariate logistic regression analyses were used to identify factors associated with spontaneous stone passage. RESULTS 220 patients met study inclusion criteria. The rate of spontaneous stone passage was similar between stented and non-stented patients (14.3% vs. 20.0%, p=0.30). The table shows univariate analysis of factors associated with spontaneous stone passage in stented patients. Smaller stone size (p<0.01) and distal stone location (p=0.01) were significantly associated with stone passage. In multivariate logistic regression analysis, small stone size was significantly associated with stone passage (p=0.01) in stented patient, whereas stent duration, stone location, and stone laterality were not. CONCLUSIONS A significant percentage of patients spontaneously pass ureteral stones after stent placement. In stented patients, smaller stones are more likely to pass spontaneously. These findings may help to identify patients who can potentially avoid additional surgical procedures for definitive stone removal. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e255-e256 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Lee Baumgarten More articles by this author Anuj Desai More articles by this author Michel Pontari More articles by this author Daniel Eun More articles by this author Jack Mydlo More articles by this author Adam Reese More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo-controlled, randomised controlled trial and cost-effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin) (the SUSPEND trial).

Ureteric colic, the term used to describe the pain felt when a stone passes down the ureter from the kidney to the bladder, is a frequent reason for people to seek emergency health care. Treatment with the muscle-relaxant drugs tamsulosin hydrochloride (Petyme, TEVA UK Ltd) and nifedipine (Coracten(®), UCB Pharma Ltd) as medical expulsive therapy (MET) is increasingly being used to improve the likelihood of spontaneous stone passage and lessen the need for interventional procedures. However, there remains considerable uncertainty around the effectiveness of these drugs for routine use. To determine whether or not treatment with either tamsulosin 400 µg or nifedipine 30 mg for up to 4 weeks increases the rate of spontaneous stone passage for people with ureteric colic compared with placebo, and whether or not it is cost-effective for the UK NHS. A pragmatic, randomised controlled trial comparing two active drugs, tamsulosin and nifedipine, against placebo. Participants, clinicians and trial staff were blinded to treatment allocation. A cost-utility analysis was performed using data gathered during trial participation. Urology departments in 24 UK NHS hospitals. Adults aged between 18 and 65 years admitted as an emergency with a single ureteric stone measuring ≤ 10 mm, localised by computerised tomography, who were able to take trial medications and complete trial procedures. Eligible participants were randomised 1 : 1 : 1 to take tamsulosin 400 µg, nifedipine 30 mg or placebo once daily for up to 4 weeks to make the following comparisons: tamsulosin or nifedipine (MET) versus placebo and tamsulosin versus nifedipine. The primary effectiveness outcome was the proportion of participants who spontaneously passed their stone. This was defined as the lack of need for active intervention for ureteric stones at up to 4 weeks after randomisation. This was determined from 4- and 12-week case-report forms completed by research staff, and from the 4-week participant self-reported questionnaire. The primary economic outcome was the incremental cost per quality-adjusted life-year (QALY) gained over 12 weeks. We estimated costs from NHS sources and calculated QALYs from participant completion of the European Quality of Life-5 Dimensions health status questionnaire 3-level response (EQ-5D-3L™) at baseline, 4 weeks and 12 weeks. Primary outcome analysis included 97% of the 1167 participants randomised (378/391 tamsulosin, 379/387 nifedipine and 379/399 placebo participants). The proportion of participants who spontaneously passed their stone did not differ between MET and placebo [odds ratio (OR) 1.04, 95% confidence interval (CI) 0.77 to 1.43; absolute difference 0.8%, 95% CI -4.1% to 5.7%] or between tamsulosin and nifedipine [OR 1.06, 95% CI 0.74 to 1.53; absolute difference 1%, 95% CI -4.6% to 6.6%]. There was no evidence of a difference in QALYs gained or in cost between the trial groups, which means that the use of MET would be very unlikely to be considered cost-effective. These findings were unchanged by extensive sensitivity analyses around predictors of stone passage, including sex, stone size and stone location. Tamsulosin and nifedipine did not increase the likelihood of stone passage over 4 weeks for people with ureteric colic, and use of these drugs is very unlikely to be cost-effective for the NHS. Further work is required to investigate the phenomenon of large, high-quality trials showing smaller effect size than meta-analysis of several small, lower-quality studies. Current Controlled Trials ISRCTN69423238. European Clinical Trials Database (EudraCT) number 2010-019469-26. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 63. See the NIHR Journals Library website for further project information.

Do not rush for surgery; stent placement may be an effective step for definitive treatment of initially unextractable common bile duct stones with ERCP

Endoscopically unextractable common bile duct stones may be challenging for the endoscopist. In this study, we investigated the rate of stone removal after the endoscopic insertion of a biliary stent in patients with common bile duct stones unextractable via ERCP. Records of patients with common bile duct stone/s who underwent ERCP at single center were retrospectively analyzed. Only patients with common bile duct stone/s who had a stent placed due to unyielding stone removal were eligible for inclusion into this study. Endoscopic biliary stents were placed in cases of unextractable stone. After a follow-up period, a second ERCP procedure was performed. Major outcomes were the rate of stent insertion because of unextractable bile duct stones, the rate of spontaneous stone passage and the rate of stone extraction after the endoscopic insertion of a biliary stent. A total of 66 (28%) patients had a stent placed due to unyielding attempts for stone removal, and 43 patients were included in the study. The second ERCP procedure revealed that 10 patients (23%) had spontaneous stone passage and 5 (12%) had spontaneous passage of both the stone and the stent. In the second procedure, biliary balloon was used successfully to extract the retained stone in 22 (51%) patients. Thus, a total of 37 patients (86%) with retained stones had a successful stone extraction during the second ERCP procedure. Biliary stenting may be an effective step for definitive treatment of initially unextractable common bile duct stones with ERCP.

Acute management of stones: when to treat or not to treat?

Stone management is often conservative due to a high spontaneous stone passage rate or non-symptomatic calyceal stones that do not necessarily require active treatment. However, stone disease may cause symptoms and complications requiring urgent intervention. In this review, we update latest research and current recommendations regarding acute management of stones, with particular focus on imaging, pain management, active stone interventions, medical expulsive therapy, and urolithiasis in pregnancy and childhood. Acute stone management should be planned with careful consideration of stone size and location, symptoms, patient comorbidity and radiation dose. In case of infective hydronephrosis, compromised renal function or persistent pain despite adequate analgesic treatment acute intervention is indicated.