Single Ureteral Stone Research Articles

MP22-08 IMPACT OF PREOPERATIVE URETERAL STENTING ON ENDOSCOPIC FINDINGS

INTRODUCTION AND OBJECTIVE: The ureteral stent placement before ureteroscopic lithotripsy (URSL) are reported to facilitate ureteroscopic management of urolithiasis. However, there is no report evaluating the ureteroscopic findings after stent placement. In this study, we first examined the effect of the preoperative ureteral stenting on endoscopic findings and surgical outcome of URSL. METHODS: Among 832 patients who underwent URSL registered in the SMART Study Group from January 2014 to February 2017, 241 cases of single ureteral stones were analyzed. The patients were divided into non-stented patients (n=185) who underwent URSL without preoperative indwelling ureteral stent and stented group (n=56). We evaluated the surgical outcome and endoscopic findings (edema, polyp, stone adhesion, distal ureteric tightness) prospectively based on the SMART classification, which was independently created for this study. RESULTS: Owing to differences in patient characteristics, a 1:1 propensity score matching was performed. In the final matched cohort, 96 cases (48 non-stented vs 48 stented) were available for analysis. The average stone size was 8.3±2.9 and 8.3±2.8 mm in the non-stented and the stented group. The mean operation time was not significantly different between the two groups (44.5±16.7 vs 47.6±26.8 minutes). However, stone free rate in the stented group was significantly higher than the non-stented group (83.3 vs 95.7%, p=0.04) Based on our endoscopic findings, the grade of edema (p=0.18) and polyps (P=0.52) at the stone site were not significantly different between two groups, however, the grade of stone adhesion (p=0.04) and distal ureteral tightness (p<0.01) in the stented group were significantly better than in the non-stented group (Figure 1). CONCLUSIONS: Preoperative ureteral stent placement is associated with better endoscopic findings of stone adhesion and distal ureteric tightness, and may result in a safe and efficacious procedure for URSL. If severe stone impaction is expected, preoperative stent placement is one of the choices to perform an ideal URS operation.Source of Funding: No

Effect of ureteral calculus in outpatients receiving semirigid ureteroscope laser lithotripsy.

The surgical outcomes of patients with single ureteral stones who had undergone ureteroscopic Holmium laser lithotripsy as outpatients and compare them with those of patients who had received the same procedure as inpatients. Records were obtained from January 2012 to December 2016 for selected patients who had undergone the above mentioned procedure at our institution. Patients were excluded if their ECOG performance status was ≥2, presented with multiple stones or concomitant renal stones, had histories of cancer or congenital urinary system abnormalities, or had undergone urinary system reconstruction surgery. Patients could decide whether to receive the procedure as an outpatient or inpatient. All surgeries were performed by a single surgeon. Patients preoperative, operative, and postoperative data were recorded. The clinical results, such as urinary tract infection, analgesic requirement, rate of returning to the emergency room, stone clearance, surgical complications, and medical expenditure for the treatment courses were analyzed and compared between the 2 cohorts. In total, 303 patients met the inclusion criteria. Among them, 119 patients decided to receive ureteroscopic laser lithotripsy as outpatients, whereas 184 decided to be inpatients. The outpatient cohort was younger (P < .001), had smaller stone diameters (P < .001), and fewer comorbidity factors (P = .038). Patients with a history of stone manipulation favored receiving the procedure under admission (P < .001). After 1:1 propensity score matching, no significant differences were discovered between the cohorts with regard to operative time, rate of lithotripsy failure, and operative complications. Furthermore, rates of stone clearance, post-op urinary tract infection, analgesic requirement, and returning to the emergency room were comparable between the 2 groups. However, the medical expenditure was significantly lower in the outpatient cohort (P < .001). Our data revealed that outpatient ureteroscopic lithotripsy with a Holmium laser was more economical compared with the inpatient group and achieved favorable outcomes for patients with a single ureteral stone.

Does silodosin offer better results than tamsulosin as medical expulsive treatment after shock wave lithotripsy for single distal ureteric stones?

IntroductionDifferent antagonists of αadrenergic receptors (α-blockers) have been used as medical expulsive treatment (MET) after extracorporeal shock wave lithotripsy (ESWL).AimTo retrospectively evaluate the expulsion rate of fragments after extracorporeal shock wave lithotripsy performed for single ureteral stones followed by different medical expulsive treatments.Material and methodsWe retrospectively analyzed stone expulsion rates of 190 patients treated by shock wave lithotripsy (SWL) for single, 5 to 10 mm, symptomatic and uncomplicated distal ureteric stones, treated with tamsulosin 0.4 mg, silodosin 8 mg or silodosin 4 mg as MET. Beside the stone-free rate after 4 weeks of treatment, we also investigated the pain intensity using the visual analogue scale (VAS), adverse events induced by the medication, safety of drug administration and the reasons for possible early treatment discontinuation.ResultsSilodosin 8 mg and tamsulosin 0.4 mg have similar results in terms of stone-free rate. For silodosin 4 mg the stone-free rate was significantly lower than for the previous two drugs. In patients treated with silodosin 4 mg the VAS was significantly higher than in patients treated with silodosin 8 mg or tamsulosin 0.4 mg, for all the follow-up visits.ConclusionsAlpha-blocker treatment after ESWL with silodosin 8 mg offers a similar stone-free rate compared with tamsulosin 0.4 mg, being well tolerated. A lower dose of silodosin (4 mg) has significantly poor results, irrespective of ureteric stone size, with more frequent renal colic and severe pain.

Incidence of Stone Retropulsion in Ureteroscopic Pneumatic Lithotripsy for lower ureteric stones by using stone cone.

Objectives: To measure the incidence of stone Retropulsion and its complication in ureteroscopic pneumatic lithotripsy for lower ureteric stones by using stone cone. Study Design: Observational cross sectional study. Setting: Gujranwala Medical College, Gujranwala. Period: January 2017 to December 2018. Material &amp; Methods: Consecutive simple random sampling technique was used. Total 120 patients were treated with URS pneumatic lithotripsy for single ureteric stone were enrolled in study. The diagnosis was established by plain spiral CT scan in all patients. The incidence of stone Retropulsion and complications of procedure were noted. Data was analyzed using SPSS 22.0, chi square test was used to check stratification of data, p value less than 0.05 was taken significant. Results: The stone was in lower ureter in all patients who were included in study regardless of side. The mean age of patients was 46±2.6 years and 65% (78) patients were male while 35% (42) patients were females. Success rate of 97.5% (116) achieved in patients in which stone cone was used. Conclusion: Use of stone cone gives high success rate in preventing stone Retropulsion by using pneumatic lithotripsy.

Peak stent discomfort occurs early and ureteral stent with distal loop design has less pain–A pilot prospective randomised single-blinded trial over 2 weeks

ObjectivesThe Polaris™ loop ureteric stent reduces the severity of stent discomfort by minimising stent material in the bladder. Early impact of ureteral stenting on quality of life (QoL) within 1 week remains unclear. The usefulness of the patient-administered ureteral stent symptoms questionnaire (USSQ) during this period of stent insertion was assessed. In this pilot single-blinded prospective randomised study, we investigate 1) the presence of early (within the 1st week) stent discomfort via the visual analog scale (VAS); 2) determine the QoL of the loop stent against conventional stent. MethodsForty adults requiring retrograde unilateral ureteral stent placements were enrolled. Patients with single ureteric stone or benign stricture were selected. Patients were randomised in 1:1 ratio to the loop and pigtail arm. The USSQ was administered before placement (baseline), USSQ and VAS were administered on Day 3, 7, and 14. ResultsThere were no significant differences between the USSQ scores. Median pain scores on Day 3 were lower in the loop stent group (2.9 vs. 4.0, p=0.047). There was a significant reduction in pain from Day 3–7 (0 vs. −1, p=0.016) in the pigtail group. ConclusionsOur results suggest that peak stent discomfort occurs but resolves quickly within 1 week of post-stent insertion. The loop stent offers a better pain profile compared with conventional stents at Day 3 but no difference in QoL. The loop stent reduces early pain experience post-stent insertion and may have a role in the care of patients who experience significant stent discomfort previously.

Factors predictive of shockwave lithotripsy failure for ureteral stones: why we need to hurry.

The aims of this study are to evaluate the prognostic factors of extracorporeal shockwave lithotripsy in patients with ureteric stones, and to identify which patients might directly benefit of an endoscopic treatment. We performed a prospective study from January 2013 and July 2016 on patients with single ureteric stone and undergoing extracorporeal shockwave lithotripsy (SWL). We divided patients into two groups: first group (success group) included cases resolved with SWL only, and a second group (failure group) including patients with stone not resolved by SWL and requiring an endoscopic treatment. We evaluated age, weight, height, body mass index, stone size, hydronephrosis, laterality, location, days elapsed from onset of symptoms to SWL and stone density when computed tomography was performed. In case of stone fragments >4 mm, the procedure was repeated up to a maximum of three times. SWL was considered as failed if patients had a residual stone of any size after a follow-up of 3 months or if a complication occurred. 274 patients completed follow-up and were enrolled in the study. Mean age was 53.22 years (standard deviation: 13.98). SWL overall success rate was 84.3% (231 patients successfully treated with shockwaves) and failure rate was 15.7% (43 patients underwent auxiliary endoscopic procedure). At the univariate analysis, we observed a statistically significant difference for hydronephrosis (P=0.006), time elapsed from symptoms onset (P=0.013), patients' age (P=0.06) and mean stone density (0.023). In the multivariate logistic regression, patients' age (OR: 1.517), and time elapsed from obstruction to SWL (OR: 3.005) were independent predictive factors for SWL failure. Furthermore, moderate and severe hydronephrosis seemed to be independent predictive factors for SWL failure, presenting an OR of 2.451 and 4.207 respectively. High stone density resulted to be a predictive factor for SWL failure (OR: 2.293 if density was higher than 1100 Hounsfield Units). We report a large series of patients undergone primary SWL for ureteric stones. Our data demonstrated the role of hydronephrosis, time elapsed from obstruction onset to treatment and stone density as independent predictive factors of SWL failure.

What predicts spontaneous passage of ≤ 1 cm ureteral stones in children?

PurposeThe aim of this study is to determine what factors predict spontaneous passage of ≤1 cm ureteral stones in children. MethodsFiles of the patients diagnosed with a single ureteral stone on a given side between 2008 and 2017 were retrospectively reviewed. Patients with congenital obstructive uropathy, neurogenic bladder, vesicoureteral reflux and those with a stone diameter of >1 cm were excluded. Detection of ureteral stones was done using ultrasonography (US) primarily, and computed tomography when US findings were inconclusive. Patients were treated either conservatively or surgically. Conservative treatment included adequate hydration and pain management whereas surgical treatment included ureteroscopic intervention. Apart from those who required urgent intervention, patients were referred for surgical treatment after 2–4 weeks of follow-up with no spontaneous passage. Factors analyzed for association of spontaneous passage included age, gender, type of hematuria, stone localization, laterality, presence of concomitant kidney stone, degree of hydronephrosis, stone size and stone composition. ResultsA total of 70 patients (38 males, 32 females); median age 4.7 years had a ≤ 1 cm ureteral stone (median diameter 7 mm). US was able to diagnose the ureteric stone in 47 patients while computed tomography was required in 23 patients. Spontaneous passage was observed in 40 patients (57.1%). Median time for stone passage was 8 days (3–34 days). Stone size and presence of hematuria (macroscopic and microscopic combined) were factors associated with spontaneous passage and 6.7 mm was found to be the cut-off (AUC = 0.953; 95% CI 0.905–1.000; sensitivity 96.7%, specificity 82.5%, p < 0.001). Moreover, age, degree of hydronephrosis or stone location were not associated with spontaneous passage. ConclusionPatients with a ureteric stone size <6.7 mm can safely be followed conservatively, with a spontaneous passage rate of 82.5%.Type of StudyCase series with no comparison group.Level of EvidenceIV

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.

30] Outcomes of emergency vs elective ureteroscopy for a single ureteric stone

ObjectiveTo compare the results of emergency vs elective ureteroscopy (URS) for the treatment of a single ureteric stone.

Predictors of spontaneous ureteral stone passage in the presence of an indwelling ureteral stent.

Patients presenting acutely with obstructing stones often have a ureteral stent placed as a temporizing solution. Ureteroscopy is then commonly performed in a staged fashion, but occasionally the stone is found to have passed. We aimed to identify the frequency and predictors of ureteral stone passage with a stent in place. Records were reviewed to identify patients who had a stent placed for a single ureteral stone. Subsequent ureteroscopy or CT scan was used to ascertain stone passage. Effect of age, gender, BMI, stone diameter, alpha blocker use, urinary tract infection, hydronephrosis, and stent duration on stone passage was assessed. Inclusion and exclusion criteria were met in 209 patients. Mean maximum stone diameter was 6.5 ± 2.5mm. Passage rates for stones < 3mm, 3-4.9mm, 5-6.9mm, and ≥ 7mm were 50%, 13%, 10%, and 0%, respectively. The overall rate of passage was 8%. Stone passage was associated with smaller maximum stone diameter, more distal stone location, and longer duration of stent before ureteroscopy/CT on univariate analysis (p < 0.01). Stone diameter and stent duration remained significantly associated on multivariable analysis (p = 0.001 and p = 0.05, respectively). Our findings suggest ureteral stone passage with a concurrent ureteral stent is not a rare event as it occurred in 14% of stones less then 7mm in maximum diameter. Stone size and duration of stent before ureteroscopy or CT were found to be independent predictors of passage. Select patients with small ureteral stones who have been stented should be considered for a trial of urine straining or repeat imaging before subsequent ureteroscopy.

Salivary Neutrophil Gelatinase-Associated Lipocalin Sampling Feasibility in Acute Renal Colic.

Neutrophil gelatinase-associated lipocalin (NGAL) levels in the serum and urine are predictive biomarkers of acute kidney injury with correlation to complication and survival in major surgery. Salivary levels of NGAL during acute renal colic may reflect the degree of renal injury as it appears in different compartments encompassing body response in time perspective. Our aim is to evaluate and examine the feasibility and correlation of salivary NGAL with serum and urine levels in acute renal colic event. A prospective controlled study of all patients presenting to the emergency room with acute renal colic event diagnosed with single ureteral stone obstruction by noncontrast CT. Saliva, urine, and blood samples were collected in patients and a control group during the first morning of admission. The study groups consisted of 44 patients and 13 controls, mean age 47 ± 15 years, body mass index 29 ± 6, mean stone size 6 ± 4 mm, mean creatinine levels 1.3 ± 0.7 mg/dL, mean white blood count 10,900 ± 3100 counts per field, and C-reactive protein 29 ± 55. Serum (190 ± 120 ng/mL vs 81 ± 24; p < 0.001) and predominantly salivary (474 ± 185 vs 328 ± 134 ng/mL; p < 0.05) NGAL levels were significantly elevated in patients compared with controls. Salivary NGAL sampling is feasible during the acute phase of renal colic. High levels of salivary NGAL are observed in a single sampling during acute ureteral stone obstruction and may advance clinical decision-making.

In Situ Extracorporeal Shock Wave Lithotripsy (ESWL) and ESWL after Push Back For Upper Ureteric Calculi: A Comparative Study

Background: ESWL is one of the most important modality for the treatment of urolithiasis. In situ ESWL is a non-invasive and safe procedure for renal and upper ureteric stones in selected cases &amp; can be performed on outpatient basis. However, some urologists claim a higher success rate of ESWL after push back procedures for upper ureteric calculi.Materials &amp; Methods: This prospective study was done to compare the results of treatment of upper ureteral calculi by in situ ESWL and ESWL after push back. 90 consenting patients with single upper ureteric stones of ≤ 1 cm in size with no distal obstruction were selected and divided into two groups. 50 patients in group 1 were treated by in situ ESWL while 40 patients in group 2 were treated by push back followed by ESWL.Results: Better clearance was achieved with ESWL after push back (92.5% clearance after 90 days) than with in situ ESWL (90% clearance after 90 days) but it was not statistically significant (p&gt;0.05). The mean shock wave was 1994 ± 449 for in situ ESWL group and 1757.5 ± 255 for ESWL after push back group, which was statistically very significant (p&lt;0.01). The mean energy used was 5.07 ± 0.81 in the in situ ESWL group and 4.6 ± 0.48 in ESWL after push back group and this difference was also statistically significant (p&lt;0.01). Post procedure complications like loin pain, hematuria, lower urinary tract symptoms (LUTS) and fever were more common in ESWL after push back group than in the in situ ESWL group and the differences were statistically significant.Conclusion: In situ ESWL is a better option than ESWL after push back for the management of upper ureteric stones in selected group of patients. Journal of Nobel Medical CollegeVolume 6, Number 1, Issue 10 (January-June, 2017), page: 72-76

Impact of Pretreatment Hydronephrosis on the Success Rate of Shock Wave Lithotripsy in Patients with Ureteral Stone.

PurposeTo evaluate predictors of the success rate for one session of shock wave lithotripsy (SWL), focusing on the relationships between pretreatment hydronephrosis grade and one-session SWL success rates.Materials and MethodsThe medical records of 1824 consecutive patients who underwent an initial session of SWL for treatment of urinary stones between 2005 and 2013 were reviewed. After exclusion, 700 patients with a single, 4–20 mm diameter radiopaque calculus were included in the study.ResultsThe mean maximal stone length (MSL) and skin-to-stone distance were 9.2±3.9 and 110.8±18.9 mm, respectively. The average values for mean stone density (MSD) and stone heterogeneity index (SHI) were 707.0±272.1 and 244.9±110.1, respectively. One-session success rates were 68.4, 75.0, 75.1, 54.0, and 10.5% in patients with hydronephrosis grade 0, 1, 2, 3, and 4, respectively. Patients were classified into success or failure groups based on SWL outcome. Multivariate logistic regression analyses revealed that MSL [odds ratio (OR) 0.888, 95% confidence intervals (CI): 0.841–0.934, p<0.001], MSD (OR 0.996, 95% CI: 0.995–0.997, p<0.001), SHI (OR 1.007, 95% CI: 1.005–1.010, p<0.001), and pretreatment hydronephrosis grade (OR 0.601, 95% CI: 0.368–0.988, p=0.043) were significantly associated with one-session success.ConclusionPretreatment grades 3 or 4 hydronephrosis were associated with failure of SWL in patients with a single ureteral stone. In the presence of severe hydronephrosis, especially hydronephrosis grade 4; physicians should proceed cautiously in choosing and offering SWL as the primary treatment for ureteral stone.

Stone Attenuation Values Measured by Average Hounsfield Units and Stone Volume as Predictors of Total Laser Energy Required During Ureteroscopic Lithotripsy Using Holmium:Yttrium-Aluminum-Garnet Lasers

To evaluate the predictors of the total laser energy (TLE) required during ureteroscopic lithotripsy (URS) using the holmium:yttrium-aluminum-garnet (Ho:YAG) laser for a single ureteral stone. We retrospectively analyzed the data of 93 URS procedures performed for a single ureteral stone in our institution from November 2011 to September 2015. We evaluated the association between TLE and preoperative clinical data, such as age, sex, body mass index, and noncontrast computed tomographic findings, including stone laterality, location, maximum diameter, volume, stone attenuation values measured using average Hounsfield units (HUs), and presence of secondary signs (severe hydronephrosis, tissue rim sign, and perinephric stranding). The mean maximum stone diameter, volume, and average HUs were 9.2 ± 3.8 mm, 283.2 ± 341.4 mm3, and 863 ± 297, respectively. The mean TLE and operative time were 2.93 ± 3.27 kJ and 59.1 ± 28.1 minutes, respectively. Maximum stone diameter, volume, average HUs, severe hydronephrosis, and tissue rim sign were significantly correlated with TLE (Spearman's rho analysis). Stepwise multiple linear regression analysis defining stone volume, average HUs, severe hydronephrosis, and tissue rim sign as explanatory variables showed that stone volume and average HUs were significant predictors of TLE (standardized coefficients of 0.565 and 0.320, respectively; adjusted R2 = 0.55, F = 54.7, P <.001). Stone attenuation values measured by average HUs and stone volume were strong predictors of TLE during URS using Ho:YAG laser procedures.

Managing Small Ureteral Stones: A Retrospective Study on Follow-Up, Clinical Outcomes and Cost-Effectiveness of Conservative Management vs. Early Surgery

Introduction: The management of ureteral calculi has evolved over the past decades with the advent of new surgical and medical treatments. The current guidelines support conservative management as a possible approach for ureteral stones sized = 10 mm. Objectives: We purport to follow the natural history of ureteral stones managed conservatively in this retrospective study, and attempt to ascribe an estimated health-care and cost-effectiveness, from presentation to time of being stone-free. Materials and methods: 192 male and female patients with a single ureteral stone sized = 10 mm were included in this study. The clinical and cost-related outcome was analyzed for different stone sizes (0-4, 4-6 and 6-10 mm). The effectiveness of selected follow-up (FU) scans was also analyzed. Results: Stone size was found to be related to the degree of hydronephrosis and to the likelihood of need for a surgical management. Conservative management was found to be clinically effective, as 88% of the patients did not require surgery for their stone. 96.1% of the patients with a stone 0-4mm managed to expel their ureteral stone. Bigger ureteral stones were found to be more costly. The cost-effectiveness of the single FU scans was found to be related to their efficiency, while the global cost-effectiveness of conservative management vs. early surgery was higher for smaller stones (26.8 vs. 17.32% for stones 0-4 vs. 6-10 mm). Conclusion: Conservative management is clinically effective with a significant cost-benefit, particularly for the subgroup of stones sized 0-4 mm, where a need for FU scans is in dispute.

Pain severity in renal colic: a retrospective evaluation of initial visits in patients at a medical center

Background: Urinary stone disease is commonly seen in urology practices. Most patients with renal colic present with excruciating flank pain and thus seek urgent medical care. This study aimed to determine correlations between clinical parameters and the perception of pain. Methods: 171 consecutive patients with initial presentation of renal colic due to a single ureteral stone were reviewed from January 2010 to November 2012. The visual analog scale (VAS) was used to assess pain intensity at the time of colic. Relationships between the clinical data and severity of colic pain were assessed. Demographic characteristics, e.g. sex, age, and body mass index (BMI), were also analyzed. Results: The mean size of the stones was 5.3±2.2 mm, and 62% were found in the lower ureters. Medical expulsive therapy alone was effective in 48% of cases; the average time for stone passage was 9±5 days. The pain score did not vary according to age (P=0.153), sex (P=0.723), or stone location (P=0.816). BMI had a negative correlation with a high VAS score (P<0.01). The stone size (<5 mm) was also inversely correlated with the pain score (P=0.025). VAS is effective for evaluating individual discomfort, as it helps to assess patients’ perception of pain. Conclusions: Our study showed that a lower BMI and smaller stones (<5 mm) tend to contribute to more severe colic pain. These results provide us with information that is helpful in the clinical management of renal colic.

Shock Wave Lithotripsy in Ureteral Stones: Evaluation of Patient and Stone Related Predictive Factors.

ABSTRACTPurpose:To evaluate the patient and stone related factors which may influence the final outcome of SWL in the management of ureteral stones.Materials and Methods:Between October 2011 and October 2013, a total of 204 adult patients undergoing SWL for single ureteral stone sizing 5 to 15 mm were included into the study program. The impact of both patient (age, sex, BMI,) and stone related factors (laterality, location, longest diameter and density as CT HU) along with BUN and lastly SSD (skin to stone distance) on fragmentation were analysed by univariate and multivariate analyses. Results: Stone free rates for proximal and distal ureteral stones were 68.8% and 72.7%, respectively with no statistically significant difference between two groups (p=0.7). According to univariate and multivariate analyses, while higher BMI (mean: 26.8 and 28.1, p=0.048) and stone density values (mean: 702 HU and 930 HU, p<0.0001) were detected as statistically significant independent predictors of treatment failure for proximal ureteral stones, the only statistically significant predicting parameter for the success rates of SWL in distal ureteral stones was the higher SSD value (median: 114 and 90, p=0.012).Conclusions:Our findings have clearly shown that while higher BMI and increased stone attenuation values detected by NCCT were significant factors influencing the final outcome of SWL treatment in proximal ureteral stones; opposite to the literature, high SSD was the only independent predictor of success for the SWL treatment of distal ureteral stones.

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.

Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial

Meta-analyses of previous randomised controlled trials concluded that the smooth muscle relaxant drugs tamsulosin and nifedipine assisted stone passage for people managed expectantly for ureteric colic, but emphasised the need for high-quality trials with wide inclusion criteria. We aimed to fulfil this need by testing effectiveness of these drugs in a standard clinical care setting. For this multicentre, randomised, placebo-controlled trial, we recruited adults (aged 18-65 years) undergoing expectant management for a single ureteric stone identified by CT at 24 UK hospitals. Participants were randomly assigned by a remote randomisation system to tamsulosin 400 μg, nifedipine 30 mg, or placebo taken daily for up to 4 weeks, using an algorithm with centre, stone size (≤5 mm or >5 mm), and stone location (upper, mid, or lower ureter) as minimisation covariates. Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants who did not need further intervention for stone clearance within 4 weeks of randomisation, analysed in a modified intention-to-treat population defined as all eligible patients for whom we had primary outcome data. This trial is registered with the European Clinical Trials Database, EudraCT number 2010-019469-26, and as an International Standard Randomised Controlled Trial, number 69423238. Between Jan 11, 2011, and Dec 20, 2013, we randomly assigned 1167 participants, 1136 (97%) of whom were included in the primary analysis (17 were excluded because of ineligibility and 14 participants were lost to follow-up). 303 (80%) of 379 participants in the placebo group did not need further intervention by 4 weeks, compared with 307 (81%) of 378 in the tamsulosin group (adjusted risk difference 1·3% [95% CI -5·7 to 8·3]; p=0·73) and 304 (80%) of 379 in the nifedipine group (0·5% [-5·6 to 6·5]; p=0·88). No difference was noted between active treatment and placebo (p=0·78), or between tamsulosin and nifedipine (p=0·77). Serious adverse events were reported in three participants in the nifedipine group (one had right loin pain, diarrhoea, and vomiting; one had malaise, headache, and chest pain; and one had severe chest pain, difficulty breathing, and left arm pain) and in one participant in the placebo group (headache, dizziness, lightheadedness, and chronic abdominal pain). Tamsulosin 400 μg and nifedipine 30 mg are not effective at decreasing the need for further treatment to achieve stone clearance in 4 weeks for patients with expectantly managed ureteric colic. UK National Institute for Health Research Health Technology Assessment Programme.

Safety and efficacy of using the stone cone and an entrapment and extraction device in ureteroscopic lithotripsy for ureteric stones

ObjectiveTo assess the safety and efficacy of using a stone cone and an entrapment and extraction device (N-Trap®, Cook Urological, Bloomington, IN, USA) to avoid stone retropulsion during ureteroscopic lithotripsy for ureteric stones. Patients and methodsThis retrospective comparative study included 436 patients treated with ureteroscopic lithotripsy for a single ureteric stone from February 2011 to January 2014. The diagnosis of a stone was confirmed by plain spiral computed tomography in all cases. Patients were divided according to the ureteric occlusion device applied to avoid stone retropulsion during pneumatic lithotripsy into three groups; group 1 (156) had no instruments used, group 2 (140) in whom the stone cone was applied, and group 3 (140) in whom the N-Trap was used. Patient demographics, stone criteria, operative duration and complications, and success rates (complete stone disintegration with no upward migration) were reported and analysed statistically. ResultsThe stone was in the lower ureter in >55% of patients in all groups. The mean (SD) of maximum stone length was 9.8 (2.5), 10.4 (2.8) and 9.7 (2.9) in groups 1–3, respectively. The use of the stone cone or N-Trap did not significantly increase the operative duration (P=0.13) or complication rates (P=0.67). There was a statistically significant difference (P<0.001) favouring groups 2 and 3 for retropulsion and success rates, being 83.3% in group 1, 97.1% in group 2 and 95.7% in group 3. ConclusionThe stone cone and N-Trap gave high success rates in preventing stone retropulsion during ureteric pneumatic lithotripsy. Both devices caused no increase in operative duration or complications when used cautiously.