Treatment Of Distal Ureteral Stones Research Articles

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We appreciate the comments of the respected reviewer. Various studies have been conducted for evaluating the role of α-blockers in assisting passage of lower ureteric stones, fragments resulting from SWL for renal and lower ureteral calculi, and fragments of steinstrasse. Tamsulosin has been the most commonly used medication; however, most studies have limitations in design, including sample size, heterogenecity of inclusion criteria, and lack of blinding and placebo-control, thereby lowering the strength of authenticity. Moreover, meta-analyses generated from such studies are similarly marred. Publication bias (file-drawer effect) and Simpson-effect are other limitations of meta-analysis. All factors combined lead to discrepancies between results of such meta-analysis and subsequent high quality large randomized controlled trials. 1 Agarwal M.S. Gupta M. Gupta A. et al. Prospective randomized trial comparing efficacy of alfuzosin and tamsulosin in management of lower ureteral stones. Urology. 2009; 73: 706-709 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar Therefore, meta-analyses which are not based on “best evidence” should be interpreted with caution. Is There an Adjunctive Role of Tamsulosin to Extracorporeal Shockwave Lithotripsy for Upper Ureteric Stones: Results of an Open Label Randomized Nonplacebo Controlled StudyUrologyVol. 74Issue 5PreviewTo investigate the role of tamsulosin as an adjunct to management of upper ureteric stones (UUS) with extracorporeal shock wave lithotripsy (SWL). Full-Text PDF Editorial CommentUrologyVol. 74Issue 5PreviewThere have been several publications that have looked at the efficacy of expulsive therapy for ureteric and indeed renal stones after SWL. The rationale of using α-1-adrenergic antagonists in medical expulsion therapy (MET) for the treatment of distal ureteral stones arose from the concept that they can induce selective relaxation of the ureteral smooth muscle. This inhibits ureteral spasms and results in dilatation of the ureteral lumen, increasing the fluid volume transported, and thereby helping expulsion of the stone. Full-Text PDF

Editorial Comment

There have been several publications that have looked at the efficacy of expulsive therapy for ureteric and indeed renal stones after SWL. The rationale of using α-1-adrenergic antagonists in medical expulsion therapy (MET) for the treatment of distal ureteral stones arose from the concept that they can induce selective relaxation of the ureteral smooth muscle. This inhibits ureteral spasms and results in dilatation of the ureteral lumen, increasing the fluid volume transported, and thereby helping expulsion of the stone. ReplyUrologyVol. 74Issue 5PreviewWe appreciate the comments of the respected reviewer. Various studies have been conducted for evaluating the role of α-blockers in assisting passage of lower ureteric stones, fragments resulting from SWL for renal and lower ureteral calculi, and fragments of steinstrasse. Tamsulosin has been the most commonly used medication; however, most studies have limitations in design, including sample size, heterogenecity of inclusion criteria, and lack of blinding and placebo-control, thereby lowering the strength of authenticity. Full-Text PDF Is There an Adjunctive Role of Tamsulosin to Extracorporeal Shockwave Lithotripsy for Upper Ureteric Stones: Results of an Open Label Randomized Nonplacebo Controlled StudyUrologyVol. 74Issue 5PreviewTo investigate the role of tamsulosin as an adjunct to management of upper ureteric stones (UUS) with extracorporeal shock wave lithotripsy (SWL). Full-Text PDF

Effectiveness of Doxazosin in Treatment of Distal Ureteral Stones in Children

We evaluated the effectiveness of doxazosin in children with distal ureteral stones in terms of stone expulsion rates and time to expulsion. A total of 39 patients 2 to 14 years old with lower ureteral stones smaller than 10 mm were enrolled and randomly divided into 2 groups. Group 1 consisted of 20 controls receiving ibuprofen for pain and group 2 consisted of 19 patients receiving doxazosin. Doxazosin dose was approximately 0.03 mg/kg daily. All patients were evaluated with x-ray, ultrasound or spiral computerized tomography. Stone expulsion rates and time to expulsion between the groups were compared. Mean followup was 19 days. Effects of doxazosin were also evaluated by comparing subgroups with stones smaller than 5 mm and 5 to 10 mm. Results were also evaluated with special emphasis on gender and age. Expulsion was observed in 14 patients (70%) in group 1 and 16 (84%) in group 2 (p >0.05). Mean expulsion times for groups 1 and 2 were 6.1 and 5.9 days, respectively (p >0.05). Although fewer pain episodes were observed in the treatment group, this finding could not be evaluated objectively. None of the patients experienced any adverse effects. Administration of 0.03 mg/kg doxazosin daily in children to treat distal ureteral stones up to 10 mm is not superior to analgesic alone. This result is not affected by gender, stone size or patient age. However, additional randomized controlled studies, especially including larger stone volumes, and different doses of doxazosin and other alpha-blockers, might highlight the usefulness of alpha-blockers for ureteral stones in children.

MP-19.07: Medical Treatment of Distal Ureteral Stones: Does the Degree of Hydronephrosis Affect Success?

We investigated the relation between the degree of calculi-induced urinary obstruction and the outcome of medical treatment in patients with distal ureteral stone.

Is There a Role for Tamsulosin in the Treatment of Distal Ureteral Stones of 7 mm or Less? Results of a Randomised, Double-Blind, Placebo-Controlled Trial

BackgroundNumerous randomised trials have confirmed the efficacy of medical expulsive therapy with tamsulosin in patients with distal ureteral stones; however, to date, no randomised, double-blind, placebo-controlled trials have been performed. ObjectiveThe objective of this trial was to evaluate the efficacy of medical expulsive therapy with tamsulosin in a randomised, double-blind, placebo-controlled setting. Design, setting, and participantsPatients presenting with single distal ureteral stones ≤7mm were included in this trial. InterventionPatients were randomised in a double-blind fashion to receive either tamsulosin or placebo for 21 d. The medication was discontinued after either stone expulsion or intervention. Abdominal computed tomography was performed to assess the initial and final stone status. Measurements and limitationsThe primary end point was the stone expulsion rate. Secondary end points were time to stone passage, the amount of analgesic required, the maximum daily pain score, safety of the therapy, and the intervention rate. ResultsTen of 100 randomised patients were excluded from the analysis. No statistically significant differences in patient characteristics and stone size (median: 4.1mm [tamsulosin arm] vs 3.8mm [placebo arm], p=0.3) were found between the two treatment arms. The stone expulsion rate was not significantly different between the tamsulosin arm (86.7%) and the placebo arm (88.9%; p=1.0). Median time to stone passage was 7 d in the tamsulosin arm and 10 d in the placebo arm (log-rank test, p=0.36). Patients in the tamsulosin arm required significantly fewer analgesics than patients in the placebo arm (median: 3 vs 7, p=0.011). A caveat is that the exact time of stone passage was missing for 29 patients. ConclusionsTamsulosin treatment does not improve the stone expulsion rate in patients with distal ureteral stones ≤7mm. Nevertheless, patients may benefit from a supportive analgesic effect. Clinicaltrials.govNCT00831701.

MULTI-INSTITUTIONAL ANALYSIS DEMONSTRATES THAT STONE SIZE IS ONLY INDEPENDENT PREDICTOR OF SWL SUCCESS IN CHILDREN

We compared the clinical outcomes of patients with ureteral or renal stones treated with ureteroscopy, shock wave lithotripsy using HM3 (Dornier®) and nonHM3 lithotripters, and percutaneous nephrolithotomy.A systematic literature search identified 6, 4 and 3 randomized, controlled trials of treatment of distal and proximal ureteral stones, and renal stones, respectively, published between 1995 and 2010. Overall stone-free, re-treatment and complication rates were calculated by meta-analytical techniques.Based on the randomized, controlled trials evaluated the treatment of distal ureteral stones with semirigid ureteroscopy showed a 55% greater probability (pooled RR 1.55, 95% CI 1.13–2.56) of stone-free status at the initial assessment than treatment with shock wave lithotripsy. Patients treated with semirigid ureteroscopy were also less likely to require re-treatment than those treated with shock wave lithotripsy (nonHM3) (RR 0.14, 95% CI 0.08–0.23). The risk of complications was no different between the 2 modalities. Only 2 of the 4 randomized, controlled trials identified for proximal ureteral stones evaluated flexible ureteroscopy and each focused specifically on the treatment of stones 1.5 cm or greater, limiting their clinical relevance. The degree of heterogeneity among the studies evaluating renal stones was so great that it precluded any meaningful comparison.Semirigid ureteroscopy is more efficacious than shock wave lithotripsy for distal ureteral stones. To our knowledge there are no relevant randomized, controlled trials of flexible ureteroscopy treatment of proximal ureteral calculi of a size commonly noted in the clinical setting. Collectively the comparative effectiveness of ureteroscopy and shock wave lithotripsy for proximal ureteral and renal calculi is poorly characterized with no meaningful published studies.

Ureteroscopic management of distal ureteral stones in children: holmium: YAG laser vs. pneumatic lithotripsy

Aim: In this retrospective study, we aimed to compare the treatment results of pneumatic and holmium laser-assisted ureteroscopy in managing distal ureteral calculi in children. Materials and methods: The study group included a total of 36 children (23 boys, 13 girls) who underwent ureteroscopy between June 1998 and April 2008 due to distal ureteral calculi. Pneumatic lithotripsy was performed in 11 children and holmium:YAG laser lithotripsy in 25. Results: Their ages ranged from 18 months to 14 years (mean: 8.5 ± 3.5 years). The overall success rate for the holmium:YAG laser lithotripsy (100%) was higher than that of pneumatic lithotripsy (81.8%), but the difference was insignificant (P = 0.087). The complication rate was higher in pneumatic lithotripsy than in holmium:YAG laser lithotripsy (36.4% versus 4%, P = 0.023). Treatment time and hospital stay were shorter in the holmium:YAG laser lithotripsy group than in the pneumatic lithotripsy group (32.4 min versus 42.3 min, P = 0.041; 17.4 h versus 33.6 h, P = 0.013, respectively). Conclusion: This study showed that the success rate for holmium:YAG laser lithotripsy was almost identical with that achieved by pneumatic lithotripsy in the treatment of distal ureteral stones; ureteroscopic holmium:YAG laser lithotripsy had significant clinical advantages over pneumatic lithotripsy in terms of operative time, and hospitalization duration, stent requirements, and complication rates.

Evaluation of Selective and Non-Selective Alpha-Andrenergic Blockers in the Treatment of Distal Ureteral Stones

Evaluation of Selective and Non-Selective Alpha-Andrenergic Blockers in the Treatment of Distal Ureteral Stones

Comparison of Treatment Efficacy between Shock Wave Lithotripsy and Ureteroscopic Stone Removal for Lower Ureteral Stones

Purpose: We compared the efficacy and patient satisfaction between shock wave lithotripsy (SWL) and ureteroscopic removal of stone (URS) for the treatment of lower ureteral stones. Materials and Methods: We reviewed 223 patients who were treated for lower ureteral stones from August 2006 to January 2009. SWL and URS were performed in 47 and 176 patients, respectively. After treatment, the patients' subjective inconvenience/pain and their satisfaction with the treatment process were estimated by questionnaire. We analyzed success rates, complication rates, inconvenience/pain scores, and satisfaction scores for each group of patients. Results: The overall success rates of SWL and URS were 82.9% and 97.7%, respectively (p=0.001). The complication rates of SWL and URS were 8.5% and 10.8%, respectively (p=0.162). The satisfaction scores of SWL and URS were 7.4 and 9.2, respectively (p=0.001). Whereas 87.5% of the URS group preferred the same treatment in case of a recurrence of ureteral stones, only 68% of the SWL group preferred the same treatment in the future (p=0.002). Conclusions: URS was more successful and satisfactory to the patients with lower ureteral stones. Although both SWL and URS were highly effective for treatment of distal ureteral stones, we believe that URS is the first-line treatment modality for lower ureteral stones. (Korean J Urol 2009;50: 884-891) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Role of Ureteral Stenting After Uncomplicated Ureteroscopy for Distal Ureteral Stones: A Randomized, Controlled Trial

We determined the differences in outcome between ureteral stenting and nonstenting following uncomplicated ureteroscopy for distal ureteral stones. A total of 220 patients treated with successful ureteroscopy for distal ureteral stones were randomized to 2 equal groups according to postoperative placement of a ureteral stent (Cook Ireland, National Technological Park, Ireland), including group 1--without a stent and group 2--with a stent. Outcome measures were flank pain and dysuria at 48 hours and 1 week, early postoperative complications, analgesia need, rehospitalization, return to normal physical activity, stone-free rate, stone recurrence and late postoperative complications. Patients were followed a mean +/- SD of 25 +/- 9 months (range 12 to 49). Early postoperative complications, including low grade fever, hematuria and urinary tract infection, were observed in 22 patients (20%) in group 1 and 19 (19%) in group 2, a difference of no significant value. Mean initial hospitalization and time to return to normal physical activity were not different between the 2 groups. At 48 hours and 1 week there was no significant difference in flank pain between the 2 groups, while dysuria was significantly less in the nonstented group. The amount of analgesics required in the recovery room was not different but after discharge from the hospital stented patients used a larger amount of analgesia while the stent was still in the ureter. The stone-free rate at 4 weeks was 100% in each group. Late postoperative sequelae, including stone recurrence and ureteral narrowing, were reported in 6 patients (5.5%) in group 1 and 4 (3.6%) in group 2, a difference of no significant value. Uncomplicated ureteroscopy for treatment of distal ureteral stones is safe without stent placement. Patients without stents have significantly fewer irritative bladder symptoms and are not at risk of increased complications.

Effectiveness of Low-dose and Standard-dose Tamsulosin in the Treatment of Distal Ureteric Stones: A Randomized Controlled Study

Low-dose (0.2 mg/day) and standard-dose (0.4 mg/day) tamsulosin were studied in a randomized controlled trial of 75 out-patients with distal ureteroliths in Thailand. Group 1 (n = 25; control) received oral sodium diclofenac 50 mg twice a day for 10 days; group 2 (n = 25) received oral sodium diclofenac 50 mg twice a day for 10 days, with oral tamsulosin 0.2 mg once a day up to 28 days; and group 3 (n = 25) received oral sodium diclofenac 50 mg twice a day for 10 days, with oral tamsulosin 0.4 mg once a day up to 28 days. For groups 1, 2 and 3, respectively, the expulsion rates were 4%, 40% and 68% (significantly different for group 1 vs group 2, and for group 1 vs group 3) and mean expulsion times were 23.00, 9.30 and 10.76 days. Both doses of tamsulosin increased stone expulsion rate and decreased expulsion time in comparison with the control, and have been shown to be safe and effective in Asian patients.

Efficacy of tamsulosin in medical expulsive therapy for distal ureteral calculi

To evaluate the potential role of tamsulosin in the medical treatment of distal ureteral stones. Ninety patients with symptomatic distal ureteral calculi were enrolled. They were randomly divided into two groups: Group A (n=45) received diclofenac 100 mg on demand for 4 weeks plus levofloxacin 250 mg daily for the first week and were well hydrated; and Group B (n=45) received the same therapy plus tamsulosin 0.4 mg/daily for 4 weeks. Abdominal ultrasound scans and KUB X-rays were performed weekly. Stone expulsion rates, time to expulsion, pain episodes and analgesic usage were determined. Intervention by means of shock-wave lithotripsy (SWL) or ureteroscopy was evaluated. The stone expulsion rate was 51.1% for Group A, compared to 88.9% for Group B (p=0.001). The average time to expulsion was 12.53+/-2.12 days for Group A and 7.32+/-0.78 days for Group B (p=0.04). The number of pain episodes was significantly lower in Group B and mean use of analgesics was lower for Group B (0.14+/-0.5 vials) than Group A (2.78+/-2.7 vials). Twenty-two patients in Group A failed to pass their stones after 4 weeks but only five in Group B. Of the patients who were not stone-free, 19 were treated with SWL and eight underwent ureteroscopy. Our study reveals the efficacy of tamsulosin for the treatment of distal ureteral stones. Tamsulosin should be added to the standard medical approach for treating these stones.

Does stone dimension affect the effectiveness of ureteroscopic lithotripsy in distal ureteral stones?

To investigate whether stone dimension is a restrictive factor for ureterorenoscopic procedures. A group of 416 patients who had undergone ureterorenoscopic pneumatic lithotripsy (URS-PL) for lower ureteral stones between January 1999 and June 2006 in our clinic had been evaluated retrospectively. Two hundred and seventy (270, 64.9%) patients were men and 146 (35.1%) were women. The mean age of the patients was 36.61 (+/- 12.43) years. Patients were grouped according to stone dimension; 193 patients with stones smaller than 1 cm being group 1 and 223 patients with stones > or = 1 cm in dimension being group 2. Stone-free rate, operative time and rate of complications of the groups were compared. Pearson's correlation test, chi2 test, Fischer's exact test and Student's t-test were used for the statistical analysis. The p value was accepted as being meaningful if p < 0.05. For group 1, the mean operative time was 39.19 (+/- 18.33) min. Proximal stone migration in five and false passage formation in three patients was observed. Three patients were stone-free after a second session of URS-PL. The cumulative stone-free rate was 97.4% (188/193). For group 2, the mean operative time was 48.5 (+/- 11.31) min. About 208 (93.27%) patients were stone-free after the first session and an additional eight patients became stone-free after the second session of URS-PL. False passage, ureteral perforation, ureteral avulsion and stricture were observed in four, six, one and one patients, respectively. No proximal stone migration was observed. The cumulative stone-free rate was 96.86% (216/223). The effectiveness of ureterorenoscopy (URS) in the treatment of distal ureteral stones was independent of stone dimension. However, the operative time was longer and the rate of perforation was higher in stones with a diameter > or = 1 cm. On the other hand, the migration rate was higher in stones < 1 cm in diameter. Generally speaking, there was no meaningful effect of stone dimension on complication rates.

Cost-Effectiveness of Medical Expulsive Therapy Using Alpha-Blockers for the Treatment of Distal Ureteral Stones

ObjectiveMedical expulsive therapy (MET) has recently emerged as an efficacious and safe option for the initial management of ureteral stones. The objective of this study was to assess the cost-effectiveness of MET compared with conservative therapy for the treatment of ureteral stones using international cost data from the United States and four European countries. Material and methodsA decision analysis model was built with the use of TreeAge Pro 2004 software with linear success rate assumptions. The likelihood of spontaneous passage of ureteral stones according to their size and location was estimated with the use of data derived from a published meta-analysis. The estimated cost of ureteroscopy (URS) in the United States ($4973) was based on the mean cost of 121 consecutive cases performed at a large metropolitan hospital. URS costs for other countries were obtained from a published international survey. The cost of tamsulosin ($2.08 per day), currently the most commonly used medical expulsive agent, was estimated as a mean of the costs obtained from two national pharmacy chains. MET and conservative therapies were compared with the use of one-way and two-way sensitivity analyses. ResultsIn the United States, MET using tamsulosin resulted in a $1132 cost advantage over observation. MET maintained its cost advantage even in countries where the cost of URS is much lower than in the United States. Two-way sensitivity analysis showed that MET remained cost-effective even with very low rates of spontaneous passage, minimal benefit of MET, or low cost of URS. ConclusionMET is a cost-effective strategy for the management of distal ureteral stones—even those with a low rate of spontaneous passage—providing another incentive for initial “facilitated observation” before embarking on surgical intervention.

Comparative Evaluation of Efficacy of Use of Tamsulosin and/or Tolterodine for Medical Treatment of Distal Ureteral Stones

To evaluate the activity of the therapeutic agents (tamsulosin and/or tolterodine) used to accelerate the expulsion of stones and to reduce the probable complications during observation of the medical treatment of distal ureteral stones to allow spontaneous passage. A total of 120 patients with distal ureteral stones were included in the study. Patients with stones less than 10 mm and allowing urinary flow were included in the study. The patients were studied in four randomly divided groups. Group 1 patients received tamsulosin 0.4 mg/day, group 2 patients received tamsulosin 0.4 mg/day plus tolterodine 2 mg (twice a day), group 3 patients received tolterodine 2 mg (twice a day), and group 4 patients did not receive any medical treatment (control group). Differences among the four groups in patient age and stone dimension were not statistically significant (P >0.05). The stone expulsion rates were greater (P <0.05) in groups 1 and 2 than in groups 3 and 4. A significant variation (P <0.05) regarding the time to stone expulsion was observed in groups 1 and 2. In our study, the use of tamsulosin for the expulsion of distal ureteral stones was effective; however, the use of tolterodine provided no additional advantages.

Alfuzosin (10 mg) Does Not Affect Blood Pressure in Young Healthy Men

ObjectivesAlfuzosin 10mg is a uroselective α1-adrenoceptor antagonist used to treat lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Recent studies have suggested the potential efficacy of alfuzosin in the treatment of distal ureteral stones and prostatitis syndrome, two conditions frequently encountered in young patients. The objective of this study was to evaluate the effect of 10mg alfuzosin on blood pressure (BP) and heart rate (HR) in young healthy volunteers. Materials and methodsIn a randomized, double-blind, placebo-controlled, crossover study, the effect of alfuzosin 10mg on BP and HR was evaluated in 14 male volunteers (mean age: 28 yr; range: 24–30). BP<135/85 obtained in two separated measurements was a main inclusion criterion. Patients were then randomized to alfuzosin (10mg once a day) or placebo for 1 wk, followed by a washout week, and then crossed over to the other treatment. Patients were instructed to self-measure systolic (SBP) and diastolic (DBP) blood pressure and HR every hour between 8am and 8pm during the first and the last day of each cycle treatment. ResultsAll 14 enrolled volunteers completed the study. No significant difference in either SBP, DBP, or HR was observed between the placebo and alfuzosin groups at baseline. Alfuzosin did not affect SBP, DBP, or HR. No hypotensive episode (SBP reduction >10%) was recorded during each treatment. ConclusionsThis study shows that alfuzosin 10mg is well tolerated by young healthy subjects and may therefore be safely administered to young normotensive patients affected by distal ureteral stones and prostatitis.

Appropriate cutoff for treatment of distal ureteral stones by single session in situ extracorporeal shock wave lithotripsy

ObjectivesTo determine an appropriate cutoff for treatment by single session in situ extracorporeal shock wave lithotripsy for a prevesical stone by determining the differences in the efficiency quotient (EQ). MethodsThis was a review of a series of patients who underwent shock wave lithotripsy for a primary, single, prevesical stone from January 1995 to June 2003. All 153 patients were treated using a Dornier MPL 9000 lithotripter in the prone position under intravenous sedation. The stone size was measured in two dimensions (parallel and perpendicular to the long axis of the ureter). The EQ was calculated using a standard formula. ResultsOf the 153 patients, 141 (92.2%) were stone free within a mean period of 12.2 ± 12.2 days (EQ 68.8). No significant complications occurred, and none of the patients required admission. The treatment failed in 10 patients (6.5%), who subsequently required an ancillary procedure (ureteroscopy). Statistically, we found 7 mm to be an appropriate cutoff for treatment using in situ shock wave lithotripsy. The EQ for stones greater than 7 mm and those 7 mm or smaller was 58 and 81, with a stone-free period of 13.6 ± 12.9 and 10.9 ± 11.6 days, respectively. ConclusionsUltrasound-guided shock wave lithotripsy is an efficient and safe modality for the treatment of prevesical stones 7 mm or less. Using an echo-guided lithotripter, the treatment was a radiation-free, day care procedure performed under intravenous sedation. Only 11% of our patients required repeat treatment.

The use of tamsulosin in the medical treatment of ureteral calculi: where do we stand?

It has recently been demonstrated that specific adrenoceptors subtypes (alpha(1A)/alpha(1D)) are prevalent in the distal part of the ureter, a finding supporting the interesting results obtained by different groups with the use of tamsulosin in the treatment of distal ureteral calculi. We performed a prospective randomized study to evaluate the effects of the addition of tamsulosin on our standard pharmacological therapy for the treatment of selected ureteral stones. A total of 64 patients referred to our department for the management of symptomatic ureteral calculi were considered. Patients were randomly divided into two treatment groups: group A (n=32) who received diclofenac (100 mg/daily) plus aescin (80 mg/daily) and group B (n=32) who received the same therapy plus tamsulosin (0.4 mg/daily) for a maximum of 2 weeks. No significant differences were found between the groups for age, gender distribution and mean stone size measured in the single largest dimension at presentation. The stone expulsion rate was 60% (19/32 patients) for group A and 88% for (28/32) for group B with a mean expulsion time of 7.4+/-2.2 (range 3.5-12) and 4.8+/-2.7 days (range 1.8-10.5), respectively. Group B showed a significant advantage in terms of both expulsion rate (P=0.01) and expulsion time (P=0.005). Different analgesics from those used in the standard treatment regimen were required in ten patients in group A (31%) but only three patients in group B (9%). This difference was significant (P=0.003). Hospitalization for recurrent colic was needed in 21% of patients in group A (7/32) and in 9% in group B (3/32) (P=0.01). Only two patients in each group (6%) experienced minor side effects associated with the expulsive therapy. Our data confirm the efficacy of tamsulosin in the treatment of distal ureteral stones up to 1 cm. This selective alpha-blocker should therefore be included in the pharmacological regimen of patients when a conservative approach is considered in the treatment of ureteral lithiasis.

PEDIATRIC STONE DISEASE: AN EVOLVING EXPERIENCE

The presentation and management of pediatric stone disease have changed due to early identification and treatment of congenital urological conditions, as well as technological advances. Therefore, we reviewed our 12-year experience. A total of 123 patients with 158 stones presented from 1991 to 2003. The 46 boys and 77 girls were 8 months to 25 years old, including 5 boys (4%) younger than 3 years, 46 (37%) 4 to 12 years old and 72 (59%) older than 13 years. A 24-hour urine collection was done in 50 patients (41%) and serum chemistry studies were performed in 66 (54%). The seasons of presentation were fall in 41% of cases, summer in 24%, spring in 22% and winter in 13%. Of the patients 94 (76%) had loin pain, 10 (8%) had urinary tract infections, 13 (11%) had a history urinary tract infection, 18 (15%) had gross hematuria, 14 (11%) had structural urological abnormalities and 7 (6%) had neurogenic bladder. Metabolic abnormalities were uncommon and included hypercalciuria in 12%, hyperoxaluria in 2% and cystinuria in 2%. A total of 57 patients (46%) passed the stones and 34 (28%) underwent extracorporeal shock wave lithotripsy, of whom 24 (71%) became stone-free. Ureteroscopy was performed in 10 patients (8%) 6 to 19 years old, percutaneous nephrostolithotomy was done in 4 (3%) and 4 (3%) underwent open surgery. Stone analysis showed calcium based in 88% of the cases, struvite in 7% and cystine in 5%. The majority of patients had no congenital abnormalities. Early diagnosis of urological abnormalities and urinary infection, and appropriate management of neurogenic bladder may have reduced the incidence in those groups. Most stones are calcium based but occur in the absence of metabolic disturbances. More patients presented in the fall, perhaps reflecting the increased concentration of urine in the summer. Half of the patients passed the stones and shock wave lithotripsy was curative in most others. Ureteroscopy, percutaneous nephrostolithotomy and open surgery were rarely required.

THE COMPARISON AND EFFICACY OF 3 DIFFERENT α1-ADRENERGIC BLOCKERS FOR DISTAL URETERAL STONES

alpha1-Adrenergic blockers have recently been shown to increase the rate of spontaneous passage of distal ureteral stones. We compared efficacy of 3 different alpha1-adrenergic blockers for this purpose. A total of 114 patients between 18 and 65 years old who had lower ureteral stones were included in the study. Patients were randomly divided into 4 groups. Group 1 consisted of 28 patients and acted as the control group. Group 2 comprised 29 patients who received tamsulosin, group 3 was 28 patients receiving terazosin and group 4 was 29 patients receiving doxazosin. These agents were given for up to a month and hydration was also recommended simultaneously. Every week patients were controlled with x-rays of the kidneys, ureters, bladder and urinary ultrasonography. Meanwhile the number of pain episodes, analgesic dosage and the number of days for spontaneous passage of the calculi through the ureter were also recorded. There were no differences between the groups with respect to age, weight, height, sex and stone size. The calculi passed through the ureter spontaneously in 15 patients in group 1 (53.57%), in 23 patients in group 2 (79.31%), in 22 patients in group 3 (78.57%), and in 22 patients in group 4 (75.86%). In groups 2 to 4 the number of pain episodes, expulsion time and analgesic dosage were found to be lower compared with those in group 1. alpha1-Adrenergic blockers increase the frequency of spontaneous passage of the distal ureteral calculi. All 3 agents tested were equally efficacious.