Use Of Medical Expulsive Therapy Research Articles

Improved stone quality of life in patients with an obstructing ureteral stone on alpha-blocker medical expulsive therapy.

Though controversial, alpha blockers are used widely for ureteral stone passage. However, its effects on the patient-reported Quality of life (QOL) is unknown. We compared the QoL of patients on alpha-blocker medical expulsive therapy (MET) to patients not on MET (noMET) utilizing the validated Wisconsin Stone Quality of Life (WISQOL). This prospective study included patients prescribed either MET or noMET after presentation with symptomatic, obstructing ureteral stones. The treatment arm was decided at the point of care by the initial treating physician and included analgesia and antiemetics. Tamsulosin (0.4mg daily) was prescribed for the MET group. The WISQOL survey was administered at baseline, 7-, 14-, 21- and 28-days following discharge from the ED or until stone expulsion. 197 patients were enrolled, of which 116 (59.2%) completed questionnaires for analysis, 91 in the MET group and 25 in noMET. Average ureteral stone size was 4.7mm (SD 1.8) and 3.1mm (SD 1.0) for MET and noMET, respectively. Of completed surveys, 105 (90%) were completed at day 7, 67 (57.6%) at day 14, 53 (45.7%) at day 21, and 40 (34.5%) at day 28. MET was associated with improved QoL scores across all WISQOL domains compared to noMET. Stone size, age, race, sex, comorbidity score and a prior stone history were not associated with reduced QoL. The use of MET was associated with improved QOL on all WISQOL metrics compared to noMET patients. Improved stone QOL may be an indication of alpha-blocker therapy in patients with ureteral stone colic.

MP70-17 IMPLEMENTATION OF AN ED NEPHROLITHIASIS PROTOCOL INCREASES USE OF MEDICAL EXPULSIVE THERAPY IN THE PEDIATRIC POPULATION

You have accessJournal of UrologyCME1 Apr 2023MP70-17 IMPLEMENTATION OF AN ED NEPHROLITHIASIS PROTOCOL INCREASES USE OF MEDICAL EXPULSIVE THERAPY IN THE PEDIATRIC POPULATION Daniel Salevitz, Chung-Yon Lin, Bernice Alcanzo, Abhijeet Namjoshi, Philip Lee, Cecilia Monteilh, and Gwen Grimsby Daniel SalevitzDaniel Salevitz More articles by this author , Chung-Yon LinChung-Yon Lin More articles by this author , Bernice AlcanzoBernice Alcanzo More articles by this author , Abhijeet NamjoshiAbhijeet Namjoshi More articles by this author , Philip LeePhilip Lee More articles by this author , Cecilia MonteilhCecilia Monteilh More articles by this author , and Gwen GrimsbyGwen Grimsby More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A review of children presenting to our emergency department (ED) from 2011 to 2017 found that ureteral stone passage was significantly higher for those prescribed medical expulsive therapy (MET), versus analgesics alone (45% vs 20%, p<0.0001). Urology consultation was also associated with increased MET use (p<0.0001). As a result, a new nephrolithiasis management protocol was implemented at our ED in August 2017 with the goal of increasing MET usage, decreasing use of CT scans, and increasing outpatient referrals to Urology and Nephrology. METHODS: This is a retrospective study of children aged 2 months to 18 years old who presented to a quaternary children’s hospital ED with an ICD-9 or ICD-10 diagnosis of urolithiasis from August 2017 to April 2022. Basic demographics, MET prescribing, use of CT for stone diagnosis, opioid prescription rate, and referral to Urology and Nephrology were compared before and after implementation of the ED nephrolithiasis protocol. Statistical analysis was performed using two sample t-test analysis and Fisher’s exact test. RESULTS: A total of 124 patients met inclusion criteria. Mean age was 14 years (SD 3.64), 47 (38%) male. Comparing pre and post-protocol implementation, there was no difference in mean age, gender, or stone size between groups (Table 1). Post-protocol, 99 patients (80%) were prescribed MET, which was significantly higher compared with 54% prior to the protocol (p<0.0001). Patients prescribed MET were older (mean 16 vs 15, p=0.014), and a higher proportion were discharged from the ED (71% vs 48%, p=0.033). Post protocol significantly less patients were prescribed opioids (27% vs 44%, p=0.0069). There was no difference in use of CT scans (79% vs 70%, p=0.1169), return to the ED (14% vs 14%, p=0.8681), outpatient urology (89% vs 89%, p=1.0) or nephrology referrals (23% vs 22%, p=1.0) pre and post protocol implementation, Table 1. CONCLUSIONS: After implementation of an ED nephrolithiasis protocol, use of MET for ureteral stones increased and prescription of opioids decreased. There was no difference in use of CT scans or outpatient referral to Urology and Nephrology pre versus post-protocol. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1010 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Salevitz More articles by this author Chung-Yon Lin More articles by this author Bernice Alcanzo More articles by this author Abhijeet Namjoshi More articles by this author Philip Lee More articles by this author Cecilia Monteilh More articles by this author Gwen Grimsby More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparison of the Efficacy of Male Sexual Activity Versus Alpha-Blockers in the Expulsion of Distal Ureteric Stones: A Systematic Review and Meta-Analysis.

Globally, the prevalence of urolithiasis is increasing, with limited effective treatment options. Though debate exists within the literature, the use of medical expulsive therapy (MET) for distal ureteric stones in the form of alpha-blockers is commonplace. Alpha-blockers work via the inhibition of norepinephrine, resulting in a small degree of distal ureteric relaxation. Nitric oxide (NO), the main neurotransmitter involved in penile erection, causes smooth muscle relaxation of the distal ureter. It is hypothesised that these alternative pathways may achieve the same desire clinical effect.To our knowledge, this is the first meta-analysis comparing the efficacy of male sexual activity, in the form of intercourse or masturbation, to alpha-blockers in the expulsion of ureteric stones.We conducted a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, SCOPUS, CENTRAL and Google Scholar), identifying studies comparing male sexual activity versus alpha-blockers, in male patients with distal ureteric stones. The Cochrane risk-of-bias tool was used to assess the included studies. For data analysis, a random effects model was used in the event of significant heterogeneity (>75%), with fixed-effects modelling in the event of low-moderate heterogeneity.A search of electronic databases found three randomised control trials (RCTs), enrolling a total of 262 patients. There was no statistically significant difference observed when patients engaged in sexual activity rather than alpha-blocker, when looking at stone expulsion rate at two weeks (P=0.36), expulsion rate at four weeks (P=0.57), or the mean stone expulsion time (P=0.21). Furthermore, there was no significant difference observed when looking at analgesic requirements (P=0.43), or the requirement for additional procedures (P=0.57).Our meta-analysis demonstrated that male sexual activity as an alternative therapy for distal ureteric stones had comparable outcomes to the use of alpha-blocker, proving a viable alternative therapy in those patients wishing to avoid pharmacological management.

Long surgical waiting list times are associated with an increased rate of negative ureteroscopies.

Negative ureteroscopy (NURS) is "a ureteroscopy in which no stone is found during the procedure." We aimed to determine the association between the surgical waiting list time (WLT) and the NURS rate. We retrospectively analyzed all patients scheduled for ureteroscopy in our center between January 2017 and July 2019. The inclusion criterion was unilateral, semirigid ureteroscopy for a single ureteral stone; exclusion criteria were renal-only stones, incomplete ureteroscopy, and stones >10 mm. We analyzed age; gender; body mass index; stone size, density, and location; presence of a temporary double-J (DJ) stent; use of medical expulsive therapy; and WLT. Complications while waiting for surgery were also collected and analyzed. We included 219 patients, 41 (18.7%) of whom had NURS. The median WLT was 74 days (interquartile range [IQR] 45-127). Variables protective against NURS were large stone size (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.66-0.93), presence of a temporary DJ stent (OR 0.43, 95% CI 0.2-0.8), and radiopaque stones (OR 0.44, 95% CI 0.21-0.88). A long WLT ((≥60 days) increased the risk of NURS (OR 2.18, 95% CI 1.02-4.61). Complications requiring emergency department visits while waiting for surgery were documented in 58/137 (42.3%) patients with indwelling DJ stents; nonetheless, a WLT greater than the median was not associated with an increased risk of complications (p=0.38). Long WLT has an independent, direct, and linear correlation with NURS rates. Patients at higher risk of NURS, may be offered preoperative re-evaluation with a computed tomography scan in a resource-limited setting.

Minimally Invasive Surgery for the Treatment of Ureteric Stones - State-of-the-Art Review.

The landscape of managing ureteric stones has evolved over the last few decades and several treatment options exist depending on the stone size, location, and other patient and stone factors. While open surgery is now rarely performed, the use of medical expulsive therapy (MET) has been controversial and perhaps only recommended for large distal ureteric stones. The mainstay treatment balances between shockwave lithotripsy (SWL) and ureteroscopy (URS), with the latter usually recommended for larger stones. While the principles of ureteric stone management have remained largely unchanged, the modern era has generated new methods and means to deliver it. Advancements have occurred in all domains of endourology to try and refine treatment and balance it with cost, patient choice and quality of life. Dissemination of technologies and demonstration of their efficacy and safety will eventually result in new recommendations among international guidelines and evolution of new gold standards.

MP43-02 PATIENTS ON MEDICAL EXPULSIVE THERAPY FOR OBSTRUCTING URETEROLITHIASIS - THE WISCONSIN STONE QUALITY OF LIFE (WISQOL) SURVEY

You have accessJournal of UrologyStone Disease: Medical & Dietary Therapy (MP43)1 Apr 2020MP43-02 PATIENTS ON MEDICAL EXPULSIVE THERAPY FOR OBSTRUCTING URETEROLITHIASIS - THE WISCONSIN STONE QUALITY OF LIFE (WISQOL) SURVEY Tarik Phillips*, Alexander Chow, Alethea Paradis, Joel Vetter, and Ramakrishna Venkatesh Tarik Phillips*Tarik Phillips* More articles by this author , Alexander ChowAlexander Chow More articles by this author , Alethea ParadisAlethea Paradis More articles by this author , Joel VetterJoel Vetter More articles by this author , and Ramakrishna VenkateshRamakrishna Venkatesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000898.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Medical expulsive therapy (MET) utilizing alpha- blockers is commonly prescribed by urologists and emergency department (ED) physicians, however, its efficacy in ameliorating ureteral stone passage is controversial. Hence, as is currently unknown, it is desirable to know the overall quality of life (QOL) of patients on MET. We evaluated the QOL of patients utilizing a validated patient reported stone specific questionnaire, Wisconsin Stone Quality of Life (WISQOL) METHODS: This is an IRB approved prospective study of 100 patients on MET who presented to a tertiary care ED with a symptomatic obstructing ureteral stone. MET consisted of one month of Tamsulosin (.4 mg PO daily) and additional medications for analgesia and emetic control as needed per recommendation of the prescribing physician. The WISQOL survey was administered at baseline, 7, 14, 21 and 28 days following discharge from the ED or until stone expulsion. RESULTS: 100 patients were enrolled, of which 47 completed questionnaires for analysis. Average ureteral stone size was 5.1(STD 1.4) mm. 38% reported having a history of stones. 39 (83%) completed the survey at day 7, and 23 (48.9%), 20 (40.6%), 12(25.5%) at days 14, 21, 28 respectively. 13 (27.7%) reported spontaneous stone passage while on MET. Two (4.3%) patients returned to the ED for intractable pain and 5 (11.1%) required surgical intervention. Compared to baseline, there was no change in WISQOL domains including social impact, emotional impact, disease impact or overall score while on MET at 7 days. Those who remain on MET at 14 days reported a significantly negative impact on all QOL domains including social (p = 0.01), emotional (p < 0.01), disease (p = 0.04), vitality (p = 0.03), and overall score (p < 0.01). In completed subsequent surveys, negative QOL impact persisted up to 28 days [Figure 1]. Stone size, age, race, sex and a prior stone history were not associated with risk of negative effect on QOL. CONCLUSIONS: Patients remaining on MET at two weeks and beyond reported a negative impact on social, emotional and vitality QOL on the WISQOL survey. Identifying factors related to the poor QOL in patients on MET, may help in use of MET in select patients and counseling about the adverse effects of MET. Surgical intervention if stone fails to pass at two weeks may need to be considered. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e647-e647 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tarik Phillips* More articles by this author Alexander Chow More articles by this author Alethea Paradis More articles by this author Joel Vetter More articles by this author Ramakrishna Venkatesh More articles by this author Expand All Advertisement PDF downloadLoading ...

Safety and efficacy of Tamsulosin as medical expulsive therapy in pregnancy.

Use of medical expulsive therapy (MET) is common practice in urology for the treatment of symptomatic urolithiasis, despite this its efficacy is debated. Its use in pregnancy is controversial. Our objective was to evaluate the safety and efficacy of Tamsulosin as a MET in pregnant women. We retrospectively identified pregnant patients who presented with renal colic at the CHU de Québec from 2000 to 2015. We compared patients who received Tamsulosin as MET to a control group without MET. We evaluated efficacy as passage rate of lithiasis and necessity of intervention. We evaluated safety of the treatment according to fetal outcomes (birth weight, APGAR, gestational age). We evaluated 207 pregnant patients presenting renal colic, 69 patients in the MET group were compared to 138 patients in the control group. Of these, 48 (70%) in the Tamsulosin therapy group and 76 (56%) in the control group had proven urolithiasis. No significant difference was found for mean gestational age at birth, birth weight and APGAR. No sudden infant death syndrome was encountered in Tamsulosin group. There was no significant difference for length of hospital stay and need for surgical intervention. The spontaneous passage rate was 58% (25/48) in the MET group compared to 43% (29/76), but this difference was not statistically significant (p = 0.18). Short-term utilisation of Tamsulosin as MET in second and third trimester of pregnancy is not associated with adverse maternal or infant outcomes. Moreover, there was no significant adjunct for the rate of stone passage.

Current use of medical expulsive therapy among endourologists.

We aimed to characterize current practice patterns among endourologists on medical expulsive therapy (MET) for treatment of ureteral calculi. An online survey was administered to Endourological Society members. Respondents' MET usage, index case management, and awareness of recent guidelines and literature were compared based on international status, practice setting, interval since training, and endourological fellowship training. Of the 237 complete responses, 65% were international, 61% were academic, 66% had &gt;10 years in practice, and 71% were endourology fellowship-trained. MET was used by 88%, with no differences between international, academic, practice length, and fellowship-trained groups. MET was used more frequently for &lt;8 mm and distal stones and more U.S.-based respondents reported use for proximal/midureteral stones (68% vs 43%; p&lt;0.001). For the index patient, 70% preferred MET as the initial approach and respondents &lt;10 years from training were more likely to choose MET (82% vs. 64%; p=0.006). While 82% of respondents were aware of the SUSPEND trial, 70% reported that it had not altered their use of MET. Current American Urological Association (AUA) guideline awareness was 90%. Mean MET prescription length was 19.9±10.3 days, and was statistically significantly longer for respondents who were U.S.-based, academic and &lt;10 years from training. MET is the preferred approach for patients with ureteral calculi &lt;10 mm among endourologists despite conflicting data in the literature. While current AUA practice guidelines are followed by the majority of respondents, our survey suggests MET is being used more liberally than the guideline criteria, specifically in proximal and midureteral stones.

MP31-02 MEDICAL EXPULSIVE THERAPY IN PREGNANCY; A RETROSPECTIVE STUDY.

You have accessJournal of UrologyStone Disease: Medical & Dietary Therapy II1 Apr 2018MP31-02 MEDICAL EXPULSIVE THERAPY IN PREGNANCY; A RETROSPECTIVE STUDY. Benoit Theriault, Fannie Morin, and Jonathan Cloutier Benoit TheriaultBenoit Theriault More articles by this author , Fannie MorinFannie Morin More articles by this author , and Jonathan CloutierJonathan Cloutier More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1031AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Background: The use of medical expulsive therapy (MET) is common practice in urology for the treatment of symptomatic urolithiasis, despite its efficacy is debated. Its use in pregnancy is even more controversial because of poor safety data. Objective: To evaluate the safety and efficacy of tamsulosin 0,4 mg once a day as a MET in pregnant women. METHODS We retrospectively identified pregnant patients who presented with renal colic at the CHU de Québec from 2000 to 2015. We compared patients who received tamsulosin as MET to a control group without MET. We evaluated efficacy as passage rate of lithiasis and necessity of intervention or additional treatment. We evaluated safety of the treatment according to fetal outcomes (fetal weight at birth, APGAR, gestational age, etc.) Groups were compared using linear regression models for continuous variables and logistic regression models for nominal variables, using the SAS software, version 9.4. RESULTS We evaluated 207 pregnant patients presenting renal colic, 69 patients in the MET group were compared to 138 patients in the control group. Of these, 48 (70%) in the tamsulosin therapy group and 76 (55%) in the control group had proven urolithiasis. Every exposition to tamsulosin occurred in the second (46%) and third (54%) trimester. No significant difference was found for mean gestational age, birthweight at term and APGAR. No sudden death infant syndrome was encountered in neither group. There was no significant difference for length of hospitalisation stay, and need for surgical intervention. The spontaneous passage rate was 52% (25/48) in the MET group compared to 38% (29/76), but this difference was not statistically significant (p= 0,13). Tamsulosin therapy was associated with longer time to spontaneous passage (mean 34 vs 17 days, p = 0,01). CONCLUSIONS Short-term utilisation of tamsulosin as MET in pregnancy is not associated with adverse maternal or infant outcomes. Moreover, there was no significant adjunct for the rate of stone passage. Conservative management of renal colic in pregnancy remains a safe treatment option. Further studies are needed in the evaluation of MET as adjunctive therapy for symptomatic urolithiasis during pregnancy. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e411 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Benoit Theriault More articles by this author Fannie Morin More articles by this author Jonathan Cloutier More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Stones: MET for distal ureteral calculi: not all stones are created equal.

Results of two large randomized controlled trials have challenged the use of medical expulsive therapy for the management of ureteral calculi. A new trial now shows that tamsulosin is effective in patients with distal calculi >5 mm in size, demonstrating that the effectiveness of MET depends on stone size and location.

Medical expulsive therapy for ureteric calculi – yes or no?

In recent years, there has been a potential paradigm shift in the conservative management of ureteric calculi away from the routine use of medical expulsive therapy (MET). A large body of evidence exists to hopefully answer this common clinical question. Multiple meta-analyses have been performed in the last decade to evaluate the existing evidence. Most, if not all have demonstrated benefit of administering MET for patients with ureteric calculi. In more recent years, the publication of several good quality, randomised controlled studies has cast doubt over the routine use of MET in these patients. These recent studies suggest that MET has no benefit in the conservative management of patients with ureteric calculi. In this article, we aim to provide a pragmatic commentary on the evidence to date and highlight the arguments both for and against the routine use of MET. We aim to highlight the steps that our unit has taken in translating good quality medical research into day-to-day clinical practice and also, to demonstrate our department’s current practice and the rationale behind it.

Re: Use of Medical Expulsive Therapy in Children: An Assessment of Nationwide Practice Patterns and Outcomes.

Re: Use of Medical Expulsive Therapy in Children: An Assessment of Nationwide Practice Patterns and Outcomes.

Use of medical expulsive therapy in children: An assessment of nationwide practice patterns and outcomes

Early data support the use of medical expulsive therapy (MET) in children. However, little is known regarding use or outcomes associated with MET outside of pediatric-specific practices. Using a national administrative dataset, we sought to characterize utilization patterns of MET as well as assess outcomes associated with MET exposure. We interrogated the MarketScan Commercial Claims and Encounters database to identify children under the age of 18 presenting to the emergency department (ED) with any diagnosis of upper urinary tract calculi (UUTC, including renal and ureteral calculi). MET exposure was defined as having a prescription filled for a MET agent within 1 week of the ED encounter. Characteristics of children receiving MET were defined and outcomes compared between children with and without MET exposure. Of 1325 children included in the study, 13.2% received MET, including 15.4% of children with a diagnosis of "calculus of the ureter." MET use increased significantly throughout the study period (p=0.004), although only 30.4% of children considered potential MET candidates received MET in the final year of the study (2013). Among all patients, receipt of MET was associated with male gender, presence of comorbidity, provider-type (urologist), and year of diagnosis, although among those with a specific diagnosis of "calculus of the ureter," only year of diagnosis remained a significant factor. Rates of unplanned physician visits and surgical interventions were similar between groups. Children receiving MET were more likely to receive follow-up imaging, although only 46% of children with ureteral calculi had appropriate follow-up imaging within 90 days, regardless of MET exposure. Odds ratios of factors and outcomes associated with MET exposure are shown in the Table. Although early data support safety and efficacy MET in children, nationwide use in children is low among potential candidates for MET. For children with ureteral calculi, only year of diagnosis was a significant factor associated with MET use. No difference in unplanned physician visits or surgical interventions was noted. Most notable, however, was the low rate of follow-up imaging within 90 days for children presenting acutely with UUTC. Use of MET for children with ureteral calculi is increasing, although still fewer than a third of children considered potential candidates receive this treatment. Follow-up imaging is not obtained for many children with ureteral calculi. Future work is needed to standardize management and follow-up protocols for children with acute renal colic.

Medical Expulsive Therapy: Worthwhile or Wishful Thinking

We set out to provide an overview of the most recent evidence for medical expulsive therapy (MET). Conflicting level 1 evidence for and against the use of MET has been published. The largest double-blind randomized control trial (1110 patients) comparing placebo, tamsulosin, and nifedipine found no benefit for MET in preventing the need for secondary intervention. A recent meta-analysis of 55 randomized trials using alpha-blockers suggests that no benefit is seen with smaller ureteric calculi, but patients with larger ureteric calculi experience shorter times to stone passage, fewer episodes of pain, require less surgical intervention, and fewer hospital admissions. All the major urological organizations (American Urological Association, European Association of Urology, Canadian Urological Association) suggest offering MET as part of conservative management for appropriate patients with ureteric calculi. MET is a reasonable option for conservative management of ureteric calculi that may avoid the need for surgical intervention. The greatest benefit is likely seen with alpha-blockers and calculi ≥5mm in the distal ureter. Expanding indications for the use of MET include facilitating stone fragment clearance after SWL. MET appears to be safe for use in pregnant and pediatric patients.

Medical expulsive therapy use in emergency department patients diagnosed with ureteral stones

ObjectiveRecent studies have clarified the role of alpha-blockers, such as tamsulosin, for patients diagnosed with ureteral stones <10mm not requiring an urgent intervention. Prior studies have reported low rates of use of MET by emergency physicians. We sought to describe patterns of alpha-blocker use and to determine factors associated with utilization in patients diagnosed with ureterolithiasis in the ED. MethodsWe used data from a randomized trial of CT scan vs. ultrasound in participants with suspected urolithiasis enrolled at 15 EDs between October 2011 and February 2013. The use of medical expulsive therapy was identified by the prescription of an alpha-blocker, calcium channel blocker, or steroid at the ED visit. The prevalence of alpha-blocker use in participants with ureteral stones on imaging was calculated, and multivariable models were used to examine risk factors for utilization. ResultsOf the 524 participants who were identified with a ureteral stone on CT scan and discharged from the ED, 375 (71.4%) received an alpha-blocker, and 2 (<1%) received a steroid. There was no significant difference in alpha-blocker use for participants based on stone size or location. However, there was a 3.6-fold difference in alpha-blocker use between the lowest and highest use ED sites. In the multivariable analysis, ED site was independently associated with utilization of alpha-blockers. ConclusionsAlpha-blockers were prescribed in more than two-thirds of patients with a distal ureteral stone on imaging, a much higher prevalence than previously reported. There was substantial variability in alpha-blocker use based on ED site.

The Role of Medical Expulsive Therapy for Ureteral Stones: Against MET

We no longer advocate the use of medical expulsive therapy in our patients. We also believe that the European Association of Urology guidelines group should believe the findings of the SUSPEND study and stop advocating the use of medical expulsive therapy.

Medical expulsive therapy for ureteral stones: where do we go from here?

Despite two decades of clinical use, the effectiveness of medical expulsive therapy (MET) for the noninvasive management of patients with ureteral stones has, in the past year, been called into in question. The primary aim of MET is to expedite stone passage, although it has also shown effectiveness in reducing time to stone passage, thus reducing the incidence of colic episodes, improving stone clearance and improving patients' quality of life. At least 11 systematic reviews and meta-analyses have been published showing clinical benefits of MET; however, the results of these analyses have been challenged by data from two randomized controlled, multicentre trials with large patient cohorts, thus providing higher quality evidence that MET is ineffective in patients with ureteral stones. Results of the various systematic reviews and meta-analyses have suggested that MET is effective, however, such analyses incorporate the biases and limitations of smaller cohort studies, resulting in their conclusions being based upon lower-quality evidence. Evidence for the use of MET for small (<5 mm) distal ureteral stones has weakened based on clinical trial data published in 2015. However, MET might remain effective in the management of larger ureteral stones (>5 mm).

Evolving Guidance on Ureteric Calculi Management in the Acute Setting.

Ureteric colic is a common presentation to acute emergency services. The gold standard test for the diagnosis of acute ureteric colic is a non-contrast computer tomography of the kidneys ureters and bladder (CT KUB). Non-steroidal anti-inflammatory drugs (NSAIDs) should be used as first-line analgesia, with studies showing that there is no role for steroid or phosphodiesterase-5 inhibitors. There is emerging evidence that a high body mass index (BMI) is a risk factor. The drugs used to facilitate stone passage are known as medical expulsive therapy (MET). The most evaluated being alpha-blockers. The Spontaneous Urinary Stone Passage Enabled by Drugs (SUSPEND) trial was designed to evaluate the use of MET (tamsulosin and nifedipine). This trial showed that there was no difference with MET and placebo for the spontaneous passage of ureteric stones. There is an emerging role for the use of primary ureteroscopy in the management of non-infective ureteric stones.

The Use of Medical Expulsive Therapy During Pregnancy: A Worldwide Perspective Among Experts.

Medical expulsive therapy (MET) is a pharmacologic approach thought to augment the spontaneous passage of ureteral calculi. The usage of MET pharmacologics for presumed ureteral calculi during pregnancy has not been studied and their safety and utility are unknown. We sought to characterize the worldwide usage of MET in the setting of pregnancy with presumed ureteral calculus (P-MET), as well as factors associated with physician use. Experts in stone management were specifically sought. A nine-question survey was delivered through society-administered e-mail. Questions gathered physician's worldwide region, degree of specialization in stone disease, practice type, interval since training, and willingness to use both MET and P-MET. We assessed drugs of choice in those using P-MET and reasons for avoidance in non-P-MET users. Finally, we assessed the impact of physician-perceived medicolegal risk on usage of P-MET. Five hundred sixty-five responses were recorded. Sixty-three percent were US-based practitioners and the remaining represented a worldwide distribution. Worldwide usage of MET was 97.6%, and tamsulosin was globally preferred by over 90% of urologists. P-MET was endorsed by only 44.3%. 23.6% of European practitioners used this strategy compared with 51.1% of US physicians. Time from training and practice type did not significantly interact with adoption of P-MET; experts were less likely to use P-MET. Physician nonuse of MET during pregnancy was adverse outcome related: 76.7% reported either the fear of legal risk (52.8%) or concerns about safety (23.9%). Respondents report impressive worldwide adoption of MET. P-MET is less trusted, and fears of legal risk and safety far outweigh questions about effectiveness. The effectiveness of drugs during pregnancy-induced ureteral dilation is unknown. Still, 44% of global respondents embrace usage of this drug strategy despite a paucity of evidence supporting either safety or effectiveness during pregnancy.

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.