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JAMA Internal Medicine Aug 2018Urinary stone disease is a common presentation in the emergency department, and α-adrenergic receptor blockers, such as tamsulosin, are commonly used to facilitate... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Urinary stone disease is a common presentation in the emergency department, and α-adrenergic receptor blockers, such as tamsulosin, are commonly used to facilitate stone passage.
OBJECTIVE
To determine if tamsulosin promotes the passage of urinary stones within 28 days among emergency department patients.
DESIGN, SETTING, AND PARTICIPANTS
We conducted a double-blind, placebo-controlled clinical trial from 2008 to 2009 (first phase) and then from 2012 to 2016 (second phase). Participants were followed for 90 days. The first phase was conducted at a single US emergency department; the second phase was conducted at 6 US emergency departments. Adult patients were eligible to participate if they presented with a symptomatic urinary stone in the ureter less than 9 mm in diameter, as demonstrated on computed tomography.
INTERVENTIONS
Participants were randomized to treatment with either tamsulosin, 0.4 mg, or matching placebo daily for 28 days.
MAIN OUTCOMES AND MEASURES
The primary outcome was stone passage based on visualization or capture by the study participant by day 28. Secondary outcomes included crossover to open-label tamsulosin, time to stone passage, return to work, use of analgesic medication, hospitalization, surgical intervention, and repeated emergency department visit for urinary stones.
RESULTS
The mean age of 512 participants randomized to tamsulosin or placebo was 40.6 years (range, 18-74 years), 139 (27.1%) were female, and 110 (22.8%) were nonwhite. The mean (SD) diameter of the urinary stones was 3.8 (1.4) mm. Four hundred ninety-seven patients were evaluated for the primary outcome. Stone passage rates were 50% in the tamsulosin group and 47% in the placebo group (relative risk, 1.05; 95.8% CI, 0.87-1.27; P = .60), a nonsignificant difference. None of the secondary outcomes were significantly different. All analyses were performed according to the intention-to-treat principle, although patients lost to follow-up before stone passage were excluded from the analysis of final outcome.
CONCLUSIONS AND RELEVANCE
Tamsulosin did not significantly increase the stone passage rate compared with placebo. Our findings do not support the use of tamsulosin for symptomatic urinary stones smaller than 9 mm. Guidelines for medical expulsive therapy for urinary stones may need to be revised.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT00382265.
Topics: Adolescent; Adrenergic alpha-1 Receptor Antagonists; Adult; Aged; Dose-Response Relationship, Drug; Double-Blind Method; Emergency Service, Hospital; Female; Follow-Up Studies; Humans; Male; Middle Aged; Retrospective Studies; Tamsulosin; Tomography, X-Ray Computed; Treatment Outcome; Ureteral Calculi; Urination; Young Adult
PubMed: 29913020
DOI: 10.1001/jamainternmed.2018.2259 -
Ugeskrift For Laeger Aug 2022
Topics: Humans; Ureteral Calculi; Ureteral Obstruction
PubMed: 36065880
DOI: No ID Found -
Basic & Clinical Pharmacology &... Jan 2022The primary goals of medical expulsive therapy are to increase the rate of stone expulsion along the ureter to avoid ureteral obstruction and reduce ureteral colic and... (Review)
Review
The primary goals of medical expulsive therapy are to increase the rate of stone expulsion along the ureter to avoid ureteral obstruction and reduce ureteral colic and thus avoid the need for surgical and more invasive interventions. This review focussed on the findings from in vivo and in vitro animal and human studies that have investigated the pharmacological mechanisms controlling ureteral motility and their translation to current and potentially new clinically used drugs for increasing the rate of stone expulsion along the ureter. The complicated contractility profile of the ureter, which alters with age, tissue segment region, orientation and species contributes to the difficulty of interpreting studies on ureteral pharmacology, which translates to the complexity of discovering ideal drug targets for medical expulsive therapy. Nevertheless, the current drug classes clinically used for patients with stone lodgement include α -adrenoceptor antagonists, calcium channel blockers and NSAIDS, whilst there are promising targets for drug development that require further clinical investigations including the phosphodiesterase type 5 enzyme, β-adrenoceptors and 5-HT receptors.
Topics: Age Factors; Animals; Drug Development; Drug Discovery; Humans; Species Specificity; Treatment Outcome; Ureter; Ureteral Calculi
PubMed: 33991399
DOI: 10.1111/bcpt.13613 -
Urolithiasis Feb 2023In patients presenting with ureterolithiasis, perirenal stranding is frequently observed in non-contrast computed tomography. Because perirenal stranding may be caused...
In patients presenting with ureterolithiasis, perirenal stranding is frequently observed in non-contrast computed tomography. Because perirenal stranding may be caused by tears in the collecting system, previous studies have described an increased risk of infectious complications and suggested broad empiric antibiotic therapy and immediate decompressing of the upper urinary tract. We hypothesized that these patients can also be managed conservatively. Therefore, we retrospectively identified patients with ureterolithiasis and perirenal stranding and compared diagnostic and treatment characteristics as well as treatment outcomes between patients undergoing conservative versus interventional management by ureteral stenting, percutaneous drainage or primary ureteroscopic stone removal. We classified perirenal stranding as mild, moderate or severe based on its radiological extent. Of 211 patients, 98 were managed conservatively. Patients in the interventional group had larger ureteral stones, more proximal ureteral stone location, more severe perirenal stranding, higher systemic and urinary infectious parameters, higher creatinine levels, and received more frequent antibiotic therapy. The conservatively managed group experienced a spontaneous stone passage rate of 77%, while 23% required delayed intervention. In the interventional and conservative groups, 4% and 2% of patients, respectively, developed sepsis. None of the patients in either group developed a perirenal abscess. Comparison of perirenal stranding grade between mild, moderate and severe in the conservatively treated group showed no difference in the spontaneous stone passage and infectious complications. In conclusion, conservative management without prophylactic antibiotics for ureterolithiasis and perirenal stranding is a valid treatment option as long as no clinical or laboratory signs of renal failure or infections are observed.
Topics: Humans; Conservative Treatment; Retrospective Studies; Ureter; Ureteral Calculi; Urinary Tract Infections; Anti-Bacterial Agents
PubMed: 36810953
DOI: 10.1007/s00240-023-01411-z -
Urolithiasis Aug 2021Early shock wave lithotripsy is associated with higher stone-free rate compared to delayed treatment of ureteral stones, but may constitute overtreatment because...
Early shock wave lithotripsy is associated with higher stone-free rate compared to delayed treatment of ureteral stones, but may constitute overtreatment because ureteral stones can pass spontaneously. We studied the association between time to treatment and stone-free rate in patients with ureteral stones to determine optimal shock wave lithotripsy timing. We retrospectively analyzed 537 patients undergoing shock wave lithotripsy for ureteral stones. Patients were divided into five groups according to time from onset of symptoms to lithotripsy-urgent (0-3 days), early (4-30 days), late (31-60 days), long-delayed lithotripsy (≥ 61 days), and asymptomatic. Stone-free rates were compared among groups. Mean age and stone size were 55.6 ± 13.1 years and 7.48 ± 3.29 mm, respectively. Mean number of shock wave lithotripsy sessions and stone-free rate were 1.37 and 91.6%, respectively, in the overall population. Stone-free rates were 95.2%, 96.8%, 91.3%, 86.3%, and 82.7% in urgent, early, late, long-delayed lithotripsy, and asymptomatic groups, respectively. Long-delayed lithotripsy and asymptomatic groups had significantly more lithotripsy sessions and lower stone-free rate, compared to urgent and early lithotripsy groups. In multivariate analysis, time to lithotripsy [long-delayed lithotripsy (odds ratio: 0.273, p = 0.004) and asymptomatic nature (odds ratio: 0.236, p = 0.002)] and age (odds ratio: 0.959, p = 0.003) independently affected stone-free rate. In conclusion, time to lithotripsy is a strong predictive factor for stone-free status following shock wave lithotripsy. Urgent shock wave lithotripsy did not improve stone-free rate if performed within 1 month. However, time to shock wave lithotripsy > 2 months reduced likelihood of stone-free status.
Topics: Adult; Aged; Humans; Lithotripsy; Middle Aged; Remission Induction; Retrospective Studies; Time Factors; Ureteral Calculi
PubMed: 33386902
DOI: 10.1007/s00240-020-01232-4 -
Singapore Medical Journal Sep 2010Ureteric pseudo-diverticulosis is an uncommon urological finding, with fewer than 150 cases reported in the literature. These are usually seen as incidental findings on...
Ureteric pseudo-diverticulosis is an uncommon urological finding, with fewer than 150 cases reported in the literature. These are usually seen as incidental findings on retrograde pyelography. We report a case of ureteric pseudo-diverticulosis that was incidentally detected on performing ureteroscopy for an upper ureteric stone.
Topics: Aged; Diverticulum; Humans; Hysteroscopy; Lithotripsy, Laser; Male; Ureter; Ureteral Calculi; Urography; Urology
PubMed: 20938602
DOI: No ID Found -
International Braz J Urol : Official... 2021
Topics: Aged; Humans; Lithotripsy; Ureteral Calculi; Ureteroscopy
PubMed: 33047913
DOI: 10.1590/S1677-5538.IBJU.2019.0638.1 -
Journal of Medicine and Life Dec 2023Ureteroscopy is a highly effective treatment for ureteral stones, characterized by a high stone-free rate and a low need for re-treatment. Ureteral stent placement can...
Ureteroscopy is a highly effective treatment for ureteral stones, characterized by a high stone-free rate and a low need for re-treatment. Ureteral stent placement can improve the insertion of the ureteral access sheath and ureteroscope but may be associated with higher morbidity prior to and after ureteroscopy. The study aimed to compare immediate post-stenting ureteroscopy for ureteral stone treatment in terms of operative time, intra- and post-operative complications, length of hospital stay, and stone-free rate. This prospective study involved 126 patients with ureteral stones divided into two groups: the post-stenting ureteroscopy group (PS-URS), who underwent primary ureteral stenting by double J followed by delayed ureteroscopy, and the immediate ureteroscopy group (I-URS), who underwent immediate ureteroscopy without previous stenting. Sixty-six patients were included in the PS-URS group and 60 patients in the I-URS group. Results were comparable, with no significant differences between both groups. The mean operative time was 33.77±3.51 minutes for the PS-URS group and 34.60±2.01 minutes for the I-URS group. The average length of hospital stay was 0.84±2.55 days for PS-URS and 0.92±1.96 days for I-URS patients. The stone-free rate was 97% in the PS-URS group and 95% in the I-URS group. The overall complication rate was 4.5% 5% in the PS-URS and I-URS groups, respectively, with all complications being minor and managed effectively. Immediate ureteroscopy is a safe and relevant operative approach for ureteral stones, with comparative results for post-stenting delayed ureteroscopy.
Topics: Humans; Ureteroscopy; Lithotripsy; Prospective Studies; Ureteral Calculi; Treatment Outcome; Stents
PubMed: 38585524
DOI: 10.25122/jml-2023-0199 -
The Cochrane Database of Systematic... Jun 2018Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction.
OBJECTIVES
To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.
SEARCH METHODS
We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence.
MAIN RESULTS
We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures.
AUTHORS' CONCLUSIONS
Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.
Topics: Adolescent; Adrenergic alpha-Antagonists; Child; Child, Preschool; Humans; Infant; Infant, Newborn; Lasers, Solid-State; Length of Stay; Lithotripsy; Nephrolithiasis; Randomized Controlled Trials as Topic; Ureterolithiasis; Ureteroscopy
PubMed: 29859007
DOI: 10.1002/14651858.CD010784.pub2 -
Academic Emergency Medicine : Official... Jul 2020The objective was to develop a decision aid (DA) to facilitate shared decision making (SDM) around whether to obtain computed tomography (CT) imaging in patients...
OBJECTIVE
The objective was to develop a decision aid (DA) to facilitate shared decision making (SDM) around whether to obtain computed tomography (CT) imaging in patients presenting to the emergency department (ED) with suspected uncomplicated ureterolithiasis.
METHODS
We used evidence-based DA development methods, including qualitative methods and iterative stakeholder engagement, to develop and refine a DA. Guided by the Ottawa Decision Support Framework, International Patient Decision Aid Standards (IPDAS), and a steering committee made up of stakeholders, we conducted interviews and focus groups with a purposive sample of patients, community members, emergency clinicians, and other stakeholders. We used an iterative process to code the transcripts and identify themes. We beta-tested the DA with patient-clinician dyads facing the decision in real time.
RESULTS
From August 2018 to August 2019, we engaged 102 participants in the design and iterative refinement of a DA focused on diagnostic options for patients with suspected ureterolithiasis. Forty-six were ED patients, community members, or patients with ureterolithiasis, and the remaining were emergency clinicians (doctors, residents, advanced practitioners), researchers, urologists, nurses, or other physicians. Patients and clinicians identified several key decisional needs including an understanding of accuracy, uncertainty, radiation exposure/cancer risk, and clear return precautions. Patients and community members identified facilitators to SDM, such as a checklist of signs and symptoms. Many stakeholders, including both patients and ED clinicians, expressed a strong pro-CT bias. A six-page DA was developed, iteratively refined, and beta-tested.
CONCLUSIONS
Using stakeholder engagement and qualitative inquiry, we developed an evidence-based DA to facilitate SDM around the question of CT scan utilization in patients with suspected uncomplicated ureterolithiasis. Future research will test the efficacy of the DA in facilitating SDM.
Topics: Decision Making, Shared; Decision Support Techniques; Emergency Service, Hospital; Female; Focus Groups; Health Knowledge, Attitudes, Practice; Humans; Male; Patient Participation; Qualitative Research; Tomography, X-Ray Computed; Ureterolithiasis
PubMed: 32064724
DOI: 10.1111/acem.13917