今日の臨床サポート

腎結石症・尿管結石症

著者: 磯谷周治 順天堂大学大学院

監修: 堀江重郎 順天堂大学大学院医学研究科 泌尿器外科学

著者校正/監修レビュー済:2022/03/16
参考ガイドライン:
  1. 日本泌尿器科学会、日本泌尿器内視鏡学会、日本尿路結石症学会:尿路結石症診療ガイドライン2013年版
  1. Surgical Management of Stones: AUA/Endourology Society Guideline (2016)
  1. Medical Management of Kidney Stones : AUA Guideline (2019)
  1. Urolithasis guideline: European Association of Urology, (EAU)(2020)
 
患者向け説明資料

概要・推奨   

  1. 確定診断を得るためには腹部CT検査が非常に有用である推奨1MGJ)。
  1. 尿管結石の疼痛に対して疼痛の緩和を迅速に行なう非ステロイド性抗炎症薬(NSAIDs)が第一選択である推奨度1MGJ)。
  1. 発熱を認める場合は腎盂腎炎の合併を考慮する。必要に応じて尿路のドレナージを行なう推奨1GJ)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
磯谷周治 : 特に申告事項無し[2022年]
監修:堀江重郎 : 特許使用料(アステラス製薬,大塚製薬,日本新薬,セティ,アストラゼネカ,杏林製薬,小野薬品,ファイザー),原稿料(キッセイ薬品工業,小野薬品工業,サノフィ,武田薬品工業,中外製薬,アステラス,旭化成ファーマ,ファイザー,日本新薬)[2022年]

改訂のポイント:
  1. 尿路結石症診療ガイドラインの情報と新しいトピックを追加した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 腎結石症・尿管結石症とは、腎および尿管に結石を認める状態である。生涯罹患率は男性で9.0%、女性で3.8%である。男性では30~60歳代、女性は50~60歳代にピークを認める。
  1. 一般に尿管結石は、通常では臨床症状として、側腹部から背部にかけての疹痛、CVA knocking painがみられる。通常は腹膜刺激症状を伴うことはない。
  1. 尿路結石は、上部尿路結石(腎結石、尿管結石)と下部尿路結石(膀胱結石、尿道結石)に分類される。Hospital surveyで報告されている頻度としては、上部尿路結石が全体の約96%を占め、また男女比は2.4:1で男性に多い傾向がある[1]。頻度が高い状態で、推計生涯罹患率は男性では約15%、女性では約7%であり、食生活や生活様式の欧米化によりここ40年で4倍に頻度が増えている。
  1. 尿路結石ではさまざまな程度の血尿も認めるが、尿管結石の完全嵌頓の場合には、尿潜血・血尿は陰性になることもある。
  1. 診断には画像診断が非常に有用で、尿路結石の確定診断・除外診断はCTにて尿路内の結石を証明するか、腎機能が正常なら排泄性尿路造影(DIP)にて患側腎、尿管の通過障害や造影不良を確認するかのどちらかで得られることが多い。
病歴・診察のポイント  
  1. 尿路結石(上部尿路結石)の症状は背部の疼痛が重要な徴候であり、通常激しい背部痛、側腹部痛が認められる。痛みは波があるが、疼痛が0にならないことが多い。また、自発痛の割には圧痛が少ないことも特徴である。発熱を認める場合は腎盂腎炎の合併を考慮する。

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文献 

Veena Chauhan, Barnet Eskin, John R Allegra, Dennis G Cochrane
Effect of season, age, and gender on renal colic incidence.
Am J Emerg Med. 2004 Nov;22(7):560-3.
Abstract/Text Our objective was to examine the effect of ambient temperature, age, and gender on the incidence of emergency department (ED) renal colic visits. We retrospectively analyzed a database of 15 New Jersey EDs from January 1, 1996 to December 31, 2002. We analyzed the number of renal colic visits as a fraction of total visits in monthly intervals. We used the Chi-squared test and Pearson's correlation coefficient, with P<.05 taken as statistically significant. Of the 3.5 million patient visits in the database, 30,358 (0.9%) had renal colic. Renal colic visits were 16% more likely in warmer than colder months (P<.001) and this effect was greatest in older patients and males. We conclude that higher ambient temperature, older age and male gender are associated with increased incidence of ED renal colic visits. Advice to patients, especially older males, to avoid dehydration particularly during hot weather may help prevent bouts of renal colic.

PMID 15666261
Yi-Kuang Chen, Herng-Ching Lin, Chin-Shyan Chen, Shauh-Der Yeh
Seasonal variations in urinary calculi attacks and their association with climate: a population based study.
J Urol. 2008 Feb;179(2):564-9. doi: 10.1016/j.juro.2007.09.067. Epub 2007 Dec 21.
Abstract/Text PURPOSE: In this nationwide population based study we used 5-year data on urinary calculi patient visits to emergency departments in Taiwan to investigate the seasonal variation in urinary calculi attacks and the association with 5 climatic parameters.
MATERIALS AND METHODS: Comprehensive details on total admissions to emergency departments were obtained from the Taiwan National Health Insurance Research Database (1999 to 2003), providing monthly urinary calculi attack rates per 100,000 of the population. Subgroups of urinary calculi incidences were created based on gender and 3 age groups (18 to 44, 45 to 64 and 65 years old or older). Following adjustment for time trend effects, evaluation of the monthly urinary calculi attack rates and the effects of climatic factors was performed using auto-regressive integrated moving average regression methodology.
RESULTS: The seasonal trends in the monthly urinary calculi attack rates revealed a peak in July to September, followed by a sharp decline in October, with the auto-regressive integrated moving average tests for seasonality demonstrating significance for each gender group, for each age group and for the whole sample (all p <0.001). Although significant associations were found between ambient temperature, atmospheric pressure and hours of sunshine vis-à-vis monthly urinary calculi attack rates for the total population, after adjustment for trends and seasonality, ambient temperature was found to be the sole major factor having any positive association with the monthly attack rates.
CONCLUSIONS: We conclude that seasonal variations do exist in the monthly urinary calculi attack rates for all age and gender populations, and that following time series statistical adjustment, only ambient temperature had any consistent association with monthly attack rates.

PMID 18082222
Christopher L Moore, Scott Bomann, Brock Daniels, Seth Luty, Annette Molinaro, Dinesh Singh, Cary P Gross
Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone--the STONE score: retrospective and prospective observational cohort studies.
BMJ. 2014 Mar 26;348:g2191. Epub 2014 Mar 26.
Abstract/Text OBJECTIVE: To derive and validate an objective clinical prediction rule for the presence of uncomplicated ureteral stones in patients eligible for computed tomography (CT). We hypothesized that patients with a high probability of ureteral stones would have a low probability of acutely important alternative findings.
DESIGN: Retrospective observational derivation cohort; prospective observational validation cohort.
SETTING: Urban tertiary care emergency department and suburban freestanding community emergency department.
PARTICIPANTS: Adults undergoing non-contrast CT for suspected uncomplicated kidney stone. The derivation cohort comprised a random selection of patients undergoing CT between April 2005 and November 2010 (1040 patients); the validation cohort included consecutive prospectively enrolled patients from May 2011 to January 2013 (491 patients).
MAIN OUTCOME MEASURES: In the derivation phase a priori factors potentially related to symptomatic ureteral stone were derived from the medical record blinded to the dictated CT report, which was separately categorized by diagnosis. Multivariate logistic regression was used to determine the top five factors associated with ureteral stone and these were assigned integer points to create a scoring system that was stratified into low, moderate, and high probability of ureteral stone. In the prospective phase this score was observationally derived blinded to CT results and compared with the prevalence of ureteral stone and important alternative causes of symptoms.
RESULTS: The derivation sample included 1040 records, with five factors found to be most predictive of ureteral stone: male sex, short duration of pain, non-black race, presence of nausea or vomiting, and microscopic hematuria, yielding a score of 0-13 (the STONE score). Prospective validation was performed on 491 participants. In the derivation and validation cohorts ureteral stone was present in, respectively, 8.3% and 9.2% of the low probability (score 0-5) group, 51.6% and 51.3% of the moderate probability (score 6-9) group, and 89.6% and 88.6% of the high probability (score 10-13) group. In the high score group, acutely important alternative findings were present in 0.3% of the derivation cohort and 1.6% of the validation cohort.
CONCLUSIONS: The STONE score reliably predicts the presence of uncomplicated ureteral stone and lower likelihood of acutely important alternative findings. Incorporation in future investigations may help to limit exposure to radiation and over-utilization of imaging.
TRIAL REGISTRATION: www.clinicaltrials.gov NCT01352676.

PMID 24671981
Jonathan S Luchs, Douglas S Katz, Michael J Lane, Brett C Mellinger, Jeffrey H Lumerman, Charles A Stillman, Evan M Meiner, Steven Perlmutter
Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results.
Urology. 2002 Jun;59(6):839-42.
Abstract/Text OBJECTIVES: To determine the utility of hematuria testing in a large series of patients with suspected renal colic using unenhanced helical computed tomography (CT) as the reference standard.
METHODS: A retrospective review of the CT reports of all patients who underwent unenhanced helical CT for suspected renal colic at one institution during a 3.5-year period and who also underwent a formal microscopic urinalysis within 24 hours of the CT study was conducted. The sensitivity, specificity, positive predictive value, and negative predictive value of the presence of any blood on the urinalysis for renal colic were calculated.
RESULTS: Urolithiasis was present in 587 (62%) of the 950 patients, and 363 patients had negative examinations for renal colic, including 69 with significant alternative diagnoses in the latter group. Of the urinalyses, 492 were true-positive, 174 were true-negative, 189 were false-positive, and 95 were false-negative, yielding a sensitivity, specificity, positive predictive value, and negative predictive value of 84%, 48%, 72%, and 65%, respectively. Forty-six percent of the urinalysis results were negative for blood in the subset of patients with significant alternative diagnoses.
CONCLUSIONS: The sensitivity of hematuria on microscopic urinalysis for renal colic using unenhanced CT as the reference standard was 84%, and the specificity and negative predictive value was low. The presence or absence of blood on urinalysis cannot be used to reliably determine which patients actually have ureteral stones.

PMID 12031364
P Bove, D Kaplan, N Dalrymple, A T Rosenfield, M Verga, K Anderson, R C Smith
Reexamining the value of hematuria testing in patients with acute flank pain.
J Urol. 1999 Sep;162(3 Pt 1):685-7.
Abstract/Text PURPOSE: Hematuria testing is routinely performed in patients with acute flank pain to screen for ureterolithiasis and to help determine the need for excretory urography. Unenhanced helical computerized tomography (CT) has recently been shown to be superior to excretory urography in diagnosing ureteral obstruction and can evaluate many other causes of flank pain. Given the speed, accuracy and safety of CT the value of hematuria testing for acute flank pain should be reexamined.
MATERIALS AND METHODS: We reviewed the medical records of 267 consecutive patients with acute flank pain referred for unenhanced helical CT. Microscopic and dipstick urinalysis data were obtained in 195 patients. Using helical CT as the gold standard, we calculated the sensitivity, specificity, predictive value and accuracy of hematuria for diagnosing ureterolithiasis.
RESULTS: Of the patients with ureterolithiasis 33% had 5 or less, 19% had 1 or less and 11% had no red blood cells (RBCs) per high power field. Of the patients without ureterolithiasis 24% had greater than 5 and 51% had greater than 1 RBC per high power field. Of the patients with ureterolithiasis 14% had a negative dipstick test and 1 RBC or less per high power field. There were 25 patients without ureterolithiasis who had CT abnormalities unrelated to the urinary tract, of whom 8 had greater than 1 RBC per high power field.
CONCLUSIONS: Absence of hematuria in the setting of acute flank pain cannot exclude a diagnosis of ureterolithiasis and should not obviate other diagnostic testing. Even when strongly positive on microscopy, hematuria has insufficient positive predictive value for diagnosing ureterolithiasis and may be misleading as other serious conditions resulting in acute flank pain may yield a positive test.

PMID 10458342
S M Press, A D Smith
Incidence of negative hematuria in patients with acute urinary lithiasis presenting to the emergency room with flank pain.
Urology. 1995 May;45(5):753-7. doi: 10.1016/S0090-4295(99)80078-8.
Abstract/Text OBJECTIVES: To determine the incidence of negative hematuria in patients with acute urinary lithiasis presenting to the emergency room with flank pain.
METHODS: We retrospectively reviewed all 140 patients who presented with flank pain to the Long Island Jewish Medical Center emergency department from January 1, 1992, through December 31, 1992, and underwent intravenous urogram (IVU). We then calculated the incidence of negative hematuria in patients with acute urinary lithiasis (AUL) diagnosed by IVU based on the complete urinalysis alone or in combination with the urine dipstick test for blood.
RESULTS: We found a 14.5% incidence of negative hematuria in patients with AUL when looking at the urinalysis alone. To our knowledge, this has never been reported in the literature. We also found that by considering a negative combination (urinalysis plus urine dipstick test) as a new definition of negative hematuria, the incidence of negative hematuria in patients with AUL was only 5.5% (P < 0.031).
CONCLUSIONS: This is the first report in the literature documenting the incidence of negative hematuria in patients with AUL to be 14.5%. With the addition of the combination of urinalysis and urine dipstick test for hematuria, the incidence is only 5.5% and, therefore, represents a low yield when evaluated by IVU.

PMID 7747369
Takashi Kobayashi, Koji Nishizawa, Kenji Mitsumori, Keiji Ogura
Impact of date of onset on the absence of hematuria in patients with acute renal colic.
J Urol. 2003 Oct;170(4 Pt 1):1093-6. doi: 10.1097/01.ju.0000080709.11253.08.
Abstract/Text PURPOSE: Hematuria is absent in a significant proportion of patients with acute ureterolithiasis. We determined whether time from pain onset has any impact on the sensitivity of hematuria tests in the diagnosis of ureterolithiasis.
MATERIALS AND METHODS: We retrospectively reviewed the records of 537 patients with suspected acute unilateral renal colic during a 29-month period with regard to the interval between pain onset and urinalysis, including the dipstick test and microscopic red blood cell count as well as other clinical findings. Although ureterolithiasis was determined by plain x-ray and ultrasonography primarily, stone absence was diagnosed by computerized tomography.
RESULTS: Ureterolithiasis was diagnosed in 452 patients (84.2%). The dipstick test had higher sensitivity (0.780 vs 0.718) but it was equivalent on ROC analysis compared with microscopic examination (area under the curve 0.696 vs 0.694, p = 0.92). Hematuria test sensitivity was 0.95, 0.83, 0.65, 0.68, 0.77, 0.86 and 0.68 on days 0, 1, 2, 3, 4, 5 to 7 and 8 or more from pain onset, respectively (ANOVA p = 0.004). On logistic regression analysis including hydronephrosis grade, and stone size and location the interval between onset and urinalysis was the only independent factor affecting the incidence of negative hematuria in patients with ureterolithiasis (p = 0.03, 95% CI 0.89 to 0.99).
CONCLUSIONS: The interval between pain onset and urine collection has a significant impact on the diagnostic performance of hematuria tests. The incidence of negative hematuria is highest on the days 3 and 4.

PMID 14501699
Fredrick M Abrahamian, Anusha Krishnadasan, William R Mower, Gregory J Moran, David A Talan
Association of pyuria and clinical characteristics with the presence of urinary tract infection among patients with acute nephrolithiasis.
Ann Emerg Med. 2013 Nov;62(5):526-33. doi: 10.1016/j.annemergmed.2013.06.006. Epub 2013 Jul 11.
Abstract/Text STUDY OBJECTIVE: Pyuria is a useful indicator of urinary tract infection among patients with compatible symptoms; however, its utility has not been adequately investigated among patients with acute nephrolithiasis. Therefore, we examine performance characteristics of pyuria and other clinical and laboratory correlates for urinary tract infection among patients with acute nephrolithiasis.
METHODS: A single-center prospective observational study examining the performance characteristics of pyuria and other clinical correlates for urinary tract infection was conducted among patients older than 17 years and presenting with acute nephrolithiasis confirmed by computed tomography and for whom urine culture was obtained.
RESULTS: Of 360 patients with acute nephrolithiasis, 28 (7.8%) had urinary tract infection, defined as growth of a single uropathogen at greater than or equal to 10(3) colony-forming units/mL. For the presence of urinary tract infection, pyuria level greater than 5 WBCs/high-power field (hpf) had a sensitivity of 86% and specificity of 79%; greater than 20 WBCs/hpf had a sensitivity of 68% and specificity of 93%. In 307 patients who lacked history of fever or measured temperature greater than 37.9°C (100.2°F), pyuria level greater than 5 WBCs/hpf had a sensitivity of 79% and specificity of 81% for urinary tract infection; greater than 20 WBCs/hpf had a sensitivity of 57% and specificity of 94%. Patients with urinary tract infection more often were female; had a history of dysuria, frequent urination, chills, urinary tract infection, or subjective fever; or had measured temperature of greater than 37.9°C (100.2°F).
CONCLUSION: About 8% of patients presenting with acute nephrolithiasis have urinary tract infection, in many without clinical findings of infection, and pyuria has only a moderate accuracy in identifying urinary tract infection in this setting. Clinical features of urinary tract infection, a greater degree of pyuria, and female sex increases the likelihood of infection.

Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
PMID 23850311
Axel Heidenreich, F Desgrandschamps, F Terrier
Modern approach of diagnosis and management of acute flank pain: review of all imaging modalities.
Eur Urol. 2002 Apr;41(4):351-62.
Abstract/Text Acute flank pain is a common and complex clinical problem which might be caused by a variety of urinary and extraurinary abnormalities among which ureterolithiasis being the most frequent cause. Plain abdominal radiographs combined with intravenous urography (IVU) have been the standard imaging procedures of choice for the evaluation of acute flank pain over the last decades. Direct detection of even small ureteral calculi is achieved in 40-60%, whereas using indirect signs such as ureteral and renal pelvic dilatation stone detection is possible in up to 80-90% of all cases. However, IVU might be hampered by poor quality due to lack of bowel preparation, by nephrotoxicity of contrast agents, by serious allergic and anaphylactic reactions in 10% and 1% of the patients, respectively, and by significant radiation exposure. The use of ultrasonography (US) in the management of acute flank pain has been growing and when combining the findings of pyeloureteral dilatation, direct visualization of stones, and the absence of ureteral ejaculation, the sensitivity to detect ureteral dilatation can be as high as 96%. Recently, unenhanced helical CT (UHCT) has been introduced as imaging modality with a high sensitivity and specificity for the evaluation of acute flank pain. UHCT has been demonstrated to be superior since (1) it detects ureteral stones with a sensitivity and specificity from 98% to 100% regardless of size, location and chemical composition, (2) it identifies extraurinary causes of flank pain in about one third of all patients presenting with acute flank pain, (3) it does not need contrast agent, and (4) it is a time saving imaging technique being performed within 5min. Based on the data published, one can predict that UHCT will become the imaging procedure of choice for evaluation of acute flank pain within the next years. The purpose of this review is to critically evaluate the role all imaging modalities available for a modern approach of diagnosis and management of acute flank pain with regard to their sensitivity, specificity, positive and negative predictive values and their complications, toxicicty and morbidity.

PMID 12074804
Gayathri Varma, Nandu Nair, Abiya Salim, Y M Fazil Marickar
Investigations for recognizing urinary stone.
Urol Res. 2009 Dec;37(6):349-52. doi: 10.1007/s00240-009-0219-z. Epub 2009 Oct 14.
Abstract/Text This study was done to identify the value of the commonly performed investigations available for identifying urinary stone disease, namely X-ray of the kidney, ureter and bladder (KUB) regions and ultrasound scan (USS) to recognize stones in patients suspected to have the disease. Two hundred patients who attended the stone clinic with symptoms suggestive of urinary stone disease and had either stone retrieved or have been followed up for minimum of 6 months were interviewed. The final opinion on stone disease was made after follow-up to assess the efficacy of the initial opinion based on the plain X-ray KUB or USS. The patients were classified as proved stone patients only after retrieval of stones. The efficacy of the initial screening investigation was assessed to calculate the specificity and sensitivity of the two modalities of investigation. Of the 200 patients studied, all had plain X-ray KUB. Only 166 patients had USS for recognizing stones in the urinary tract; 74 patients showed positive evidence of stones either by X-ray or USS. The findings of the two modalities of investigation are given below. Number of X-rays done, 200; number positive, 24; proved positive, 24 (stone retrieved); proved negative, 0; number negative, 176; proved positive, 32 (stone retrieved); proved negative, 144; number of USS done, 166; number positive, 120; proved positive, 50 (stone retrieved); proved negative, 70; number negative, 46; proved positive, 14 (stone retrieved); proved negative, 32. USS showed back presence effects in 62 patients. Of these, 12% showed stones in the ureter, whereas the rest did not show evidence of stones. Those selected as positive stones finally had either passed stones or had PCNL, URS, cystolithotripsy or open surgery or were put on high-dose chemotherapy. Forty-six patients who had no ROS in KUB and no stones in USS passed stones subsequently. It is concluded that the plain both X-ray KUB and USS should be performed in patients with suspected stone disease for identifying stone disease and also to exclude other pathology which may produce similar urinary symptoms.

PMID 19826802
Rebecca Smith-Bindman, Chandra Aubin, John Bailitz, Rimon N Bengiamin, Carlos A Camargo, Jill Corbo, Anthony J Dean, Ruth B Goldstein, Richard T Griffey, Gregory D Jay, Tarina L Kang, Dana R Kriesel, O John Ma, Michael Mallin, William Manson, Joy Melnikow, Diana L Miglioretti, Sara K Miller, Lisa D Mills, James R Miner, Michelle Moghadassi, Vicki E Noble, Gregory M Press, Marshall L Stoller, Victoria E Valencia, Jessica Wang, Ralph C Wang, Steven R Cummings
Ultrasonography versus computed tomography for suspected nephrolithiasis.
N Engl J Med. 2014 Sep 18;371(12):1100-10. doi: 10.1056/NEJMoa1404446.
Abstract/Text BACKGROUND: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography.
METHODS: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy.
RESULTS: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups.
CONCLUSIONS: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).

PMID 25229916
S Sourtzis, J F Thibeau, N Damry, A Raslan, M Vandendris, M Bellemans
Radiologic investigation of renal colic: unenhanced helical CT compared with excretory urography.
AJR Am J Roentgenol. 1999 Jun;172(6):1491-4. doi: 10.2214/ajr.172.6.10350278.
Abstract/Text OBJECTIVE: Our aim was to compare unenhanced helical CT and excretory urography in the assessment of patients with renal colic.
SUBJECTS AND METHODS: Fifty-three of 70 consecutive patients with acute signs of renal colic were prospectively examined with unenhanced helical CT, which was followed immediately by excretory urography. Two radiologists who were unaware of the findings independently interpreted these examinations to determine the presence or absence of ureteral obstruction. On all CT scans that had positive findings for ureteral stones or obstruction, we looked for secondary signs of obstruction (perinephric or periureteral fat stranding, ureteral wall edema, ureteral dilatation, and blurring of renal sinus fat).
RESULTS: A stone was recovered in 45 of the 53 patients, nine before and 36 after imaging. The latter 36 patients had their stones identified on CT, whereas only 24 patients had their stones identified on excretory urography. Eight patients without stone disease had normal ureters on both CT and excretory urography. Of the 45 patients who had stone disease, 26 had ureteral dilatation on both CT and excretory urography, and 36 patients who recovered a stone after CT had secondary signs of obstruction. Of the nine patients who recovered a stone before CT, three had secondary signs of obstruction. Two patients had periureteral fat stranding, ureteral wall edema, and renal sinus fat blurring. One patient had only ureteral wall edema.
CONCLUSION: Compared with excretory urography, unenhanced helical CT is better for identifying ureteral stones in patients with acute ureterolithiasis. Secondary CT signs of obstruction, including renal sinus fat blurring, were frequently present even when the stone was eliminated before imaging.

PMID 10350278
O Niall, J Russell, R MacGregor, H Duncan, J Mullins
A comparison of noncontrast computerized tomography with excretory urography in the assessment of acute flank pain.
J Urol. 1999 Feb;161(2):534-7.
Abstract/Text PURPOSE: We compare noncontrast enhanced computerized tomography (CT) and excretory urography (IVP) in the evaluation of acute flank pain.
MATERIALS AND METHODS: A total of 40 consecutive patients presenting to the emergency department with acute flank pain were evaluated with noncontrast CT, films of the kidneys, ureters and bladder, and IVP. The patients were treated according to the clinical picture. All 40 sets of evaluations were later assessed randomly by an independent consultant radiologist for the presence, size and location of a stone, ureteral dilatation and secondary signs of ureteral obstruction.
RESULTS: Of 40 patients 12 had no calculus and 28 had a calculus confirmed on removal or documented passage of a stone. Absence of a stone was based on clinical and radiological followup with clinical resolution. CT revealed all 28 calculi and no calculus in 11 of 12 patients with 100% sensitivity and 92% specificity. IVP demonstrated 18 calculi (64% sensitivity) and no calculus in 11 of 12 patients (92% specificity). Ureteral obstruction was seen in 28 of the 40 patients, and CT and IVP were equivalent in detection (100% sensitivity). Films of the kidneys, ureters and bladder alone demonstrated 15 of 28 stones (54% sensitivity).
CONCLUSIONS: Noncontrast CT is an accurate, safe, rapid technique to assess acute flank pain, and the evaluation of choice for patients who would otherwise require IVP for diagnosis.

PMID 9915442
Jia-Hwia Wang, Shu-Huei Shen, Shan-Su Huang, Cheng-Yen Chang
Prospective comparison of unenhanced spiral computed tomography and intravenous urography in the evaluation of acute renal colic.
J Chin Med Assoc. 2008 Jan;71(1):30-6. doi: 10.1016/S1726-4901(08)70069-8.
Abstract/Text BACKGROUND: The purpose of this prospective study was to evaluate the feasibility of replacing intravenous urography (IVU) with unenhanced computed tomography (CT) as the first line diagnostic modality for acute renal colic in the emergency department.
METHODS: In the 1-year study period, 82 patients who presented themselves to the emergency room with acute renal colic and who were suspected to have ureteral stones were included. They received both IVU and unenhanced CT on the same day.
RESULTS: Sixty-six patients were proven to have ureteral stone. Four had other urologic pathology (acute pyelonephritis, angiomyolipoma with hemorrhage, ureteropelvic junction stenosis). The remaining 12 had no definite urologic problem. Among the 66 patients with ureteral stone, the sensitivity for detecting ureteral stone was 98.5% for unenhanced CT and 59.1% for IVU. Correct diagnosis could be obtained in most of the patients receiving unenhanced CT, while IVU could provide only limited information about the intra-abdominal pathology other than urologic system, and as many as 31.7% of the patients needed further imaging examination (sonography, CT, magnetic resonance imaging). In 5 patients, the relationship of the calcified spot and ureter were unclear on axial images. With curved multiplanar reformatted reconstruction, the diagnosis of ureter stone could be confidently made. No side effect (renal toxicity, allergic reaction) from intravenous administration of iodine-containing contrast medium should be taken into consideration in CT. Besides, the average examination time was 108 minutes for IVU, which was significantly more than the 30 minutes for CT, including the time for curved multiplanar reformatted reconstruction.
CONCLUSION: We consider that unenhanced CT is more effective and efficient than IVU and should replace IVU as the first-line diagnostic tool for ureteral stone in the emergency department.

PMID 18218557
S Yilmaz, T Sindel, G Arslan, C Ozkaynak, K Karaali, A Kabaalioğlu, E Lüleci
Renal colic: comparison of spiral CT, US and IVU in the detection of ureteral calculi.
Eur Radiol. 1998;8(2):212-7. doi: 10.1007/s003300050364.
Abstract/Text The aim of our study was to compare non-contrast spiral CT, US and intravenous urography (IVU) in the evaluation of patients with renal colic for the diagnosis of ureteral calculi. During a period of 17 months, 112 patients with renal colic were examined with spiral CT, US and IVU. Fifteen patients were lost to follow-up and excluded. The remaining 97 patients were defined to be either true positive or negative for ureterolithiasis based on the follow-up data. Sensitivity, specificity, positive and negative predictive value and accuracy of spiral CT, US and IVU were determined, and secondary signs of ureteral stones and other pathologies causing renal colic detected with these modalities were noted. Of 97 patients, 64 were confirmed to have ureteral calculi based on stone recovery or urological interventions. Thirty-three patients were proved not to have ureteral calculi based on failure to recover a stone and diagnoses unrelated to ureterolithiasis. Spiral CT was found to be the best modality for depicting ureteral stones with a sensitivity of 94 % and a specificity of 97 %. For US and IVU, these figures were 19, 97, 52, and 94 %, respectively. Spiral CT is superior to US and IVU in the demonstration of ureteral calculi in patients with renal colic, but because of its high cost, higher radiation dose and high workload, it should be reserved for cases where US and IVU do not show the cause of symptoms.

PMID 9477267
Pierre-Alexandre Poletti, Alexandra Platon, Olivier T Rutschmann, Franz R Schmidlin, Christophe E Iselin, Christoph D Becker
Low-dose versus standard-dose CT protocol in patients with clinically suspected renal colic.
AJR Am J Roentgenol. 2007 Apr;188(4):927-33. doi: 10.2214/AJR.06.0793.
Abstract/Text OBJECTIVE: The purpose of our study was to compare a low-dose abdominal CT protocol, delivering a dose of radiation close to the dose delivered by abdominal radiography, with standard-dose unenhanced CT in patients with suspected renal colic.
MATERIALS AND METHODS: One hundred twenty-five patients (87 men, 38 women; mean age, 45 years) who were admitted with suspected renal colic underwent both abdominal low-dose CT (30 mAs) and standard-dose CT (180 mAs). Low-dose CT and standard-dose CT were independently reviewed, in a delayed fashion, by two radiologists for the characterization of renal and ureteral calculi (location, size) and for indirect signs of renal colic (renal enlargement, pyeloureteral dilatation, periureteral or renal stranding). Results reported for low-dose CT, with regard to the patients' body mass indexes (BMIs), were compared with those obtained with standard-dose CT (reference standard). The presence of non-urinary tract-related disorders was also assessed. Informed consent was obtained from all patients.
RESULTS: In patients with a BMI < 30, low-dose CT achieved 96% sensitivity and 100% specificity for the detection of indirect signs of renal colic and a sensitivity of 95% and a specificity of 97% for detecting ureteral calculi. In patients with a BMI < 30, low-dose CT was 86% sensitive for detecting ureteral calculi < 3 mm and 100% sensitive for detecting calculi > 3 mm. Low-dose CT was 100% sensitive and specific for depicting non-urinary tract-related disorders (n = 6).
CONCLUSION: Low-dose CT achieves sensitivities and specificities close to those of standard-dose CT in assessing the diagnosis of renal colic, depicting ureteral calculi > 3 mm in patients with a BMI < 30, and correctly identifying alternative diagnoses.

PMID 17377025
Agnes J Wang, Zachariah G Goldsmith, Chu Wang, Giao Nguyen, Gastón M Astroza, Andreas Neisius, Muhammad W Iqbal, Amy M Neville, Carolyn Lowry, Greta Toncheva, Terry T Yoshizumi, Glenn M Preminger, Michael N Ferrandino, Michael E Lipkin
Obesity triples the radiation dose of stone protocol computerized tomography.
J Urol. 2013 Jun;189(6):2142-6. doi: 10.1016/j.juro.2012.12.029. Epub 2012 Dec 20.
Abstract/Text PURPOSE: Patients with recurrent nephrolithiasis are often evaluated and followed with computerized tomography. Obesity is a risk factor for nephrolithiasis. We evaluated the radiation dose of computerized tomography in obese and nonobese adults.
MATERIALS AND METHODS: We scanned a validated, anthropomorphic male phantom according to our institutional renal stone evaluation protocol. The obese model consisted of the phantom wrapped in 2 Custom Fat Layers (CIRS, Norfolk, Virginia), which have been verified to have the same radiographic tissue density as fat. High sensitivity metal oxide semiconductor field effect transistor dosimeters were placed at 20 organ locations in the phantoms to measure organ specific radiation doses. The nonobese and obese models have an approximate body mass index of 24 and 30 kg/m(2), respectively. Three runs of renal stone protocol computerized tomography were performed on each phantom under automatic tube current modulation. Organ specific absorbed doses were measured and effective doses were calculated.
RESULTS: The bone marrow of each model received the highest dose and the skin received the second highest dose. The mean ± SD effective dose for the nonobese and obese models was 3.04 ± 0.34 and 10.22 ± 0.50 mSv, respectively (p <0.0001).
CONCLUSIONS: The effective dose of stone protocol computerized tomography in obese patients is more than threefold higher than the dose in nonobese patients using automatic tube current modulation. The implication of this finding extends beyond the urological stone population and adds to our understanding of radiation exposure from medical imaging.

Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
PMID 23261481
Michael W Ciaschini, Erick M Remer, Mark E Baker, Michael Lieber, Brian R Herts
Urinary calculi: radiation dose reduction of 50% and 75% at CT--effect on sensitivity.
Radiology. 2009 Apr;251(1):105-11. doi: 10.1148/radiol.2511081084. Epub 2009 Feb 27.
Abstract/Text PURPOSE: To retrospectively determine the effect of 50% and 75% dose reduction on sensitivity and specificity of computed tomography (CT) for the detection of urinary calculi.
MATERIALS AND METHODS: This HIPAA compliant study was institutional review board approved; informed consent was waived. Raw CT data from 47 consecutive patients (24 male patients, 23 female patients; mean age, 46.0 years) who underwent unenhanced CT for flank pain were collected. Original CT examinations were performed by utilizing an automated dose modulation algorithm. Reconstructions of raw CT data were performed at 100%, 50%, and 25% of the original tube current by using simulation software; tube currents averaged 177, 88, and 44 mA, respectively. All reconstructed examinations were randomized and evaluated by two radiologists blinded to the presence, number, location, and size of calculi. The opinion of an unblinded radiologist who separately reviewed the original examination and report and the electronic medical record served as the reference standard. One hundred eight calculi (85 renal, 21 ureteral, and two in the bladder) were present in 32 of 47 patients. Calculus diameter ranged from 0.14 to 1.32 cm (mean, 0.34 cm). The decrease in sensitivity was assessed between doses and was independently evaluated for all calculi and separately for calculi greater than 3 mm in diameter by using the McNemar test, adjusted for clustered data.
RESULTS: For all calculi, the blinded readers demonstrated combined sensitivities of 91.7%, 83.3%, and 67.1% for the 100%, 50%, and 25% tube current reconstructions, respectively. For stones greater than 3 mm, combined sensitivities were 97.7%, 93.0%, and 91.9%, respectively, for the 100%, 50%, and 25% reconstructions. There was no significant difference between the 100% examinations and the 50% and 25% reconstructions for detection of stones greater than 3 mm (P = .106 and .099, respectively).
CONCLUSION: There were no significant differences between the 100% examinations and the 50% and 25% examinations for the detection of calculi greater than 3 mm.

PMID 19251939
Christopher L Moore, Brock Daniels, Monica Ghita, Gowthaman Gunabushanam, Seth Luty, Annette M Molinaro, Dinesh Singh, Cary P Gross
Accuracy of reduced-dose computed tomography for ureteral stones in emergency department patients.
Ann Emerg Med. 2015 Feb;65(2):189-98.e2. doi: 10.1016/j.annemergmed.2014.09.008. Epub 2014 Nov 4.
Abstract/Text STUDY OBJECTIVE: Reduced-dose computed tomography (CT) scans have been recommended for diagnosis of kidney stone but are rarely used in the emergency department (ED) setting. Test characteristics are incompletely characterized, particularly in obese patients. Our primary outcome is to determine the sensitivity and specificity of a reduced-dose CT protocol for symptomatic ureteral stones, particularly those large enough to require intervention, using a protocol stratified by patient size.
METHODS: This was a prospective, blinded observational study of 201 patients at an academic medical center. Consenting subjects underwent both regular- and reduced-dose CT, stratified into a high and low body mass index (BMI) protocol based on effective abdominal diameter. Reduced-dose CT scans were interpreted by radiologists blinded to regular-dose interpretations. Follow-up for outcome and intervention was performed at 90 days.
RESULTS: CT scans with both regular and reduced doses were conducted for 201 patients, with 63% receiving the high BMI reduced-dose protocol. Ureteral stone was identified in 102 patients (50.7%) of those receiving regular-dose CT, with a ureteral stone greater than 5 mm identified in 26 subjects (12.9%). Sensitivity of the reduced-dose CT for any ureteral stone was 90.2% (95% confidence interval [CI] 82.3% to 95.0%), with a specificity of 99.0% (95% CI 93.7% to 100.0%). For stones greater than 5 mm, sensitivity was 100% (95% CI 85.0% to 100.0%). Reduced-dose CT identified 96% of patients who required intervention for ureteral stone within 90 days. Mean reduction in size-specific dose estimate was 18.6 milligray (mGy), from 21.7 mGy (SD 9.7) to 3.4 mGy (SD 0.9).
CONCLUSION: CT with substantial dose reduction was 90.2% (95% CI 82.3% to 95.0%) sensitive and 98.9% (95% CI 85.0% to 100.0%) specific for ureteral stones in ED patients with a wide range of BMIs. Reduced-dose CT was 96.0% (95% CI 80.5% to 99.3%) sensitive for ureteral stones requiring intervention within 90 days.

Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID 25441242
Miguel Angel Arrabal-Polo, Miguel Arrabal-Martin, Salvador Arias-Santiago, Juan Garrido-Gomez, Antonio Poyatos-Andujar, Armando Zuluaga-Gomez
Importance of citrate and the calcium : citrate ratio in patients with calcium renal lithiasis and severe lithogenesis.
BJU Int. 2013 Apr;111(4):622-7. doi: 10.1111/j.1464-410X.2012.11292.x. Epub 2012 Jul 3.
Abstract/Text UNLABELLED: Different studies have shown the importance of citrate in the formation of calcium stones. It has further been shown that the states of metabolic acidosis result in an increase in bone resorption and lower urinary citrate levels. Increasing the intake of citrate in these patients can reduce the lithogenic risk and improve bone mineral density (BMD), contributing to control of both diseases. The study shows the importance of citrate in patients with calcium stones and BMD loss. The deficit in citrate excretion is associated with a decrease in bone mineralization and increased β-crosslaps. A calcium : citrate ratio >0.25 in patients with calcium stones and loss of mineral density may predict severe lithogenic activity.
OBJECTIVE: To analyse the importance of urinary citrate and the urinary calcium : citrate ratio in patients with calcium renal lithiasis and severe lithogenesis compared with a control group of patients without lithiasis.
MATERIAL AND METHODS: A cross-sectional study of 115 patients in eastern Andalusia, Spain was conducted. The patients were divided into two groups: Group A: 56 patients aged 25-60 years without calcium renal lithiasis; Group B: 59 patients aged 25-60 years, presenting with calcium renal lithiasis and severe lithogenesis. The citrate levels and the calcium : citrate ratio in the patients' urine and the relationship of these two factors to lithiasic activity were analysed and compared.
RESULTS: In Group B, 32.2% of the patients presented with hypocitraturia, compared with 14.3% of the patients in Group A (P = 0.02). The urinary citrate levels were lower in Group B than in Group A (P = 0.001) and the calcium : citrate ratio was higher in Group B than in Group A (P = 0.005). The results suggest that a patient urinary calcium : citrate ratio > 0.25 indicates severe lithogenesis (with a sensitivity of 89% and a specificity of 57%). After linear regression analysis, we found that the urinary citrate level is an independent factor associated with the changes in bone densitometry T-score values of patients.
CONCLUSIONS: The patients with severe lithogenesis presented with hypocitraturia, which was associated with lower bone mineral density. The calcium : citrate ratio, which is linearly related to the bone resorption marker β-crosslaps, could be useful in evaluating the risk of severe lithogenesis when this ratio is >0.25.

© 2012 BJU International.
PMID 22757744
Takahiro Yasui, Masanori Iguchi, Sadao Suzuki, Kenjiro Kohri
Prevalence and epidemiological characteristics of urolithiasis in Japan: national trends between 1965 and 2005.
Urology. 2008 Feb;71(2):209-13. doi: 10.1016/j.urology.2007.09.034.
Abstract/Text OBJECTIVES: We evaluated the epidemiological details and chronological trends of upper urinary tract stones in Japan using a nationwide survey of urolithiasis.
METHODS: All patient visits to urologists that resulted in a diagnosis of first-episode upper urinary tract stones in 2005 were enumerated irrespective of admission and treatment. The study included all hospitals approved by the Japanese Board of Urology, thus covering nearly all urologists practicing in Japan. We compared the estimated annual incidence according to gender and age with the incidence determined from nationwide surveys between 1965 and 1995.
RESULTS: The estimated annual incidence of first-episode upper urinary tract stones in 2005 was 134.0 per 100,000 (192.0 in men and 79.3 in women). The estimated age-standardized annual incidence of first-episode upper urinary tract stones in 2005 was 114.3 per 100,000 (165.1 for men and 65.1 for women), which represents a steady increase from 54.2 in 1965. The annual incidence has increased in all age groups except during the first 3 decades of life and the peak age for both men and women has also increased.
CONCLUSIONS: The annual incidence of upper urinary tract stones has steadily increased in Japan and this trend will continue in the near future. This probably results from improvements in clinical-diagnostic procedures, changes in nutritional and environmental factors, and general apathy toward metabolic clarification and metaphylaxis.

PMID 18308085
Takahiro Yasui, Masanori Iguchi, Sadao Suzuki, Atsushi Okada, Yasunori Itoh, Keiichi Tozawa, Kenjiro Kohri
Prevalence and epidemiologic characteristics of lower urinary tract stones in Japan.
Urology. 2008 Nov;72(5):1001-5. doi: 10.1016/j.urology.2008.06.038. Epub 2008 Sep 25.
Abstract/Text OBJECTIVES: To analyze the changes in the annual incidence and epidemiologic details of lower urinary tract stones in Japan, a nationwide survey of urolithiasis was performed.
METHODS: Data were obtained from all patients who had been diagnosed by urologists in 2005 as having lower urinary tract stones, including both first and recurrent stones. The data were separately enumerated according to hospital size, irrespective of admission and treatment. The study included all hospitals approved by the Japanese Board of Urology and thus covered nearly all urologists practicing in Japan. The estimated annual incidence according to sex, age, and stone composition was compared with other nationwide surveys taken from 1965 to 1995.
RESULTS: The incidence of lower urinary tract stones in Japan has steadily increased from 4.7/100,000 in 1965 to 9.1/100,000 in 2005. However, the age-standardized annual incidence of lower urinary tract stones in Japan decreased slightly from 5.5/100,000 in 1965 to 5.4/100,000 in 2005. The incidence of stones containing calcium has significantly increased from 50.7% to 72.0% among men and the incidence of infection-related stones has decreased significantly from 26.2% to 10.1%. The ratios of uric acid calculi in men and of infection-related stones in women increased with age.
CONCLUSIONS: The increased incidence of lower urinary tract stones is in slight contrast to the sudden increase in the incidence of upper urinary tract stones, which might be associated with the aging of the Japanese population.

PMID 18817962
A Skolarikos, M P Laguna, G Alivizatos, A R Kural, J J M C H de la Rosette
The role for active monitoring in urinary stones: a systematic review.
J Endourol. 2010 Jun;24(6):923-30. doi: 10.1089/end.2009.0670.
Abstract/Text BACKGROUND AND PURPOSE: All urinary stones may not need prompt active treatment. The aim of our study was to identify urinary stones that can be actively monitored safely.
MATERIALS AND METHODS: We performed a systematic review of the natural history and the role of active monitoring for urinary stones.
RESULTS: Thirty-seven studies have selected. Of symptomatic ureteral calculi <4 mm, 38% to 71% will pass spontaneously while only 4.8% of stones <2 mm will need intervention during surveillance. Follow-up with history, physical examination, urinalysis, and plain radiography every 2 weeks for 1 month is necessary. If spontaneous passage does not occur within this period, intervention is recommended. When shockwave lithotripsy for caliceal stones is prospectively compared with observation, there is no difference in stone-free rates (28% vs 17%), need for additional treatment (15% vs 21%), or visits to a general practitioner (18.5% vs 20.8%). Patients under observation may need more invasive procedures and may be more commonly left with residual stone fragments >5 mm (58% vs 30%). Isolated, nonuric acid calculi <4 mm may be most amenable to active monitoring. Physical examination, urinalysis, and CT scan performed on an annual basis up to year 2 or 3, followed by intervention, are recommended. Lower pole stones <10 mm could be actively monitored on an annual basis by alternating ultrasonoraphy with CT scan, provided the patients are adequately informed. Up to 58.6% and 43% of patients with residual fragments after shockwave and percutaneous lithotripsy, respectively, may become symptomatic or require intervention during follow-up. Noninfected, asymptomatic fragments, <4 mm postextracorporeal lithotripsy, and <2 mm postpercutaneous surgery could be followed expectantly on an annual basis, in combination with medical therapy.
CONCLUSION: Active stone monitoring has a certain role in the treatment of patients with urinary stones. The success is largely dependent on the stone size, location, and composition, as well as the time after the diagnosis. Medical therapy is a useful adjunct to observation.

PMID 20482232
Glenn M Preminger, Hans-Göran Tiselius, Dean G Assimos, Peter Alken, A Colin Buck, Michele Gallucci, Thomas Knoll, James E Lingeman, Stephen Y Nakada, Margaret Sue Pearle, Kemal Sarica, Christian Türk, J Stuart Wolf, American Urological Association Education and Research, Inc, European Association of Urology
2007 Guideline for the management of ureteral calculi.
Eur Urol. 2007 Dec;52(6):1610-31.
Abstract/Text
PMID 18074433
Tomoyuki Kaneko, Hisashi Matsushima, Hirohiko Morimoto, Yasuo Tsuzaka, Yukio Homma
Efficacy of low dose tamsulosin in medical expulsive therapy for ureteral stones in Japanese male patients: a randomized controlled study.
Int J Urol. 2010 May;17(5):462-5. doi: 10.1111/j.1442-2042.2010.02499.x. Epub 2010 Feb 25.
Abstract/Text OBJECTIVE: To evaluate the efficacy of low dose tamsulosin for facilitating spontaneous passage of ureteral stones in Japanese male patients.
METHODS: A total of 71 patients with symptomatic ureteral stones, 10 mm or smaller in size, were randomly allocated into groups 1 and 2. Group 1 received tamsulosin (0.2 mg/day) for a maximum of 4 weeks and group 2 received no medication. The primary endpoint was the stone expulsion rate and the secondary endpoints were stone expulsion time and analgesic use.
RESULTS: There were no significant differences between the groups in terms of age, stone size and location. The stone expulsion rate was significantly higher in group 1 than in group 2 (77% vs 50%, P = 0.002). No significant differences were noted in the stone expulsion time and analgesic use between the groups.
CONCLUSION: Low dose tamsulosin can significantly facilitate spontaneous passage of ureteral stones without significant side-effects in Japanese male patients.

PMID 20202002
Yasunori Itoh, Atsushi Okada, Takahiro Yasui, Shuzo Hamamoto, Masahito Hirose, Yoshiyuki Kojima, Keiichi Tozawa, Shoichi Sasaki, Kenjiro Kohri
Efficacy of selective α1A adrenoceptor antagonist silodosin in the medical expulsive therapy for ureteral stones.
Int J Urol. 2011 Sep;18(9):672-4. doi: 10.1111/j.1442-2042.2011.02810.x. Epub 2011 Jun 26.
Abstract/Text Recently, we reported that α1A adrenoceptor (AR) is the main participant in phenylephrine-induced human ureteral contraction. We therefore decided to carry out a prospective randomized study to evaluate the effects of silodosin, a selective α1A AR antagonist, as a medical expulsive therapy for ureteral stones. A total of 187 male patients, who were referred to our department for the management of symptomatic unilateral ureteral calculi of less than 10 mm, were randomly divided into two groups: group A (92 patients), who were instructed to drink 2 L of water daily, and group B (95 patients), who received the same instruction and were also given silodosin (8 mg/daily) for a maximum of 8 weeks. Expulsion rate, mean expulsion time and need for analgesics were examined. Overall, the mean expulsion time was 15.19 ± 7.14 days for group A and 10.27 ± 8.35 days for group B (P = 0.0058). In cases involving distal ureteral stones, the mean expulsion time was 13.40 ± 5.90 and 9.29 ± 5.91 days, respectively (P = 0.012). For stones of 1-5 mm in diameter, the mean expulsion time was 14.28 ± 6.35 and 9.56 ± 8.45 days, respectively (P = 0.017). For stones of 6-9 mm in diameter, the stone expulsion rate was 30.4% and 52.2% (P = 0.036), and the mean expulsion time was 21.00 ± 9.9 and 11.33 ± 8.31 days, respectively (P = 0.038). Herein, we report the first on silodosin in the management of ureteral lithiasis. Our findings suggest that silodosin might have potential as a medical expulsive therapy for ureteral stones.

© 2011 The Japanese Urological Association.
PMID 21707766
Deirdre M Coll, Michael J Varanelli, Robert C Smith
Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT.
AJR Am J Roentgenol. 2002 Jan;178(1):101-3. doi: 10.2214/ajr.178.1.1780101.
Abstract/Text OBJECTIVE: Prior studies using radiography have examined the relationship of ureteral stone size and location to the probability of spontaneous passage. Given the improved accuracy and new role of unenhanced CT in the diagnosis of acute ureterolithiasis, we studied the relationship of stone size and location as determined by unenhanced CT to the rate of spontaneous passage.
MATERIALS AND METHODS: Over a 29-month period, 850 patients with acute flank pain were evaluated with unenhanced CT. Confirmation of the CT diagnosis was obtained retrospectively for 172 patients with ureteral stones: 115 stones passed spontaneously and 57 required intervention. Stone size was defined as the maximum diameter within the plane of the axial CT section. Stone location was classified as proximal ureter (above the sacroiliac joints), mid ureter (overlying the sacroiliac joints), distal ureter (below the sacroiliac joints), and ureterovesical junction.
RESULTS: The spontaneous passage rate for stones 1 mm in diameter was 87%; for stones 2-4 mm, 76%; for stones 5-7 mm, 60%; for stones 7-9 mm, 48%; and for stones larger than 9 mm, 25%. Spontaneous passage rate as a function of stone location was 48% for stones in the proximal ureter, 60% for mid ureteral stones, 75% for distal stones, and 79% for ureterovesical junction stones.
CONCLUSION: The rate of spontaneous passage of ureteral stones does vary with stone size and location as determined by CT. These rates are similar to those previously published based on radiography.

PMID 11756098
O F Miller, C J Kane
Time to stone passage for observed ureteral calculi: a guide for patient education.
J Urol. 1999 Sep;162(3 Pt 1):688-90; discussion 690-1.
Abstract/Text PURPOSE: We analyze the natural history of stone passage in patients with ureterolithiasis, and define factors predictive of spontaneous passage.
MATERIALS AND METHODS: A total of 75 patients with ureteral calculi were prospectively followed for stone passage. Clinical data included patient gender and age, stone size and location, pain medication requirements and interval to stone passage. Of the 75 patients 13 (17%) required intervention and 62 (83%) were followed until spontaneous stone passage. Stones requiring intervention were not included in the time to passage analysis.
RESULTS: Of the 75 patients 41 (55%) had ureteral stones 2 mm. or smaller with an average time to stone passage of 8.2 days and only 2 (4.8%) required intervention, 18 (24%) had stones between 2 and 4 mm. with an average time to stone passage of 12.2 days and 3 (17%) required intervention, and 16 had stones 4 mm. or greater with an average time to stone passage of 22.1 days and 8 required intervention. For 95% of stones to pass it took 31 days for those 2 mm, or less, 40 days for those 2 to 4 mm. and 39 days for those 4 to 6 mm. Multivariate analysis revealed that size, location and side were statistically related to stone passage interval (p = 0.012). Stones that were smaller, more distal and on the right side were more likely to pass spontaneously and required fewer interventions.
CONCLUSIONS: Interval to stone passage is highly variable and dependent on stone size, location and side. Degree of pain, and patient gender and age had no bearing on the time to stone passage. Of ureteral stones 95% 2 to 4 mm. pass spontaneously but passage may take as long as 40 days. Intervention may be required in 50% of ureteral calculi greater than 5 mm.

PMID 10458343
O S Better, A I Arieff, S G Massry, C R Kleeman, M H Maxwell
Studies on renal function after relief of complete unilateral ureteral obstruction of three months' duration in man.
Am J Med. 1973 Feb;54(2):234-40.
Abstract/Text
PMID 4539855
Kourosh Afshar, Siavash Jafari, Andrew J Marks, Arash Eftekhari, Andrew E MacNeily
Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic.
Cochrane Database Syst Rev. 2015 Jun 29;(6):CD006027. doi: 10.1002/14651858.CD006027.pub2. Epub 2015 Jun 29.
Abstract/Text BACKGROUND: Renal colic is acute pain caused by urinary stones. The prevalence of urinary stones is between 10% and 15% in the United States, making renal colic one of the common reasons for urgent urological care. The pain is usually severe and the first step in the management is adequate analgesia. Many different classes of medications have been used in this regard including non-steroidal anti-inflammatory drugs and narcotics.
OBJECTIVES: The aim of this review was to assess benefits and harms of different NSAIDs and non-opioids in the treatment of adult patients with acute renal colic and if possible to determine which medication (or class of medications) are more appropriate for this purpose. Clinically relevant outcomes such as efficacy of pain relief, time to pain relief, recurrence of pain, need for rescue medication and side effects were explored.
SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register (to 27 November 2014) through contact with the Trials' Search Co-ordinator using search terms relevant to this review.
SELECTION CRITERIA: Only randomised or quasi randomised studies were included. Other inclusion criteria included adult patients with a clinical diagnosis of renal colic due to urolithiasis, at least one treatment arm included a non-narcotic analgesic compared to placebo or another non-narcotic drug, and reporting of pain outcome or medication adverse effect. Patient-rated pain by a validated tool, time to relief, need for rescue medication and pain recurrence constituted the outcomes of interest. Any adverse effects (minor or major) reported in the studies were included.
DATA COLLECTION AND ANALYSIS: Abstracts were reviewed by at least two authors independently. Papers meeting the inclusion criteria were fully reviewed and relevant data were recorded in a standardized Cochrane Renal Group data collection form. For dichotomous outcomes relative risks and 95% confidence intervals were calculated. For continuous outcomes the weighted mean difference was estimated. Both fixed and random models were used for meta-analysis. We assessed the analgesic effects using four different outcome variables: patient-reported pain relief using a visual analogue scale (VAS); proportion of patients with at least 50% reduction in pain; need for rescue medication; and pain recurrence. Heterogeneity was assessed using the I² test.
MAIN RESULTS: A total of 50 studies (5734 participants) were included in this review and 37 studies (4483 participants) contributed to our meta-analyses. Selection bias was low in 34% of the studies or unclear in 66%; performance bias was low in 74%, high in 14% and unclear in 12%; attrition bias was low in 82% and high in 18%; selective reporting bias low in 92% of the studies; and other biases (industry funding) was high in 4%, unclear in 18% and low in 78%.Patient-reported pain (VAS) results varied widely with high heterogeneity observed. For those comparisons which could be pooled we observed the following: NSAIDs significantly reduced pain compared to antispasmodics (5 studies, 303 participants: MD -12.97, 95% CI -21.80 to - 4.14; I² = 74%) and combination therapy of NSAIDs plus antispasmodics was significantly more effective in pain control than NSAID alone (2 studies, 310 participants: MD -1.99, 95% CI -2.58 to -1.40; I² = 0%).NSAIDs were significantly more effective than placebo in reducing pain by 50% within the first hour (3 studies, 197 participants: RR 2.28, 95% CI 1.47 to 3.51; I² = 15%). Indomethacin was found to be less effective than other NSAIDs (4 studies, 412 participants: RR 1.27, 95% CI 1.01 to 1.60; I² = 55%). NSAIDs were significantly more effective than hyoscine in pain reduction (5 comparisons, 196 participants: RR 2.44, 95% CI 1.61 to 3.70; I² = 28%). The combination of NSAIDs and antispasmodics was not superior to NSAIDs only (9 comparisons, 906 participants: RR 1.00, 95% CI 0.89 to 1.13; I² = 59%). The results were mixed when NSAIDs were compared to other non-opioid medications.When the need for rescue medication was evaluated, Patients receiving NSAIDs were significantly less likely to require rescue medicine than those receiving placebo (4 comparisons, 180 participants: RR 0.35, 95% CI 0.20 to 0.60; I² = 24%) and NSAIDs were more effective than antispasmodics (4 studies, 299 participants: RR 0.34, 95% CI 0.14 to 0.84; I² = 65%). Combination of NSAIDs and antispasmodics was not superior to NSAIDs (7 comparisons, 589 participants: RR 0.99, 95% CI 0.62 to 1.57; I² = 10%). Indomethacin was less effective than other NSAIDs (4 studies, 517 participants: RR 1.36, 95% CI 0.96 to 1.94; I² = 14%) except for lysine acetyl salicylate (RR 0.15, 95% CI 0.04 to 0.65).Pain recurrence was reported by only three studies which could not be pooled: a higher proportion of patients treated with 75 mg diclofenac (IM) showed pain recurrence in the first 24 hours of follow-up compared to those treated with 40 mg piroxicam (IM) (60 participants: RR 0.05, 95% CI 0.00 to 0.81); no significant difference in pain recurrence at 72 hours was observed between piroxicam plus phloroglucinol and piroxicam plus placebo groups (253 participants: RR 2.52, 95% CI 0.15 to12.75); and there was no significant difference in pain recurrence within 72 hours of discharge between IM piroxicam and IV paracetamol (82 participants: RR 1.00, 95% CI 0.65 to 1.54).Side effects were presented inconsistently, but no major events were reported.
AUTHORS' CONCLUSIONS: Although due to variability in studies (inclusion criteria, outcome variables and interventions) and the evidence is not of highest quality, we still believe that NSAIDs are an effective treatment for renal colic when compared to placebo or antispasmodics. The addition of antispasmodics to NSAIDS does not result in better pain control. Data on other types of non-opioid, non-NSAID medication was scarce.Major adverse effects are not reported in the literature for the use of NSAIDs for treatment of renal colic.

PMID 26120804
M Lishner, R Lang, I Jutrin, C De-Paolis, M Ravid
Analgesic effect of ceruletide compared with pentazocine in biliary and renal colic: a prospective, controlled, double-blind study.
Drug Intell Clin Pharm. 1985 Jun;19(6):433-6.
Abstract/Text The analgesic effect of ceruletide in biliary and renal colic was evaluated by a randomized, double-blind study in 82 patients. Ceruletide was compared with pentazocine, a well-established analgetic agent. Rapid and effective analgesia was obtained by intramuscular injection of ceruletide 0.5 micrograms/kg in 56 patients with biliary colic. The analgesic effect of ceruletide compared well with pentazocine 0.5 mg/kg im, and was associated with remarkably fewer side effects. In 26 patients with renal colic, ceruletide was significantly inferior to pentazocine. These data support the recommendation of ceruletide as a first-choice analgetic agent for biliary colic.

PMID 3891284
Sung Wook Song, Kyuseok Kim, Joong Eui Rhee, Jin Hee Lee, Gil Joon Seo, Hyun Mi Park
Butylscopolammonium bromide does not provide additional analgesia when combined with morphine and ketorolac for acute renal colic.
Emerg Med Australas. 2012 Apr;24(2):144-50. doi: 10.1111/j.1742-6723.2011.01502.x. Epub 2011 Nov 28.
Abstract/Text OBJECTIVE: To evaluate the effect of adding butylscopolammonium bromide (BB) to morphine and ketorolac in the treatment of acute renal colic in the ED.
METHODS: A prospective, double-blind, randomized controlled trial of i.v. triple therapy (morphine, ketorolac and BB) versus double therapy (morphine and ketorolac) in adult ED patients with a clinical diagnosis of acute renal colic and a pain rating greater than five on a 10 cm visual analogue scale (VAS). VAS was recorded at time 0, 20 and 40 min. Patients received rescue morphine at 20 or 40 min according to the protocol if needed. We compared pain reduction and the need for rescue analgesia at 4 min between two groups.
RESULTS: Eighty-nine patients were randomized over a 13 month period. A total of 46 (51.7%) patients received BB in addition to morphine and ketorolac. The mean difference in change in pain score in the triple therapy group and double therapy group was 7.1 cm (95% CI 6.4-7.8) and 5.9 cm (95% CI 5.1-6.7), respectively (P= 0.024). Rescue morphine was required by 7/46 (15.2% [95% CI 4.4-20.6]) patients in the triple therapy group and 14/43 (32.6% [95% CI 18.0-47.1]) in the double therapy group (OR 0.37 [95% CI 0.133-1.038]).
CONCLUSIONS: Although the addition of BB to morphine and ketorolac appeared to show a statistically significant reduction in pain compared with morphine and ketorolac alone, a reduction of 1.2 cm on VAS is unlikely to be clinically significant.

© 2011 The Authors. EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.
PMID 22487663
John M Hollingsworth, Mary A M Rogers, Samuel R Kaufman, Timothy J Bradford, Sanjay Saint, John T Wei, Brent K Hollenbeck
Medical therapy to facilitate urinary stone passage: a meta-analysis.
Lancet. 2006 Sep 30;368(9542):1171-9. doi: 10.1016/S0140-6736(06)69474-9.
Abstract/Text BACKGROUND: Medical therapies to ease urinary-stone passage have been reported, but are not generally used. If effective, such therapies would increase the options for treatment of urinary stones. To assess efficacy, we sought to identify and summarise all randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat urinary stone disease.
METHODS: We searched MEDLINE, Pre-MEDLINE, CINAHL, and EMBASE, as well as scientific meeting abstracts, up to July, 2005. All randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat ureteral stones were eligible for inclusion in our analysis. Data from nine trials (number of patients=693) were pooled. The main outcome was the proportion of patients who passed stones. We calculated the summary estimate of effect associated with medical therapy use using random-effects and fixed-effects models.
FINDINGS: Patients given calcium-channel blockers or alpha blockers had a 65% (absolute risk reduction=0.31 95% CI 0.25-0.38) greater likelihood of stone passage than those not given such treatment (pooled risk ratio 1.65; 95% CI 1.45-1.88). The pooled risk ratio for alpha blockers was 1.54 (1.29-1.85) and for calcium-channel blockers with steroids was 1.90 (1.51-2.40). The proportion of heterogeneity not explained by chance alone was 28%. The number needed to treat was 4.
INTERPRETATION: Although a high-quality randomised trial is necessary to confirm its efficacy, our findings suggest that medical therapy is an option for facilitation of urinary-stone passage for patients amenable to conservative management, potentially obviating the need for surgery.

PMID 17011944
Christian Seitz, Evangelos Liatsikos, Francesco Porpiglia, Hans-Göran Tiselius, Ulrike Zwergel
Medical therapy to facilitate the passage of stones: what is the evidence?
Eur Urol. 2009 Sep;56(3):455-71. doi: 10.1016/j.eururo.2009.06.012. Epub 2009 Jun 21.
Abstract/Text CONTEXT: Medical expulsive therapy (MET) for urolithiasis has gained increasing attention in the last years. It has been suggested that the administration of alpha-adrenoreceptor antagonists (alpha-blockers) or calcium channel blockers augments stone expulsion rates and reduces colic events.
OBJECTIVE: To evaluate the efficacy and safety of MET with alpha-blockers and calcium channel blockers for upper urinary tract stones with and without prior extracorporeal shock wave lithotripsy (ESWL).
EVIDENCE ACQUISITION: A systematic review of the literature was performed in Medline, Embase, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews searched through 31 December 2008 without time limit. Efficacy and safety end points were evaluated in 47 randomised, controlled trials assessing the role of MET. Meta-analysis was conducted using Review Manager (RevMan) v.5.0 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).
EVIDENCE SYNTHESIS: Pooling of alpha-blocker and calcium channel blocker studies demonstrated a higher and faster expulsion rate compared to a control group (risk ratio [RR]: 1.45 vs 1.49; 95% confidence interval [CI]: 1.34-1.57 vs 1.33-1.66). Similar results have been obtained after ESWL (RR: 1.29 vs 1.57; 95% CI: 1.16-1.43 vs 1.21-2.04). Additionally, lower analgesic requirements, fewer colic episodes, and fewer hospitalisations were observed within treatment groups.
CONCLUSIONS: Pooled analyses suggest that MET with alpha-blockers or calcium channel blockers augments stone expulsion rates, reduces the time to stone expulsion, and lowers analgesia requirements for ureteral stones with and without ESWL for stones < or = 10 mm. There is some evidence that a combination of alpha-blockers and corticosteroids might be more effective than treatment with alpha-blockers alone. Renal stones after ESWL also seem to profit from MET. The vast majority of randomised studies incorporated into the present systematic review are small, single-centre studies, limiting the strength of our conclusions. Therefore, multicentre, randomised, placebo-controlled trials are needed.

PMID 19560860
Zhangqun Ye, Huan Yang, Hong Li, Xiaochun Zhang, Yaoliang Deng, Guohua Zeng, Lingwu Chen, Yue Cheng, Jianggen Yang, Qiwu Mi, Yonghai Zhang, Zhong Chen, Hui Guo, Wei He, Zhiqiang Chen
A multicentre, prospective, randomized trial: comparative efficacy of tamsulosin and nifedipine in medical expulsive therapy for distal ureteric stones with renal colic.
BJU Int. 2011 Jul;108(2):276-9. doi: 10.1111/j.1464-410X.2010.09801.x. Epub 2010 Nov 17.
Abstract/Text OBJECTIVE: • To determine the comparative efficacy of tamsulosin and nifedipine in medical expulsive therapy (MET) for distal ureteric stones with renal colic.
PATIENTS AND METHODS: • We evaluated the comparative efficacy of tamsulosin and nifedipine in MET in a prospective randomized trial of 3189 outpatients from 10 centres in China. • Eligible patients randomly received tamsulosin or nifedipine. Efficacies of the two agents in MET were compared at 4 weeks. • The primary endpoint was overall stone-expulsion rate. • Secondary endpoints were stone-expulsion time, rate of pain relief therapy, mean analgesic consumption for renal colic recurrence, and side-effects incidence.
RESULTS: • Stone-expulsion rates in the tamsulosin group (group 1) were greater than those in the nifedipine group (group 2; P < 0.01). • There was a significant variation in stone-expulsion rates and times between groups 1 and 2 (P < 0.01); with improvements in stone-expulsion rate and time significantly better in group 1 than in group 2. • There was a significant variation in the rate of pain relief therapy for renal colic recurrence between groups 1 and 2 (P < 0.01); patients in group 1 required significantly less analgesics than those in group 2 (P < 0.01). • There were no statistically significant differences in side-effects incidence between the groups.
CONCLUSIONS: • Administration of tamsulosin and nifedipine in MET was determined to be safe and effective for distal ureteric stones with renal colic. • Tamsulosin was significantly better than nifedipine in relieving renal colic and facilitating ureteric stone expulsion.

© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.
PMID 21083640
Miguel Arrabal-Martin, Francisco Valle-Diaz de la Guardia, Miguel Angel Arrabal-Polo, Francisco Palao-Yago, Jose Luis Mijan-Ortiz, Armando Zuluaga-Gomez
Treatment of ureteral lithiasis with tamsulosin: literature review and meta-analysis.
Urol Int. 2010;84(3):254-9. doi: 10.1159/000288224. Epub 2010 Apr 13.
Abstract/Text OBJECTIVE: Ninety percent of ureteral calculi <4 mm are expelled over a period of 3 months; if they are >6 mm the elimination possibilities are reduced to 30%. Presently, investigations in the treatment of ureteral lithiasis have the objective of modifying ureter contractibility with the aid of calcium antagonist and alpha-blocking drugs. The objective of this study is to analyze the effect of tamsulosin in the treatment of the distal ureter lithiasis and to make a systematic analysis of the literature.
PATIENTS AND METHODS: In a prospective study 70 cases of distal ureter lithiasis were divided into 2 groups: group 1 = 35 cases treated with ibuprofen (600 mg/12 h) and 2,000 ml water/24 h with tramadol on demand, and group 2 = 35 cases with the same treatment as described before plus tamsulosin 0.4 mg/day over 3 weeks. The number of stone-free patients, time to expulsion and the necessity for analgesia were evaluated. A literature review (2002-2007) and meta-analysis of 11 studies was performed. Statistical analysis included relative risk (RR), number needed to treat (NNT) and chi(2) test.
RESULTS: Group 1 reported 19 stone expulsions (54.3%) and group 2 30 expulsions [85.7%, chi(2) = 8.23 (p < 0.01), RR = 1.58, NNT = 3 (95% CI 2-9)]. The mean time to expulsion was 14 days in group 1 and 8 days in group 2. No side effects were detected. Meta-analysis included 792 patients: 392 patients in group 1 and 400 patients in group 2. Group 1 reported 211 stone expulsions (53.8%) and group 2 reported 332 expulsions [83%, chi(2) = 78.17 (p < 0.01), RR = 1.54, absolute benefit = 29.2% (95% CI 23-35.3%), NNT = 3 (95% CI 3-4)]. The mean time to expulsion was 9.45 days in group 1 and 6.07 days in group 2 treated with tamsulosin; a significant difference was observed in all studies.
CONCLUSIONS: Tamsulosin increases the elimination of distal ureter lithiasis of <10 mm.

Copyright 2010 S. Karger AG, Basel.
PMID 20389151
Thijs Campschroer, Yefang Zhu, Diederick Duijvesz, Diederick E Grobbee, M T W Tycho Lock
Alpha-blockers as medical expulsive therapy for ureteral stones.
Cochrane Database Syst Rev. 2014 Apr 2;(4):CD008509. doi: 10.1002/14651858.CD008509.pub2. Epub 2014 Apr 2.
Abstract/Text BACKGROUND: Urinary stone disease is one of the most common reasons for patients visiting a urology practice, affecting about 5% to 10% of the population. Annual costs for stone disease have rapidly increased over the years and most patients with ureteral colic or other symptoms seek medical care. Stone size and location are important predictors of stone passage. In most cases medical expulsive therapy is an appropriate treatment modality and most studies have been performed with alpha-blockers. Alpha-blockers tend to decrease intra-ureteral pressure and increase fluid passage which might increase stone passage. Faster stone expulsion will decrease the rate of complications, the need for invasive interventions and eventually decrease healthcare costs. A study on the effect of alpha-blockers as medical expulsive therapy in ureteral stones is therefore warranted.
OBJECTIVES: This review aimed to answer the following question: does medical treatment with alpha-blockers compared to other pharmacotherapy or placebo impact on stone clearance rate, in adult patients presenting with symptoms of ureteral stones less than 10 mm confirmed by imaging? Other clinically relevant outcomes such as stone expulsion time, hospitalisation, pain scores, analgesic use and adverse effects have also been explored.
SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register to 9 July 2012 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, handsearching conference proceedings, and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.
SELECTION CRITERIA: Randomised controlled trials (RCTs), comparing alpha-blockers with other pharmacotherapy or placebo on ureteral stone passage in adult patients were included.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed study quality and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Reporting bias was investigated using funnel plots. Subgroup analysis was used to explore possible sources of heterogeneity. Sensitivity analysis was performed removing studies of poor methodological quality.
MAIN RESULTS: Thirty-two studies (5864 participants) were included. The stone-free rates were significantly higher in the alpha-blocker group (RR 1.48, 95% CI 1.33 to 1.64) when compared to standard therapy. Stone expulsion time was 2.91 days shorter with the use of alpha-blockers (MD -2.91, 95% CI -4.00 to -1.81). Use of alpha-blockers reduced the number of pain episodes (MD -0.48, 95% CI -0.94 to -0.01), the need for analgesic medication (diclofenac) (MD -38.17 mg, 95% CI -74.93 to -1.41) and hospitalisation (RR 0.35, 95% CI 0.13 to 0.97). Patients using alpha-blockers were more likely to experience adverse effects when compared to standard therapy (RR 2.74, 95% CI 1.38 to 5.45) or placebo (RR 2.73, 95% CI 1.50 to 4.96). Most adverse effects were mild of origin and did not lead to cessation of therapy, and several studies reported no adverse events in either the treatment or control group.In 7/32 studies patients and doctors were both blinded. In the other studies blinding was not described in the methods or no blinding had taken place. Two studies described incomplete data and only one study showed a relatively high number of patients who withdrew from the study. These factors limited the methodological strength of the evidence found.
AUTHORS' CONCLUSIONS: The use of alpha-blockers in patients with ureteral stones results in a higher stone-free rate and a shorter time to stone expulsion. Alpha-blockers should therefore be offered as part of medical expulsive therapy as one of the primary treatment modalities.

PMID 24691989
Bo Fan, Deyong Yang, Jianbo Wang, Xiangyu Che, Xiancheng Li, Lina Wang, Feng Chen, Tiezheng Wang, Xishuang Song
Can tamsulosin facilitate expulsion of ureteral stones? A meta-analysis of randomized controlled trials.
Int J Urol. 2013 Aug;20(8):818-30. doi: 10.1111/iju.12048. Epub 2012 Dec 20.
Abstract/Text OBJECTIVES: To determine the efficacy and safety of the adrenergic alpha-antagonist tamsulosin in facilitating ureteral stones expulsion.
METHODS: A literature search was carried out using the PubMed database, Medline via Ovid, Embase and the Cochrane Library database to identify randomized controlled trials evaluating the efficiency of tamsulosin in the treatment of ureteral stones. Meta-analysis and forest plots were carried out by use of Review Manager version 5.1 software (Cochrane Collaboration).
RESULTS: Compared with the control group, the tamsulosin group had an increase in expulsion rate of 51% and a decrease in expulsion time of 2.63 days. Furthermore, tamsulosin was found to reduce the risk of ureteral colic during treatment by 40% and also the risk of requirement of auxiliary procedures during follow up by 60%. In terms of safety, the tamsulosin group had a 117% increase in the incidence of side-effects compared with the control group, especially for incidence of dizziness.
CONCLUSION: Tamsulosin facilitates the expulsion of ureteral calculi by providing a higher expulsion rate, a shorter expulsion time, a lower incidence of ureteral colic during treatment and a lower requirement of auxiliary procedures. However, the incidence of dizziness occurring during tamsulosin treatment is significantly higher in this setting.

© 2012 The Japanese Urological Association.
PMID 23278872
Kenji Ohgaki, Kazutaka Horiuchi, Norio Hikima, Yukihiro Kondo
Facilitation of expulsion of ureteral stones by addition of α1-blockers to conservative therapy.
Scand J Urol Nephrol. 2010 Dec;44(6):420-4. doi: 10.3109/00365599.2010.497769. Epub 2010 Jul 7.
Abstract/Text OBJECTIVE: An antispasmodic agent and a medicine that facilitates stone expulsion are given commonly as conservative therapy for ureteral stones in Japan. The goal of this study was to compare the efficacy of the addition of various α(1)-blockers to the conservative therapy for spontaneous passage of ureteral stones.
MATERIAL AND METHODS: The subjects were 132 patients with stones from the upper to the lower ureter who were randomly placed into one of four groups and followed for 1 month to assess spontaneous passage of stones. The control group received daily doses of 240 mg flopropione as an antispasmodic agent and 1350 mg extract of Quercus salicina Blume/Quercus stenophylla Makino as a medicine that facilitates stone expulsion. The other three groups received this therapy and daily doses of 30 mg urapidil, 0.2 mg tamsulosin or 50 mg naftopidil, respectively. The characteristics of the stones and stone expulsion were evaluated by urinalysis, a kidney, ureter and bladder (KUB) X-ray, ultrasound and computed tomography.
RESULTS: All patients completed the study and there were no major side-effects. There was no difference in age, stone position or stone size among the groups. Multivariate analysis using a Cox proportional hazards model indicated that the probability of stone expulsion for 1 month was increased 2.38 times (95% confidence interval 1.23-4.61) by naftopidil compared with control therapy alone (p = 0.01).
CONCLUSION: Naftopidil in combination with an antispasmodic agent and a medicine that facilitates stone expulsion produces a significantly increased rate of ureteral stone expulsion.

PMID 20604720
Yasuo Tsuzaka, Hisashi Matsushima, Tomoyuki Kaneko, Tsuyoshi Yamaguchi, Yukio Homma
Naftopidil vs silodosin in medical expulsive therapy for ureteral stones: a randomized controlled study in Japanese male patients.
Int J Urol. 2011 Nov;18(11):792-5. doi: 10.1111/j.1442-2042.2011.02850.x. Epub 2011 Sep 14.
Abstract/Text The aim of the present study was to compare the efficacy of the selective α(1D) -adrenoceptor antagonist naftopidil and the selective α(1A) -adrenoceptor antagonist silodosin (as an example) in the management of ureteral stones in Japanese male patients. A total of 74 patients with symptomatic ≤ 10 mm ureteral stones were enrolled in a prospective study and randomized into two groups: Group 1 received 50 mg naftopidil daily, whereas Group 2 received 8 mg silodosin daily. Patients were followed-up for up to 6 weeks. The primary endpoint was stone expulsion rate and secondary endpoints were stone expulsion time, the rate of interventions, such as transurethral ureterolithotripsy, extracorporeal shock wave lithotripsy, or ureteral stenting, and side effects. There were no significant differences between the two groups with respect to age, stone size, and location. The stone expulsion rate was 61% and 84% in the naftopidil and silodosin groups, respectively (P = 0.038). No significant differences were noted in stone expulsion time or the rate of interventions between the two groups. The findings suggest that α(1A)-adrenoceptor blockade was clinically superior for stone expulsion our study population.

© 2011 The Japanese Urological Association.
PMID 21917021
Marco Dellabella, Giulio Milanese, Giovanni Muzzonigro
Randomized trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi.
J Urol. 2005 Jul;174(1):167-72. doi: 10.1097/01.ju.0000161600.54732.86.
Abstract/Text PURPOSE: Recent studies show the interesting efficacy of different drug combinations for the spontaneous expulsion of distal ureteral stones. We performed a randomized, prospective study to assess and compare the efficacy of 3 drugs as medical expulsive therapy for distal ureteral calculi.
MATERIALS AND METHODS: A total of 210 symptomatic patients with distal ureteral calculi greater than 4 mm were randomly allocated to home treatment with phloroglucinol, tamsulosin or nifedipine (groups 1 to 3, respectively). Each group was given a corticosteroid drug and antibiotic prophylaxis with an injectable nonsteroidal anti-inflammatory drug was also used on demand. The primary end point was the expulsion rate and the secondary end points were expulsion time, analgesic use, need for hospitalization and endoscopic treatment as well as the number of workdays lost, quality of life and drug side effects
RESULTS: The expulsion rate was significantly higher in group 2 (97.1%) than in groups 1 (64.3%, p <0.0001) or 3 (77.1%, p <0.0001). Group 2 significantly achieved stone passage in a shorter time than the other 2 groups and showed a significantly decreased number of hospitalizations as well as a better decrease in endoscopic procedures performed to remove the stone. The control of renal colic pain was significantly superior in group 2 compared with the other groups, resulting in fewer workdays lost. Group 3 showed lower analgesic use and decreased workdays lost compared with group 1. No difference in side effects was observed among the groups.
CONCLUSIONS: Medical expulsive therapy should be considered for distal ureterolithiasis without complications before ureteroscopy or extracorporeal lithotripsy. The use of tamsulosin in this treatment regimen produced stone expulsion in almost all cases in a short time, allowing complete home patient treatment.

PMID 15947613
Michelle Jo Semins, Bruce J Trock, Brian R Matlaga
The effect of shock wave rate on the outcome of shock wave lithotripsy: a meta-analysis.
J Urol. 2008 Jan;179(1):194-7; discussion 197. doi: 10.1016/j.juro.2007.08.173. Epub 2007 Nov 14.
Abstract/Text PURPOSE: Although experimental evidence suggests that the rate of shock wave delivery can affect the outcome of shock wave lithotripsy, clinical studies produce conflicting results. We performed a systematic review and meta-analysis to define the effect of shock wave rate on the outcome of shock wave lithotripsy.
MATERIALS AND METHODS: A search of MEDLINE and EMBASE was performed and all randomized controlled trials comparing SWL treatment at 60 shocks per minute to 120 shocks per minute were included in the analysis. Data from 4 trials (589 patients) were pooled. The primary outcome measure was treatment outcome (success, failure), as defined by the authors of the source studies. The difference in the proportion of patients with a successful treatment outcome was compared between the 60 and 120 shocks per minute groups as a risk difference, and risk differences were pooled across the 4 trials with a fixed effects model.
RESULTS: Patients treated at a rate of 60 shocks per minute had a significantly greater likelihood of a successful treatment (risk difference 10.2, 95% CI 3.7-16.8, p = 0.002).
CONCLUSIONS: Our meta-analysis suggests that patients treated at a rate of 60 shocks per minute have a significantly greater likelihood of a successful treatment outcome than patients treated at a rate of 120 shocks per minute.

PMID 18001796
Kenneth T Pace, Daniela Ghiculete, Melanie Harju, R John D'A Honey, University of Toronto Lithotripsy Associates
Shock wave lithotripsy at 60 or 120 shocks per minute: a randomized, double-blind trial.
J Urol. 2005 Aug;174(2):595-9. doi: 10.1097/01.ju.0000165156.90011.95.
Abstract/Text PURPOSE: The rate of shock wave administration is a factor in the per shock efficiency of shock wave lithotripsy (SWL). Experimental evidence suggests that decreasing shock wave frequency from 120 shocks per minute results in improved stone fragmentation. To our knowledge this study is the first to examine the effect of decreased shock wave frequency in patients with renal stones.
MATERIALS AND METHODS: Patients with previously untreated radiopaque stones in the renal collecting system were randomized to SWL at 60 or 120 shocks per minute. They were followed at 2 weeks and 3 months. The primary outcome was the success rate, defined as stone-free status or asymptomatic fragments less than 5 mm 3 months after treatment.
RESULTS: A total of 220 patients were randomized, including 111 to 60 shocks per minute and 109 to 120 shocks per minute. The 2 groups were comparable in regard to age, sex, body mass index, stent status and initial stone area. The success rate was higher for 60 shocks per minute (75% vs 61%, p = 0.027). Patients with larger stones (stone area 100 mm or greater) experienced a greater benefit with treatment at 60 shocks per minute. The success rate was 71% for 60 shocks per minute vs 32% (p = 0.002) and the stone-free rate was 60% vs 28% (p = 0.015). Repeat SWL was required in 32% of patients treated with 120 shocks per minute vs 18% (p = 0.018). Fewer shocks were required with 60 shocks per minute (2,423 vs 2,906, p <0.001) but treatment time was longer (40.6 vs 24.2 minutes, p <0.001). There was a trend toward fewer complications with 60 shocks per minute (p = 0.079).
CONCLUSIONS: SWL treatment at 60 shocks per minute yields better outcomes than at 120 shocks per minute, particularly for stones 100 mm or greater, without any increase in morbidity and with an acceptable increase in treatment time.

PMID 16006908
Khaled Madbouly, Abdel Moneim El-Tiraifi, Mohamed Seida, Salah R El-Faqih, Ramiz Atassi, Riyadh F Talic
Slow versus fast shock wave lithotripsy rate for urolithiasis: a prospective randomized study.
J Urol. 2005 Jan;173(1):127-30. doi: 10.1097/01.ju.0000147820.36996.86.
Abstract/Text PURPOSE: We determined the effect of shock wave lithotripsy (SWL) rate on treatment outcome in patients with renal and ureteral stones.
MATERIALS AND METHODS: A total of 156 patients were prospectively randomized to receive SWL using a slow (60 pulses per minute) or fast wave rate (120 pulses per minute). Inclusion criteria were patients with a single radiopaque renal or ureteral stone not exceeding 30 mm in maximum diameter. Patient characteristics, stone and therapy features were reviewed, and the relation to success rate and total number of shock waves required was assessed using the chi-square, Fisher exact and Mann-Whitney tests. Factors proven to be significant in univariate analysis were entered in a multivariate logistic regression analysis.
RESULTS: The study included 114 male (73.1%) and 42 female (26.9%) patients with a mean age +/- SD of 42.1 +/- 13.3 years. Stone length measured in maximum diameter was 13.2 +/- 5.9 mm (range 5 to 30). Renal stones were encountered in 94 (60.3%) patients and ureteral stones in 62 (39.7%). The slow SWL rate was used in 76 (48.7%) patients and the fast rate in 80 (51.3%). Baseline variables were comparable in both groups. However, the total number of shock waves required was statistically significantly lower in the slow rate group (p = 0.004) and the treatment time was significantly longer (p = 0.000). The rate of success, defined as being completely stone-free or having clinically insignificant gravel less than 2 mm, was significantly higher with the slow rate (p = 0.034), an increased number of sessions (p = 0.001), decreased stone length (p = 0.000) and greater total number of shock waves (p = 0.011). However, only the slow SWL rate and stone length maintained a statistically significant impact in multivariate analysis.
CONCLUSIONS: The slow SWL rate is associated with a significantly higher success rate at a lower number of total shock waves compared to the fast SWL rate.

PMID 15592053
Erdal Yilmaz, Ertan Batislam, Murad Basar, Devrim Tuglu, Cagatay Mert, Halil Basar
Optimal frequency in extracorporeal shock wave lithotripsy: prospective randomized study.
Urology. 2005 Dec;66(6):1160-4. doi: 10.1016/j.urology.2005.06.111.
Abstract/Text OBJECTIVES: To determine the optimal frequency of extracorporeal shock wave lithotripsy of urolithiasis, in terms of efficacy and duration, by comparing three different shock wave frequencies.
METHODS: A total of 170 patients between the ages of 18 and 69 years with radiopaque kidney stones were included in the study. The patients were randomly separated into three groups. Group 1 (56 patients) received 120 shock waves per minute, group 2 (57 patients) received 90 shock waves per minute, and group 3 (57 patients) received 60 shock waves per minute. The duration, analgesic or sedative requirement, and complications were recorded for each treatment. All patients were evaluated in terms of successful treatment by radiography of the kidneys, ureters, and bladder and abdominal ultrasonography 10 days after the single-session therapy.
RESULTS: No statistically significant difference was observed in patients according to age, sex, stone size, side, composition, location in the kidney, total energy level, or number of shocks. The successful therapy rate in groups 2 and 3 was prominently greater compared with that for group 1, and the difference was statistically significant (P = 0.032 between groups 1 and 2 and P = 0.015 between groups 1 and 3). The analgesic or sedative requirement in groups 2 and 3 was lower than that in group 1, and the difference was statistically significant (P = 0.003 between groups 1 and 2 and P = 0.001 between groups 1 and 3). The duration was longer in group 3 than in groups 1 and 2, and the difference was statistically significant (P = 0.000 between groups 1 and 3 and P = 0.009 between groups 2 and 3).
CONCLUSIONS: The results of our study have shown that the optimal frequency during extracorporeal shock wave lithotripsy is 90 shock waves per minute in terms of duration, efficacy, and analgesic and sedative requirement at the same total energy level.

PMID 16360432
Kim Davenport, Andrea Minervini, Stephen Keoghane, John Parkin, Francis X Keeley, Anthony G Timoney
Does rate matter? The results of a randomized controlled trial of 60 versus 120 shocks per minute for shock wave lithotripsy of renal calculi.
J Urol. 2006 Nov;176(5):2055-8; discussion 2058. doi: 10.1016/j.juro.2006.07.012.
Abstract/Text PURPOSE: In this study we prospectively compared 2 rates of shock wave delivery, 60 and 120 shock waves per minute, to determine whether rate affects outcome with the Dornier Lithotripter S, a lithotriptor with an electromagnetic shock wave source, for renal calculi.
MATERIALS AND METHODS: A total of 104 patients with uncomplicated single renal calculus were randomized and treated. Following a single treatment patients were reviewed at 3 months to determine outcome. A plain abdominal x-ray was performed and the size of any residual fragments was noted. Four patients were lost to followup, 1 in the 60 shock waves per minute group and 3 in the 120 shock waves per minute group.
RESULTS: Of the 100 patients with complete followup 49 were treated at 60 shock waves per minute and 51 at 120 shock waves per minute. There was no statistically significant difference between mean stone area treated (p = 0.32) or additional analgesic use in the form of patient controlled alfentanil (p = 0.82). A successful outcome was defined by fragments smaller than 4 mm or stone-free status. At 60 shock waves per minute 59% of patients had a successful outcome compared with 61% at 120 shock waves per minute (p = 0.87) following a single treatment. Post-treatment complications were similar in both groups at 8% for 120 shock waves per minute and 10% for 60 shock waves per minute (p = 0.68).
CONCLUSIONS: There was no significant difference in patient controlled analgesia use, complications or outcome between rates 60 and 120. Contrary to previous studies these results suggest that a slower rate of shock wave delivery during extracorporeal shock wave lithotripsy for renal calculi does not improve treatment efficacy with the Dornier Lithotripter S.

PMID 17070254
Daniel P Nguyen, Stefanie Hnilicka, Bernhard Kiss, Roland Seiler, George N Thalmann, Beat Roth
Optimization of Extracorporeal Shock Wave Lithotripsy Delivery Rates Achieves Excellent Outcomes for Ureteral Stones: Results of a Prospective Randomized Trial.
J Urol. 2015 Aug;194(2):418-23. doi: 10.1016/j.juro.2015.01.110. Epub 2015 Feb 7.
Abstract/Text PURPOSE: Management of ureteral stones remains controversial. To determine whether optimizing the extracorporeal shock wave lithotripsy delivery rate would improve the treatment of solitary ureteral stones we compared the outcomes of 2 delivery rates in a prospective randomized trial.
MATERIALS AND METHODS: From July 2010 to October 2012, 254 consecutive patients were randomized to extracorporeal shock wave lithotripsy at a shock wave delivery rate of 60 and 90 pulses per minute in 130 and 124, respectively. The primary study end point was the stone-free rate at 3-month followup. Secondary end points were stone disintegration, treatment time, complications and the rate of secondary treatments. Descriptive statistics were used to compare end points between the 2 groups. The adjusted OR and 95% CI were calculated to assess predictors of success.
RESULTS: The stone-free rate at 3 months was significantly higher in patients who underwent extracorporeal shock wave lithotripsy at a shock wave delivery rate of 90 pulses per minute than in those who received 60 pulses per minute (91% vs 80%, p = 0.01). Patients with proximal (100% vs 83%, p = 0.005) and mid ureteral stones (96% vs 73%, p = 0.03) accounted for the observed difference but not those with distal ureteral stones (81% vs 80%, p = 0.9, respectively). Treatment time, complications and the rate of secondary treatments were comparable between the 2 groups. On multivariable analysis the shock wave delivery rate of 90 pulses per minute, proximal stone location, stone density, stone size and an absent indwelling Double-J® stent were independent predictors of success.
CONCLUSIONS: Optimizing the extracorporeal shock wave lithotripsy delivery rate can achieve excellent results for ureteral stones.

Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
PMID 25661296
N F Logarakis, M A Jewett, J Luymes, R J Honey
Variation in clinical outcome following shock wave lithotripsy.
J Urol. 2000 Mar;163(3):721-5.
Abstract/Text PURPOSE: We measure and compare operator specific success rates of extracorporeal shock wave lithotripsy (ESWL) performed by 12 urologists in 1 unit to determine interoperator variation.
MATERIALS AND METHODS: From January 1, 1994 to September 1, 1997 a total of 5,769 renal and ureteral stones received 9,607 ESWL treatments by 15 urologists with a Dornier MFL 5000 lithotriptor. The 3-month followup data are available for 4,409 stones. Outcome measures consisted of patient demographics, stone characteristics, technical details of lithotripsy, and stone-free and success rates by treating urologists.
RESULTS: Treatment results were analyzed for 12 urologists (surgeons A to L) who treated more than 100 stones each, totaling 4,244 with followup information available. Mean stone-free and success rates were 50.6% and 72.3%, respectively. Surgeon A had significantly higher stone-free and success rates of 56.2% and 76.7%, respectively (p<0.05), with treatment results from 877 stones, which was a significantly higher number than others (p<0.05). Significant differences existed in mean number of shocks delivered among urologists (p = 0.0001), with surgeons A and J delivering the highest mean numbers (2,317 and 2,801, respectively). There was no difference in treatment duration (p = 0.75) but variation existed among urologists in terms of mean maximum treatment voltage (p = 0.0001). Mean fluoroscopy time at 4.1 minutes was higher for surgeon A than others (p<0.05). Mean complication rate following ESWL was 4.9% with no difference among urologists (p = 0.175). Re-treatment was required in 21.7% of cases and surgeon A had the lowest rate (15.9%, p<0.05).
CONCLUSIONS: We demonstrated clinically and statistically significant intra-institutional differences in success rates following ESWL. The best results were obtained by the urologist who treated the greatest number of patients, used a high number of shocks and had the longest fluoroscopy time. Accurate targeting is crucial when using a lithotriptor, such as the Dornier MFL 5000, with a narrow focal zone of 6.5 mm. in diameter. Other centers should be encouraged to develop similar programs of outcome analysis in an attempt to improve performance.

PMID 10687964
P M Knapp, T B Kulb, J E Lingeman, D M Newman, J H Mertz, P G Mosbaugh, R E Steele
Extracorporeal shock wave lithotripsy-induced perirenal hematomas.
J Urol. 1988 Apr;139(4):700-3.
Abstract/Text Subcapsular or perirenal bleeding is the most commonly experienced adverse effect directly attributable to externally applied shock waves. The first consecutive 3,620 extracorporeal shock wave lithotripsy treatments with the HM3 Dornier lithotriptor at our institution resulted in 24 hematomas in 21 patients, for an incidence of 0.66 per cent. Various factors associated with treatment were examined. The number of shock waves (up to 2,000) and voltage up to 24 kv. did not correlate with the development of hematoma. Coagulation studies were normal in all patients with hematomas. There was no correlation of patients size and weight, or stone size, number or location with the occurrence rate of perinephric hematoma. Patients with pre-existing hypertension, particularly those with unsatisfactory control of hypertension, had a significantly increased incidence of perinephric hematoma. The incidence of hematoma in hypertensive patients was 2.5 per cent and it increased to 3.8 per cent in patients with unsatisfactory control of hypertension. Therefore, pre-existing hypertension is a significant risk factor in the occurrence of post-extracorporeal shock wave lithotripsy bleeding. The incidence of perinephric hematoma also was increased in patients with pre-treatment urinary tract infection and those who underwent simultaneous bilateral treatment. Management of post-extracorporeal shock wave lithotripsy bleeding generally is conservative although a third of the patients required transfusion.

PMID 3352025
Yong Bum Jang, Kyung Pyo Kang, Sik Lee, Won Kim, Myung Ki Kim, Young Gon Kim, Sung Kwang Park
Treatment of subcapsular haematoma, a complication of extracorporeal shock wave lithotripsy (ESWL), by percutaneous drainage.
Nephrol Dial Transplant. 2006 Apr;21(4):1117-8. doi: 10.1093/ndt/gfk002. Epub 2005 Dec 19.
Abstract/Text
PMID 16364989
Feza Karakayali, Sinasi Sevmiş, Ibrahim Ayvaz, Ilteriş Tekin, Fatih Boyvat, Gökhan Moray
Acute necrotizing pancreatitis as a rare complication of extracorporeal shock wave lithotripsy.
Int J Urol. 2006 May;13(5):613-5. doi: 10.1111/j.1442-2042.2006.01366.x.
Abstract/Text Extracorporeal shock wave lithotripsy (ESWL) is considered the standard treatment for most renal and upper ureteral stones. Some centers use ESWL to treat bile duct stones and pancreatic calculi. Although ESWL is generally considered safe and effective, major complications, including acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury, rupture of an aortic aneurysm and intracranial hemorrhage, have been reported to occur in less than 1% of patients. Here, we present an extremely rare case of acute necrotizing pancreatitis occurring after ESWL for a right-sided urinary stone, which was treated by non-operative percutaneous interventions.

PMID 16771736
Shun-Fa Hung, Shiu-Dong Chung, Shuo-Meng Wang, Hong-Jeng Yu, Ho-Shiang Huang
Chronic kidney disease affects the stone-free rate after extracorporeal shock wave lithotripsy for proximal ureteric stones.
BJU Int. 2010 Apr;105(8):1162-7. doi: 10.1111/j.1464-410X.2009.08974.x. Epub 2009 Nov 20.
Abstract/Text OBJECTIVE: To investigate the effect of renal function on the stone-free rate (SFR) of proximal ureteric stones (PUS) after extracorporeal shock wave lithotripsy (ESWL), as urinary obstruction caused by PUS can impair renal function, and elevated serum creatinine levels are associated with decreased ureteric stone passage.
PATIENTS AND METHODS: From January 2005 to December 2007, 1534 patients had ESWL for urolithiasis, 319 having ESWL in situ for PUS; they were reviewed retrospectively. Patients requiring simultaneous treatment of kidney stones, placement of a double pigtail stent, or percutaneous pigtail nephrostomy tube were excluded. We divided patients into groups by chronic kidney disease (CKD) stage according to the estimated glomerular filtration rate (eGFR) of ≥ 60 and <60 mL/min/1.73 m(2). Stone-free status was defined as no visible stone fragments on a plain abdominal film at 3 months after ESWL. A logistic regression model was used to evaluate the possible significant factors that influenced the SFR of PUS after ESWL, and to develop a prediction model.
RESULTS: The overall SFR of PUS (276/319 patients) was 86.5%; the SFR was 93% in patients with an eGFR of ≥ 60 and 50% in those with an eGFR of <60 (P < 0.001). After univariate and multivariate analysis, the three significant factors affecting SFR were an eGFR of ≥ 60, stone width, and gender, with odds ratios (95% confidence intervals) of 19.54 (8.25-46.30) (P < 0.001), 0.67 (0.55-0.82) (P < 0.001) and 0.16 (0.05-0.50 (P = 0.002), respectively. A logistic regression model was developed to estimate the probability of SFR after ESWL, the equation being 1/(1 + exp [-(3.8137 - 0.3967 × (stone width) + 2.9724 × eGFR - 1.8120 × Male)]), where stone width is the observed value (mm), eGFR = 1 for eGFR ≥ 60 and 0 for <60, and male = 1 for male, 0 for female.
CONCLUSIONS: Gender, eGFR ≥ 60 and a stone width of >7 mm were significant predictors affecting the SFR after one session of ESWL for PUS.

© 2009 THE AUTHORS. JOURNAL COMPILATION © 2009 BJU INTERNATIONAL.
PMID 19930180
Shen Pengfei, Li Yutao, Yang Jie, Wei Wuran, Dai Yi, Zeng Hao, Wang Jia
The results of ureteral stenting after ureteroscopic lithotripsy for ureteral calculi: a systematic review and meta-analysis.
J Urol. 2011 Nov;186(5):1904-9. doi: 10.1016/j.juro.2011.06.066. Epub 2011 Sep 23.
Abstract/Text PURPOSE: We evaluated the necessity and adverse effects of routine ureteral stent placement after ureteroscopic lithotripsy for ureteral stones.
MATERIALS AND METHODS: A systematic search of PubMed®, Embase® and the Cochrane Library was performed to identify all randomized controlled trials. All relevant studies were on the outcomes and complications of ureteroscopic lithotripsy in the management of ureteral stones with or without a Double-J stent. The outcomes and complications included stone-free rate, operative time, lower urinary tract symptoms, hematuria, fever, urinary tract infection, pain and analgesia, unplanned medical visits and late postoperative complications. The Cochrane Collaboration Review Manager software (RevMan 5.0.2) was used for statistical analysis.
RESULTS: A total of 16 randomized controlled trials were enrolled for analysis and involved 1,573 patients. Of these patients 797 were in the nonstented group and 776 in the stented group. There was a statistically significant difference in mean operative time between the 2 groups. The incidence of lower urinary tract symptoms and pain was significantly higher in the stented group than in the nonstented group. Significant differences between the groups were not found in fever, urinary tract infection, need for analgesia, unplanned readmission and late postoperative complications.
CONCLUSIONS: This systematic review reveals the obvious disadvantages of ureteral stents after ureteroscopic lithotripsy in lower urinary tract symptoms and pain. Stents do not improve stone-free rate, fever, incidence of urinary tract infection, unplanned medical visits, requirement for analgesia and late postoperative complications. Ureteral stenting after uncomplicated ureteroscopic lithotripsy could be unnecessary.

Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
PMID 21944085
Petrişor Geavlete, Dragoş Georgescu, Gheorghe Niţă, Victor Mirciulescu, Victor Cauni
Complications of 2735 retrograde semirigid ureteroscopy procedures: a single-center experience.
J Endourol. 2006 Mar;20(3):179-85. doi: 10.1089/end.2006.20.179.
Abstract/Text BACKGROUND AND PURPOSE: Ureteroscopy is nowadays one of the techniques most widely used for upper urinary- tract pathology. Our goal is to describe its complications in a large series of patients.
PATIENTS AND METHODS: Between June 1994 and February 2005, 2436 patients aged 5 to 87 years underwent retrograde ureteroscopy (2735 procedures) under video and fluoroscopic assistance. We used semirigid ureteroscopes (8/9.8F Wolf, 6.5F Olympus, 8F and 10F Storz) for 384 diagnostic and 2351 therapeutic procedures. Upper urinary-tract lithiasis (2041 cases), ureteropelvic junction stenosis (95 cases), benign ureteral stenosis (29 cases), tumoral extrinsic ureteral stenosis (84 cases), iatrogenic trauma (35 cases), superficial ureteral tumors (16 cases), superficial pelvic tumors (7 cases), and ascending displaced stents (44 cases) were the indications. The mean follow-up period was 56 months (range 4-112 months).
RESULTS: The rate of intraoperative incidents was 5.9% (162 cases). Intraoperative incidents consisted of the impossibility of accessing calculi (3.7%), trapped stone extractors (0.7%), equipment damage (0.7%), and double- J stent malpositioning (0.76%). In addition, migration of calculi or stone fragments during lithotripsy was apparent in 116 cases (4.24%). The general rate of intraoperative complications was 3.6% (98 cases). We also saw mucosal injury (abrasion [1.5%] or false passage [1%]), ureteral perforation (0.65%), extraureteral stone migration (0.18%), bleeding (0.1%), and ureteral avulsions (0.11%). Early complications were described in 10.64%: fever or sepsis (1.13%), persistent hematuria (2.04%), renal colic (2.23%), migrated double-J stent (0.66%), and transitory vesicoureteral reflux (4.58%, especially in cases with indwelling double-J stents). We also found late complications such as ureteral stenosis (3 cases) and persistent vesicoureteral reflux (2 cases). Most (87%) of the complications followed ureteroscopic therapy for stones. Three fourths (76%) of the complications occurred in the first 5 years of the series.
CONCLUSIONS: According to our experience, mastery of ureteroscopic technique allows the urologist to proceed endourologically with minimum morbidity. Despite the new smaller semirigid instruments, this minimally invasive maneuver may sometimes be aggressive, and adequate training is imperative.

PMID 16548724
Shuba De, Riccardo Autorino, Fernando J Kim, Homayoun Zargar, Humberto Laydner, Raffaele Balsamo, Fabio C Torricelli, Carmine Di Palma, Wilson R Molina, Manoj Monga, Marco De Sio
Percutaneous nephrolithotomy versus retrograde intrarenal surgery: a systematic review and meta-analysis.
Eur Urol. 2015 Jan;67(1):125-37. doi: 10.1016/j.eururo.2014.07.003. Epub 2014 Jul 23.
Abstract/Text CONTEXT: Recent advances in technology have led to the implementation of mini- and micro-percutaneous nephrolithotomy (PCNL) as well as retrograde intrarenal surgery (RIRS) in the management of kidney stones.
OBJECTIVE: To provide a systematic review and meta-analysis of studies comparing RIRS with PCNL techniques for the treatment of kidney stones.
EVIDENCE ACQUISITION: A systematic literature review was performed in March 2014 using the PubMed, Scopus, and Web of Science databases to identify relevant studies. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. A subgroup analysis was performed comparing standard PCNL and minimally invasive percutaneous procedures (MIPPs) including mini-PCNL and micro-PCNL with RIRS, separately.
EVIDENCE SYNTHESIS: Two randomised and eight nonrandomised studies were analysed. PCNL techniques provided a significantly higher stone-free rate (weighted mean difference [WMD]: 2.19; 95% confidence interval [CI], 1.53-3.13; p<0.00001) but also higher complication rates (odds ratio [OR]: 1.61; 95% CI, 1.11-2.35; p<0.01) and a larger postoperative decrease in haemoglobin levels (WMD: 0.87; 95% CI, 0.51-1.22; p<0.00001). In contrast, RIRS led to a shorter hospital stay (WMD: 1.28; 95% CI, 0.79-1.77; p<0.0001). At subgroup analysis, RIRS provided a significantly higher stone-free rate than MIPPs (WMD: 1.70; 95% CI, 1.07-2.70; p=0.03) but less than standard PCNL (OR: 4.32; 95% CI, 1.99-9.37; p=0.0002). Hospital stay was shorter for RIRS compared with both MIPPs (WMD: 1.11; 95% CI, 0.39-1.83; p=0.003) and standard PCNL (WMD: 1.84 d; 95% CI, 0.64-3.04; p=0.003).
CONCLUSIONS: PCNL is associated with higher stone-free rates at the expense of higher complication rates, blood loss, and admission times. Standard PCNL offers stone-free rates superior to those of RIRS, whereas RIRS provides higher stone free rates than MIPPs. Given the added morbidity and lower efficacy of MIPPs, RIRS should be considered standard therapy for stones <2 cm until appropriate randomised studies are performed. When flexible instruments are not available, standard PCNL should be considered due to the lower efficacy of MIPPs.
PATIENT SUMMARY: We searched the literature for studies comparing new minimally invasive techniques for the treatment of kidney stones. The analysis of 10 available studies shows that treatment can be tailored to the patient by balancing the advantages and disadvantages of each technique.

Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
PMID 25064687
Christian Seitz, Mahesh Desai, Axel Häcker, Oliver W Hakenberg, Evangelos Liatsikos, Udo Nagele, David Tolley
Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy.
Eur Urol. 2012 Jan;61(1):146-58. doi: 10.1016/j.eururo.2011.09.016. Epub 2011 Sep 28.
Abstract/Text CONTEXT: Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus.
OBJECTIVE: To review the epidemiology of complications and their prevention and management.
EVIDENCE ACQUISITION: A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications.
EVIDENCE SYNTHESIS: Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproducible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or interventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but potentially debilitating complications are scarce and consist mainly of case reports.
CONCLUSIONS: Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials.

Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
PMID 21978422
Gaston Labate, Pranjal Modi, Anthony Timoney, Luigi Cormio, Xiaochun Zhang, Michael Louie, Magnus Grabe, Jean Rosette On Behalf Of The Croes Pcnl Study Group
The percutaneous nephrolithotomy global study: classification of complications.
J Endourol. 2011 Aug;25(8):1275-80. doi: 10.1089/end.2011.0067. Epub 2011 Jul 13.
Abstract/Text PURPOSE: This study evaluated postoperative complications of percutaneous nephrolithotomy (PCNL) and the influence of selected factors on the risk of complications using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database.
PATIENTS AND METHODS: The CROES PCNL Global Study collected prospective data for consecutive patients who were treated with PCNL at centers around the world for 1 year. Complications were evaluated by the modified Clavien classification system.
RESULTS: Of 5724 patients with Clavien scores, 1175 (20.5%) patients experienced one or more complications. The most frequent complications were fever and bleeding. Urinary leakage, hydrothorax, hematuria, urinary tract infection, pelvic perforation, and urinary fistula also occurred in ≥20 patients in each group. The majority of complications (n=634, 54.0%) were classified as Clavien grade I. Two patients died in the postoperative period. The largest absolute increases in mean Clavien score were associated with American Society of Anesthesiologists (ASA) physical status classification IV (0.75) or III (0.34), anticoagulant medication use (0.29), positive microbiologic culture from urine (0.24), and the presence of concurrent cardiovascular disease (0.15). Multivariate regression analysis revealed that operative time and ASA score were significant predictors of higher mean Clavien scores.
CONCLUSION: The majority of complications after PCNL are minor. Longer operative time and higher ASA scores are associated with the risk of more severe postoperative complications in PCNL.

PMID 21751882
Antonio Corrêa Lopes Neto, Fernando Korkes, Jarques Lúcio Silva, Rodrigo Dal Moro Amarante, Mario H Elias Mattos, Marcos Tobias-Machado, Antonio Carlos Lima Pompeo
Prospective randomized study of treatment of large proximal ureteral stones: extracorporeal shock wave lithotripsy versus ureterolithotripsy versus laparoscopy.
J Urol. 2012 Jan;187(1):164-8. doi: 10.1016/j.juro.2011.09.054. Epub 2011 Nov 17.
Abstract/Text PURPOSE: The best treatment modalities for large proximal ureteral stones are controversial, and include extracorporeal shock wave lithotripsy, ureterolithotripsy, percutaneous nephrolithotripsy, laparoscopic ureterolithotomy and open surgery. To the best of our knowledge extracorporeal shock wave lithotripsy, semirigid ureterolithotripsy and laparoscopic ureterolithotomy have not been previously compared for the treatment of large proximal ureteral stones. Therefore, we compared these modalities for the treatment of large proximal ureteral stones.
MATERIALS AND METHODS: A total of 48 patients with large proximal ureteral stones (greater than 1 cm) were prospectively randomized and enrolled in the study at a single institution between 2008 and 2010. Eligible patients were assigned to extracorporeal shock wave lithotripsy, semirigid ureterolithotripsy or laparoscopic ureterolithotomy.
RESULTS: Extracorporeal shock wave lithotripsy had a 35.7% success rate, semirigid ureterolithotripsy 62.5% and laparoscopic ureterolithotomy 93.3%. Stone-free rates showed a statistically significant difference among the groups (p = 0.005). Patients treated with laparoscopic ureterolithotomy vs semirigid ureterolithotripsy vs extracorporeal shock wave lithotripsy required fewer treatment sessions (mean ± SD 1.9 ± 0.3 vs 2.2 ± 0.6 vs 2.9 ± 1.4, p = 0.027). Neither major nor long-term complications were observed.
CONCLUSIONS: Proximal ureteral stone treatment requires multiple procedures until complete stone-free status is achieved. Laparoscopic ureterolithotomy is associated with higher success rates and fewer surgical procedures, but with more postoperative pain, longer procedures and a longer hospital stay. Although it is associated with the highest success rates for large proximal ureteral calculi, laparoscopic ureterolithotomy remains a salvage, second line procedure, and it seems more advantageous than open ureterolithotomy. At less well equipped centers, where semirigid ureterolithotripsy or extracorporeal shock wave lithotripsy is not available, it remains a good treatment option.

Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
PMID 22100003
Abbas Basiri, Nasser Simforoosh, Amirmohsen Ziaee, Hamid Shayaninasab, Seyed Mohamad Mehdi Hosseini Moghaddam, Samad Zare
Retrograde, antegrade, and laparoscopic approaches for the management of large, proximal ureteral stones: a randomized clinical trial.
J Endourol. 2008 Dec;22(12):2677-80. doi: 10.1089/end.2008.0095.
Abstract/Text BACKGROUND AND PURPOSE: Multiple procedures have been introduced for the management of urinary stones in the upper ureter. In this randomized clinical trial, we compared three surgical options in this regard.
PATIENTS AND METHODS: From September 2004 to May 2006, we enrolled in the study 150 patients with upper ureteral stones who were referred to our center. We included patients with a stone size >or= 1.5 cm in the greatest diameter. Using the random table, patients were divided into three 50-patient groups by treatment: Group A, retrograde ureteroscopic lithotripsy using a semirigid ureteroscope; group B, transperitoneal laparoscopic ureterolithotomy; and group C, percutaneous nephrolithotripsy. All procedures were performed in a training program.
RESULTS: The stone-free rates for patients in groups A, B, and C, at discharge and 3 weeks later, were 56%, 88% and 64% and 76%, 90% and 86%, respectively. Conversion to open surgery and repeated laparoscopy was necessary for two and one patients in group B. Urinary leakage continued more than 3 days in eight (16%) and nine (18%) patients in groups B and C after operation, respectively (P = 0.7).
CONCLUSIONS: Although the success rate of ureteroscopy was not significantly lower than the two other options, the complications seen with this technique were negligible. Consequently, the procedure of choice for large proximal ureteral stones seems to depend on surgeon expertise and availability of equipment.

PMID 19025388
S Koga, Y Arakaki, M Matsuoka, C Ohyama
Staghorn calculi--long-term results of management.
Br J Urol. 1991 Aug;68(2):122-4.
Abstract/Text We have treated 167 patients with staghorn calculi. Conservative therapy was used in 61 patients who have been followed up for 1 to 18 years (average 7.8). Chronic renal failure occurred in 22 of these patients and 7 died from uraemia. The causes of chronic renal failure were bilateral staghorn calculi, staghorn calculi and contralateral urinary calculi, and chronic pyelonephritis of the contralateral kidney. The morbidity and mortality rates following conservative treatment were higher than those following surgical management. The pathological findings in 47 kidneys after nephrectomy showed severe hydronephrosis, renal abscess and xanthogranulomatous pyelonephritis. These results indicated that staghorn calculi destroyed the kidney and early complete removal of these stones is advisable.

PMID 1884136
J M Teichman, R D Long, J C Hulbert
Long-term renal fate and prognosis after staghorn calculus management.
J Urol. 1995 May;153(5):1403-7.
Abstract/Text We analyzed retrospectively 177 consecutive staghorn calculus patients to determine risk factors for ultimate renal deterioration and renal cause specific death. Mean followup was 7.7 years. Overall rate of renal deterioration was 28%. Renal deterioration was associated more frequently among patients with solitary versus nonsolitary kidneys (77% versus 21%, p < 0.001), previous versus initial stones (39% versus 14%, p = 0.03), recurrent versus nonrecurrent calculi (39% versus 22%, p = 0.07), hypertension versus normotension (50% versus 22%, p = 0.006), complete versus partial staghorn calculi (34% versus 13%, p = 0.02), diversion versus no diversion (58% versus 19%, p < 0.001) and neurogenic bladder versus normal voiding (47% versus 21%, p = 0.006), as well as those who refused treatment versus treated patients (100% versus 28%, p < 0.001). No patient with complete clearance of fragments died of renal related causes compared to 3% of those without clearance of fragments and 67% of those who refused treatment (p < 0.001). Our study suggests that long-term renal preservation in the staghorn calculus patient may depend on normal blood pressure, staghorn size, absence of diversion or voiding dysfunction, and complete stone eradication.

PMID 7714951
Abstract/Text PURPOSE: We determined the immediate and long-term efficacy of combination "sandwich" therapy for management of large, extensively branched calculi in 100 consecutively treated patients.
MATERIALS AND METHODS: We treated 61 women and 39 men for stones ranging from 2.2 to 66 cm2 (mean 20.8) with percutaneous debulking followed by shock wave lithotripsy and, when necessary, secondary nephroscopy via the mature tract. The primary debulking was performed via 1 to 3 tracts (total 106, mean 1.06 per patient), following which 1 to 3 shock wave treatments (total 127, mean 1.3 per patient) were administered. Subsequently, 62 patients underwent 71 secondary or tertiary percutaneous procedures (mean 1.1 per patient).
RESULTS: Total hospital stay ranged from 3 to 44 nights (mean 12.2) and decreased with experience. In 34 patients 40 complications developed, the most frequent of which were bleeding requiring transfusion in 14 patients and fever or sepsis delaying a planned procedure or hospital discharge in 20 patients. For patients with struvite stones the transfusion rate and fever/sepsis rate was 20 and 33%, respectively, compared to only 10 and 12%, respectively, for those patients with noninfection related stones. Of 87 patients available for 1-month radiographic followup 55 (63%) were stone-free, while 32 (37%) had discrete residual gravel. With time and experience, the stone-free rate improved from 52 to 70%. Of 55 patients followed for a mean of 40.5 months ipsilateral stones recurred in 13 (22.8%). Of 39 patients with struvite calculi 11 (28%) had recurrent bacteriuria or infection. Renal function, defined by serum creatinine, ranged from 0.6 to 3.9 mg./dl. (mean 1.3) before treatment and from 0.5 to 6.4 mg./dl. (mean 1.4) 1 to 101 months (mean 31) after treatment.
CONCLUSIONS: This combined sandwich approach offers immediate and long-term results comparable to other forms of management currently available for these challenging cases. Furthermore, this approach may be applied successfully to virtually any patient with large, extensively branched or otherwise complex stones.

PMID 9224299
S Meretyk, O N Gofrit, O Gafni, D Pode, A Shapiro, A Verstandig, T Sasson, G Katz, E H Landau
Complete staghorn calculi: random prospective comparison between extracorporeal shock wave lithotripsy monotherapy and combined with percutaneous nephrostolithotomy.
J Urol. 1997 Mar;157(3):780-6.
Abstract/Text PURPOSE: We determined the preferred treatment of staghorn calculi.
MATERIALS AND METHODS: Between January 1992 and December 1994 we performed a prospective, randomized, single center study involving 50 kidneys with complete staghorn calculi: 27 renal units were treated with extracorporeal shock wave lithotripsy (ESWL) monotherapy (group 1) and 23 were treated with combined (initial) percutaneous nephrostolithotomy with ESWL (group 2). The 2 treatment groups were compared regarding stone size, grade of collecting system dilatation and urine culture at presentation. The number of treatment sessions, narcotic doses, renal colic episodes, septic complications, unplanned ancillary procedures, length of hospitalization, total treatment duration and stone-free rate at 6 months were recorded and compared.
RESULTS: At the conclusion of therapy the stone-free rate was significantly greater in group 2 than in group 1 (74 versus 22%, respectively, p = 0.0005). The complication rate was significantly greater in group 1, with 15 septic complications (fever greater than 38.5C for longer than 3 days) in 10 patients compared to only 2 episodes in group 2 (p = 0.007). The unplanned ancillary procedure rate was significantly greater in group 1 (8 procedures in 7 patients versus 1 procedure in group 2, p = 0.03). The overall treatment length was significantly shorter in group 2 (1 versus 6 months, p = 0.0006). There was no significant difference in the number of procedures performed with anesthesia or in the number of hospitalization days between the 2 treatment groups.
CONCLUSIONS: Combined percutaneous nephrostolithotomy and ESWL should be recommended as the first line treatment choice for most patients with staghorn stones.

PMID 9072566
Abstract/Text PURPOSE: The current clinical practice of shock wave lithotripsy is reviewed, specifically regarding patients in whom the presence of presumed absolute or relative contraindications may preclude treatment.
MATERIALS AND METHODS: Peer reviewed basic scientific and clinical studies on shock wave lithotripsy in patients with urinary stones and concomitant conditions that might contraindicate treatment reported between 1982 and 1996 were critically reviewed.
RESULTS: The exclusion of patients with conditions previously believed to contraindicate shock wave lithotripsy has almost always been empiric rather than based on experimental or clinical studies showing adverse effects in those settings. The contemporary literature suggests that shock wave lithotripsy in patients with proximate calcified aneurysms, implanted cardiac pacemakers and defibrillators, and bleeding diatheses can be accomplished safely and effectively with careful treatment and monitoring before, during and after shock wave lithotripsy. Likewise, patients with morbid obesity, children, and those with mid and distal ureteral calculi can also be treated successfully, even with first generation lithotriptors, with minor modifications that allow for appropriate positioning of the patient and stone.
CONCLUSIONS: The designation of most conditions as absolute or relative contraindications to shock wave lithotripsy has been empiric. A review of experimental and clinical studies pertinent to these issues clearly shows that most concomitant conditions previously precluding shock wave treatment can be circumvented to allow safe and effective use of this minimally invasive technology. Currently, pregnancy is the only condition that should remain an absolute contraindication to this treatment.

PMID 9120901
L Borghi, T Meschi, F Amato, A Briganti, A Novarini, A Giannini
Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study.
J Urol. 1996 Mar;155(3):839-43.
Abstract/Text PURPOSE: We define the role of urine volume as a stone risk factor in idiopathic calcium stone disease and test the actual preventive effectiveness of a high water intake.
MATERIALS AND METHODS: We studied 101 controls and 199 patients from the first idiopathic calcium stone episode. After a baseline study period the stone formers were divided by randomization into 2 groups (1 and 2) and they were followed prospectively for 5 years. Followup in group 1 only involved a high intake of water without any dietetic change, while followup in group 2 did not involve any treatment. Each year clinical, laboratory and radiological evaluation was obtained to determine urinary stone risk profile (including relative supersaturations of calcium oxalate, brushite and uric acid by Equil 2), recurrence rate and mean time to relapse.
RESULTS: The original urine volume was lower in male and female stone formers compared to controls (men with calcium oxalate stones 1,057 +/- 238 ml./24 hours versus normal men 1,401 +/- 562 ml./24 hours, p < 0.0001 and women calcium oxalate stones 990 +/- 230 ml./24 hours versus normal women 1,239 +/- 440 ml./24 hours, p < 0.001). During followup recurrences were noted within 5 years in 12 of 99 group 1 patients and in 27 of 100 group 2 patients (p = 0.008). The average interval for recurrences was 38.7 +/- 13.2 months in group 1 and 25.1 +/- 16.4 months in group 2 (p = 0.016). The relative supersaturations for calcium oxalate, brushite and uric acid were much greater in baseline urine of the stone patients in both groups compared to controls. During followup, baseline values decreased sharply only in group 1. Finally the baseline urine in patients with recurrences was characterized by a higher calcium excretion compared to urine of the patients without recurrences in both groups.
CONCLUSIONS: We conclude that urine volume is a real stone risk factor in nephrolithiasis and that a large intake of water is the initial therapy for prevention of stone recurrences. In cases of hypercalciuria it is suitable to prescribe adjuvant specific diets or drug therapy.

PMID 8583588
Kemal Sarica, Yener Inal, Sakip Erturhan, Faruk Yağci
The effect of calcium channel blockers on stone regrowth and recurrence after shock wave lithotripsy.
Urol Res. 2006 Jun;34(3):184-9. doi: 10.1007/s00240-006-0040-x. Epub 2006 Feb 4.
Abstract/Text We evaluated the possible effects of a calcium entry blocking agent "verapamil" on new stone formation and/or regrowth of residual fragments after shock wave lithotripsy (SWL) during long-term follow-up (>30 months) and compared the results with the success rates of adequate fluid intake. A total of 70 patients treated with SWL were randomly divided into three different groups, in the first two of which the patients received different preventive measures with respect to stone recurrence and/or regrowth. While 25 patients received a calcium channel blocking agent, verapamil hydrochloride, beginning 3 days before SWL and continued 4 weeks after the procedure, an additional 25 patients were put in an enforced fluid intake program and the remaining 20 patients received no specific medication and/or measure apart from close follow-up. Patients were followed regularly with respect to the clearance/regrowth of the residual fragments and that of new stone formation during long-term follow-up (within a mean follow-up of 30.4 months). The overall stone recurrence rate was 14% (10/70). Of the patients who became stone free (12/25, 48%) in group I, only one patient (1/12, 8.3%) showed a new stone formation during long-term follow-up. The figure was 40% (4/10) in group II patients and 55% (5/9) in group III patients receiving no specific medication. Regarding the residual stone fragments (<5 mm) after SWL, again high fluid intake was found to be the most effective on stone regrowth rates (2/13, 15.3%). Patients treated with verapamil also had acceptable regrowth rates (3/15, 20%). Finally, verapamil treatment significantly improved the clearance of residual fragments; while 7 out of 15 patients with residual fragments passed these particles successfully, (46.5%) in this group; these figures were 46% (6/13) and 18% (2/13) in the remaining groups. Residual fragments located in lower calyces demonstrated a poor clearance rate with higher regrowth rates. Verapamil administration was found to be effective enough to limit the regrowth of residual fragments and also to facilitate residual fragment clearance after SWL. Patients receiving this medication seemed to pass the retained fragments easily in a shorter time than the others.

PMID 16463053
Howard A Fink, Joseph W Akornor, Pranav S Garimella, Rod MacDonald, Andrea Cutting, Indulis R Rutks, Manoj Monga, Timothy J Wilt
Diet, fluid, or supplements for secondary prevention of nephrolithiasis: a systematic review and meta-analysis of randomized trials.
Eur Urol. 2009 Jul;56(1):72-80. doi: 10.1016/j.eururo.2009.03.031. Epub 2009 Mar 13.
Abstract/Text CONTEXT: Although numerous trials have evaluated efficacy of diet, fluid, or supplement interventions for secondary prevention of nephrolithiasis, few are included in previous systematic reviews or referenced in recent nephrolithiasis management guidelines.
OBJECTIVE: To determine efficacy and safety of diet, fluid, or supplement interventions for secondary prevention of nephrolithiasis.
EVIDENCE ACQUISITION: Systematic review and meta-analysis of trials published January 1950 to March 2008. Sources included Medline and bibliographies of retrieved articles. Eligible trials included adults with a history of nephrolithiasis; compared diet, fluids, or supplements with control; compared relevant outcomes between randomized groups (eg, stone recurrence); had > or = 3 mo follow-up; and were published in the English language. Data were extracted on participant and trial characteristics, including study methodologic quality.
EVIDENCE SYNTHESIS: Eight trials were eligible (n=1855 participants). Study quality was mixed. In two trials, water intake > 2 l/d or fluids to achieve urine output > 2.5 l/d reduced stone recurrence (relative risk: 0.39; 95% confidence interval: 0.19-0.80). In one trial, fewer high soft drink consumers assigned to reduced soft drink intake had renal colic than controls (34% vs 41%, p=0.023). Content and results of multicomponent dietary interventions were heterogeneous; in one trial, fewer participants assigned increased dietary calcium, low animal protein, and low sodium had stone recurrence versus controls (20% vs 38%, p=0.03), while in another trial, more participants assigned diets that included low animal protein, high fruit and fiber, and low purine had recurrent stones than controls (30% vs 4%, p=0.004). No trials examined the independent effect of altering dietary calcium, sodium, animal protein, fruit and fiber, purine, oxalate, or potassium. Two trials showed no benefit of supplements over control treatment. Adverse event reporting was poor.
CONCLUSIONS: High fluid intake decreased risk of recurrent nephrolithiasis. Reduced soft drink intake lowered risk in patients with high baseline soft drink consumption. Data for other dietary interventions were inconclusive, although limited data suggest possible benefit from dietary calcium.

PMID 19321253
P Barcelo, O Wuhl, E Servitge, A Rousaud, C Y Pak
Randomized double-blind study of potassium citrate in idiopathic hypocitraturic calcium nephrolithiasis.
J Urol. 1993 Dec;150(6):1761-4.
Abstract/Text In an attempt to document the efficacy of potassium citrate in stone formation, 57 patients with active lithiasis (2 or more stones during the preceding 2 years) and hypocitraturia were randomly allocated into 2 groups, with 1 group taking 30 to 60 mEq. potassium citrate daily in wax matrix tablet formation and the other group receiving placebo. In 18 patients receiving potassium citrate for 3 years stone formation significantly declined after treatment from 1.2 +/- 0.6 to 0.1 +/- 0.2 per patient year (p < 0.0001), in 13 patients (72%) the disease was in remission and all patients showed a reduced stone formation rate individually. In contrast, 20 patients taking placebo medication for 3 years showed no significant change in stone formation rate (1.1 +/- 0.4 to 1.1 +/- 0.3 per patient year) and in only 4 patients (20%) was the disease in remission. The stone formation rate during potassium citrate treatment was significantly lower than during the placebo treatment (0.1 +/- 0.2 versus 1.1 +/- 0.3 per patient year, p < 0.001). Potassium citrate therapy caused a significant increase in urinary citrate, pH and potassium, whereas placebo did not. Adverse reactions to potassium citrate were mild causing only 2 patients in the potassium citrate group and 1 in the placebo group to withdraw from the study. In summary, our randomized trial showed the efficacy of potassium citrate in preventing new stone formation in idiopathic hypocitraturic calcium nephrolithiasis.

PMID 8230497
J Hofbauer, K Höbarth, N Szabo, M Marberger
Alkali citrate prophylaxis in idiopathic recurrent calcium oxalate urolithiasis--a prospective randomized study.
Br J Urol. 1994 Apr;73(4):362-5.
Abstract/Text OBJECTIVE: To assess the efficacy of alkali citrate therapy in patients suffering from recurrent idiopathic calcium oxalate stone formation.
PATIENTS AND METHODS: Fifty patients suffering from active stone formation who had had at least one stone annually over the previous 3 years were recruited and randomly divided into two groups. They were given either general prophylactic instructions, i.e. abundant liquid intake and dietary restrictions (group I, n = 25)--or were additionally treated with alkali citrate (group II, n = 25).
RESULTS: In group I, the rate of stone formation was reduced from 1.8 to 0.7 stones per patient per year. Similar results were obtained for group II, the corresponding figures being 2.1 and 0.9. There was a statistically significant higher urinary citrate excretion in group II than in group I. No difference was seen between the two groups regarding recurrent stone formation (Student's t-test). Stone formation decreased in both groups (group I 27%, group II 31%). Subjectively, 56% of group II patients, all of whom had previously experienced severe colic, reported spontaneous stone elimination to be painless, whereas in group I all but one patient suffered pain.
CONCLUSION: An objective benefit of alkali citrate could not be established.

PMID 8199822
Abstract/Text BACKGROUND AND PURPOSE: To evaluate the efficacy of potassium citrate treatment in preventing stone recurrences and residual fragments after shockwave lithotripsy (SWL) for lower pole calcium oxalate urolithiasis.
PATIENTS AND METHODS: One hundred ten patients who underwent SWL because of lower caliceal stones and who were stone free or who had residual stone 4 weeks later were enrolled in the study. The average patient age was 41.7 years. All patients had documented simple calcium oxalate lithiasis without urinary tract infection and with normal renal morphology and function. Four weeks after SWL, patients who were stone free (N = 56) and patients who had residual stones (N = 34) were independently randomized into two subgroups that were matched for sex, age, and urinary values of citrate, calcium, and uric acid. One group was given oral potassium citrate 60 mEq per day, and the other group served as controls.
RESULTS: In patients who were stone free after SWL and receiving medical treatment, the stone recurrence rate at 12 months was 0 whereas untreated patients showed a 28.5% stone recurrence rate (P < 0.05). Similarly, in the residual fragment group, the medically treated patients had a significantly greater remission rate than the untreated patients (44.5 v 12.5%; P < 0.05).
CONCLUSION: Potassium citrate therapy significantly alleviated calcium oxalate stone activity after SWL for lower pole stones in patients who were stone free. An important observation was the beneficial effect of medical treatment on stone activity after SWL among patients with residual calculi.

PMID 12028622
F L Coe, L Raisen
Allopurinol treatment of uric-acid disorders in calcium-stone formers.
Lancet. 1973 Jan 20;1(7795):129-31.
Abstract/Text
PMID 4118468
B Ettinger, A Tang, J T Citron, B Livermore, T Williams
Randomized trial of allopurinol in the prevention of calcium oxalate calculi.
N Engl J Med. 1986 Nov 27;315(22):1386-9. doi: 10.1056/NEJM198611273152204.
Abstract/Text In a double-blind study, we examined the efficacy of allopurinol in the prevention of recurrent calcium oxalate calculi of the kidney. Sixty patients with hyperuricosuria and normocalciuria who had a history of calculi were randomly assigned to receive either allopurinol (100 mg three times daily) or a placebo. After the study, the placebo group had 63.4 percent fewer calculi (P less than 0.001), whereas the allopurinol group had 81.2 percent fewer calculi (P less than 0.001). During the study period, the mean rate of calculous events was 0.26 per patient per year in the placebo group and 0.12 in the allopurinol group. When the treatment groups were compared by actuarial analysis, the allopurinol group was found to have a significantly longer time before recurrence of calculi (P less than 0.02). We conclude that allopurinol is effective in the prevention of calcium oxalate stones in patients with hyperuricosuria. The large reduction in the frequency of calculi in the placebo group underscores the positive treatment bias that regularly occurs in trials of prophylaxis against renal calculi when historical controls are used.

PMID 3534570

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