Litiase

12-06-06
Management of Ureteral Calculi:

Trends and Controversies
Reza Hamidizadeh
PGY-2
Department of Urologic Sciences
Grand Rounds
June 6, 2012
Objectives
To review
Use of medical adjuncts in treatment of ureteral
calculi
The role of early vs. late shockwave lithotripsy
(SWL)
Management of patients who fail initial SWL
Data regarding efficacy of SWL vs. ureteroscopy
(URS)
Contemporary results of SWL: Is the new
technology any better?
12-06-06
Acknowledgements
Dr.
Ben Chew
Dr.
Ryan Paterson
Urolithiasis
Lifetime
risk 5-12% (13% men, 7% women)

50% recurrent renal colic within 5 years
7/1000 hospitalizations
2 million annual outpatient visits (USA)
$2.1 billion annual billing claims (USA)
Bader et al, Eur Urol, 61: 764-772, 2012
12-06-06
Management Options:
Observation
/ Medical expulsive therapy
(MET)
Shock wave lithotripsy
Ureteroscopy
2007 EUA/AUA Nephrolithiasis

Guideline Panel: Guideline for
Management of Ureteral Calculi
<10mm:
observation + offer MET
>10mm:
Most will require surgical intervention
SWL and URS both acceptable first line
options
Preminger et al, J Urol, 178: 2418-2434, 2007
stones 57 mm in diameter was 60%. The

for such information has become important,
frequency of spontaneous passage was 56%
because CT is replacing radiography and IV
for 8-mm stones, 33% for 9-mm stones, and
urography as the initial imaging evaluation
27% for stones that were 10 mm or larger in
for patients with suspected renal colic. In
diameter. As a group, these differences were
most portions of the ureter, the plane of the
12-06-06
not statistically significant (p = 0.43); the
CT section will be nearly perpendicular to
overall frequency of spontaneous passage for
the long axis of the ureter and therefore will
stones that were 8 mm or larger was 39%.
allow determination of the greatest width of
When we compare the overall frequency
the stone. In addition, unenhanced CT will
s of this study, we defined spontaof spontaneous passage among the three
reveal virtually all stones regardless of comoccurring if no intervention was
means that spontaneous passage
groups of stones (measuring 14 mm, 57
position, with pure indinavir stones being the
dent, because many factors, such
mm, or 8 mm and larger), the differences are
only known exception [7].
and the presence of infection, destatistically significant (p < 0.001).
Our study showed that CT measurements of
for intervention independent of
Table 2 shows the relationship of stone loureteral stone size have a nearly linear relationship
ation. In our study population of
cation to the overall frequency of spontaneous
with the frequency of spontaneous passage. Our
with a solitary stone, 115 stones
passage
as
well
as
the
frequency
at
each
locaresults are very similar to those of studies reported
usly; 57 patients required interven<5mm
>5mm
tion
as
a
function
of
size.
The
overall
frein the literature that used radiography to measure
luding ureteroscopy (n = 26), perStudy
No.
p
atients
Passing
Stone found
(%)
quency
of
spontaneous
passage
was
48%
for
stoneNo. size.
We
that stones measuring 4 mm
Study
No.
No
P
assing
S
tone
tomy (n = 18), and extracorporeal
(%) for mid ureteral stones,
proximal Patients
stones, 60%
or smaller will usually pass spontaneously (freipsy (n = 13).
Miller and Kane, 59
54 (92)
Miller and Kane,
16
8 (50)
quency of spontaneous passage = 78%); stones
nations were performed with a 1999 75% for distal stones, and 79% for
1999 stones loge CT scanner (General Electric
cated at the
ureterovesical
junction. These difmeasuring 57 mm frequently pass spontaneously
Hussain et al,
9
9 (100)
Milwaukee, WI). Axial images 2001 ferences in overall frequency areHusain
et al, 2001 15
9 (60)
statistically
(frequency
of spontaneous passage = 60%); and
om the top of the kidneys to the
significant
for
stones
in
the
proximal
ureter
stones
measuring
8 mm or larger usually will not
Coll et al, 2002
114
85 (75)
r using a 5-mm slice thickness, a
versus stones in the distal ureter Coll
(pet <
0.001)
pass
spontaneously
(frequency of spontaneous
al, 2002
73
31 (42)
reconstruction interval of 5 mm.
located
passage = 39%). In our study, no stones larger than
Van Sand
avage efor
t al, stones
27
12 (44) at the ureterovesical
trast material was administered. 2000
junction (p < 0.002). In addition, for each loca10 mm passed spontaneously.
s were interpreted together by one
Kuplei
et al, except
2004 15 the ureterovesical
3 (20)
tion
junction,
no
stary radiologist and one senior radiWeighted
104
46%
tistically significant differences were
noted in
one size was measured at the maxAverage
Spontaneous Passage Rate of
68%
frequency224
of spontaneous
passage based on
hin the plane of the axial CT image Weighted
TABLE 2 Ureteral Calculi as a
size. For stones at the ureterovesical junction,
t-tissue window and level settings. Average
Function of Stone Location
in whom the course of the ureter
the differences in frequency of spontaneous
ent in the plane of the CT section,
Stones in Proximal Ureter
passage based on sizePreminger
were statistically
signifiet al, J Urol,
178: 2418-2434, 2007
was taken perpendicular to the
cant (p < 0.02). Two of the seven stones at the
Passage Rate
er. Stone location was defined as
Size (mm)
No.
ureterovesical junction that failed to pass spon(%)
he sacroiliac joints), mid (overlytaneously measured 2 mm in diameter.
clinical follow-up. This confirmatrospectively. Of these 440 pandings on CT of acute ureteral

d by a solitary stone in the ureter.
72 patients comprised our study
cluded 110 men and 62 women.
18 years old or older; their mean
oints), distal (below the sacroiliac

ureterovesical junction.
spontaneous passage was calcuy for stone size and stone location.
ation, frequencies were also calcuof stone size. All frequency comde using a chi-square test.
ws the relationship of stone

increments) to the frequency
s passage. The number of
ize is also indicated. The fretaneous passage was 87% for
83% for 3-mm stones, and
-mm and 4-mm stones. As a
ferences were not statistically
0.58); the overall frequency
passage for stones 14 mm in
8%. The frequency of spontawas 60% for 5-mm stones,
stones, and 47% for 7-mm
roup, these differences were
significant (p = 0.32); the
cy of spontaneous passage for
Natural History
Discussion
No prior studies, to our knowledge, have

examined the relationships between stone
size and location on unenhanced CT to the
frequency of spontaneous passage. The need
14
57
>7
All stones
Natural History Size Matters

TABLE 1
Stone Size
(mm)
1
2
3
4
5
6
7
8
9
10
Spontaneous Passage Rate of

Ureteral Calculi as a
Function of Stone Size
No. of Stones
15
43
23
18
15
18
17
9
3
11
Passage Rate
(%)
87
72
83
72
60
72
47
56
33
27
14
57
>7
All stones
19
27
16
62
47
63
25
48
Stones in Mid Ureter

5
3
2
10
80
0
100
60
Stones in Distal Ureter

14
57
>7 78%
All stones
39
14
3
56
77
71
67
75
Stones in Ureterovesical Junction

14
5760%
>7
All stones
25
6
3
34
92
50
33
79
39%
Note.Proximal ureter = above sacroiliac joints, mid ureter =

overlying sacroiliac joints, distal ureter = below sacroiliac joints.
Coll et al, AJR, 178: 101-103, 2001
AJR:178, January 2002
passage based on size were statistically signifi-
he
wasfrequency
taken perpendicular
to the results
ge measurement
as well as the
at each locasimilar
those
studies
reported
cantare
(p very
< 0.02).
Twotoof
the of
seven
stones
at the
as
a of
function
of Stone
size. location
The overall
fre- as in the literature that used radiography to measure
ourse
the ureter.
was defined
ureterovesical junction that failed to pass sponcy
of spontaneous
passagejoints),
was 48%
for stone size. We found that stones measuring 4 mm
roximal
(above the sacroiliac
mid (overlytaneously measured 2 mm in diameter.
malthestones,
60%
for distal
mid ureteral
ng
sacroiliac
joints),
(below thestones,
sacroiliac or smaller will usually pass spontaneously (frefor
distal
stones,
and
79%
for
stones
loquency
of spontaneous passage = 78%); stones
oints), and at the ureterovesical junction.
at the ureterovesical junction. These difmeasuring
57 mm frequently pass spontaneously
Discussion
Frequency of spontaneous passage was calcuces in overall frequency are statistically (frequency of spontaneous passage = 60%); and
No prior studies, to our knowledge, have
ated independently for stone size and stone location.
ficant for stones in the proximal ureter stones measuring 8 mm or larger usually will not
each stone
frequencies
also calcu- passexamined
the relationships
stone
sorstones
in location,
the distal
ureter (pwere
< 0.001)
spontaneously
(frequency ofbetween
spontaneous
ated
as
a
function
of
stone
size.
All
frequency
comsize
and
location
on
unenhanced
CT
to
the
or stones located at the ureterovesical passage = 39%). In our study, no stones larger than
arisons
madeInusing
a chi-square
test.loca- 10 frequency
spontaneous passage. The need
on (p <were
0.002).
addition,
for each
mm passedof
spontaneously.
xcept the ureterovesical junction, no sta-
Results
ally significant differences were noted in
Location
Spontaneous
PassageRate
Rateofof
Spontaneous
Passage
ency
passage based
Tableof 1spontaneous
shows the relationship
of on
stone TABLE
2
Ureteral
Calculi
as
a
TABLE
1
Ureteral
Calculi
as
a
For stones at the ureterovesical junction,
Function
ize (in 1-mm increments) to the frequency
FunctionofofStone
StoneLocation
Size
ifferences in frequency of spontaneous
fge spontaneous
passage.
The
number
of
Stones
in
Proximal
Ureter
based on size were statistically signifiStone Size
Passage Rate
No. of Stones Passage Rate
tones
of each
size
indicated.
The
p < 0.02).
Two
of is
thealso
seven
stones at
thefre(mm)
(%)
Size
(mm)
No.
ovesical
that failed
to pass
uency
ofjunction
spontaneous
passage
was spon87% for
(%)
usly
2 mmfor
in diameter.
1
15
87
-mmmeasured
stones, 83%
3-mm stones, and
14
19
47
57
>7
All stones
14
3
56
71
67
75
Size (mm)
No.
Passage Rate
(%)
14
19
47
57
27
63
>7
All stones
16
62
25
48
12-06-06
Stones in Mid Ureter

14
57
>7
All stones
5
3
80
0
2
10
100
60

14
57
>7
39
14
3
77
71
67
2
2% for both 2-mm and 4-mm stones. As a 57
27 43
6372
All stones
56
75
3
23
roup,
these
differences
were
not
statistically
>7
16
2583
o prior studies, to our knowledge, have
All
stones
62
48
ignificant
(p
=
0.58);
the
overall
frequency
4
18
72
ined the relationships between stone
f spontaneous
passage
for stones
and
location on
unenhanced
CT14
to mm
the in
5 Stones in Mid
15 Ureter
60
14
25
92
ency
of was
spontaneous
The
iameter
78%. Thepassage.
frequency
of need
sponta- 14
6
5 18
8072
57
6
50
eous passage was 60% for 5-mm stones, 57
3 17
047
7
Spontaneous
>7
3
33
2% for 6-mm
stones, Passage
and 47%Rate
for of
7-mm >7
2
100
8
9
56
BLE 1 Ureteral Calculi as a
All stones
34
79
tones. AsFunction
a group,ofthese
differences
were All stones
10
60
Stone
Size
9
3
33
ot
statistically
significant
(p
=
0.32);
the
ne Size
Passage Rate
10
11
27
No. of Stones
verall frequency
of spontaneous(%)
passage forUVJ
overlying
sacroiliac joints, distal ureter = below sacroiliac joints.
mm)
(75-79%
vs.
48%)
14 /Distal > Proximal
39
77
ussion
1
2
02
3
15
43
23
87
72
83
4
5
6
7
18
15
18
17
72
60
72
47
8
9
10
9
3
11
56
33
27
AJR:178,
January 2002
Coll et al, AJR, 178: 101-103,
2001

14
25
92
57
>7
All stones
6
3
34
50
33
79
Articles

overlying sacroiliac joints, distal ureter = below sacroiliac joints.
Medical Expulsive Therapy

AJR:178, January 2002
Medical therapy to facilitate urinary stone passage:

a meta-analysis
John M Hollingsworth, Mary A M Rogers, Samuel R Kaufman, Timothy J Bradford, Sanjay Saint, John T Wei, Brent K Hollenbeck
Summary
Background Medical therapies to ease urinary-stone passage have been reported, but are not generally used. If eective,
therapies would increase the options for treatment of urinary stones. To assess ecacy, we sought to identify
such
Alpha
blockers and CCBs vs. observation alone
and summarise all randomised controlled trials in which calcium-channel blockers or blockers were used to treat
stone included
disease.
urinary
Only
trials with placebo as control
Methods
9 RCTs,
693
patients
We searched
MEDLINE,
Pre-MEDLINE, CINAHL, and EMBASE, as well as scientific meeting abstracts, up
July, 2005. All randomised controlled trials in which calcium-channel blockers or blockers were used to treat
toureteral
Mean
stone
size
3.9-7.8mm
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 eect
associated
Distal
ureteral
stones
(8 out of 9 studies)
with medical therapy use using random-eects and fixed-eects models.
Findings Patients given calcium-channel blockers or blockers had a 65% (absolute risk reduction=031 95% CI
025038) greater likelihood of stone passage than those not given such treatment (pooled risk ratio 165; 95% CI
Hollingsworth
et154
al, (129185)
Lancet, 368:1171-79,
2006blockers with steroids
145188). The pooled risk ratio
for blockers was
and for calcium-channel
was 190 (151240). 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 ecacy, 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.
Introduction
The lifetime risk of urinary stone disease (urolithiasis) is
estimated to be between 5% and 12% in Europe and the
USA,14 aicting 13% of men and 7% of women.5 Since
50% of patients will have a recurrence of renal colic
within 5 years of their first episode,6 urolithiasis is a
chronic disease with substantial economic consequences
and great public health importance. In the USA alone,
these drug classes stems from our understanding of

ureteral smooth-muscle physiology and urinary
obstruction.1117 Despite growing evidence from clinical
trials in support of its ecacy, expulsive therapy is rarely
used. Two explanations for underuse are: first, that
minimally invasive surgical techniques, such as
shock-wave lithotripsy and ureteroscopy have evolved to
allow for resolution of stone burden,18,19 but carry
18,2027
Lancet 2006; 368: 117179

See Comment page 1138
Department of Urology
(J M Hollingsworth MD,
T J Bradford MD, J T Wei MD,
B K Hollenbeck MD); Division of
General Medicine, Department
of Internal Medicine
(M A M Rogers PhD,
S R Kaufman MA, S Saint MD);
Veterans Affairs/University of
Michigan Patient Safety
Enhancement Program
(M A M Rogers, S R Kaufman,
S Saint); Center for Practice
Management and Outcomes
Research, Ann Arbor Veterans
Affairs Health Services Research
& Development Center of
Excellence, Ann Arbor (S Saint),
MI, USA
Correspondence to:
Brent K Hollenbeck
1500 E Medical Center Dr
TC 3875-0330, Ann Arbor,
MI 48109-0330, USA
bhollen@umich.edu
as editorials or commentaries, or studies on the wrong

topiceg, trials that used dierent interventions, trials
with dierent outcomes measured, or observational
studies.
There were five additional randomised studies that
made a substantial contribution to the literature,
including the first trial of expulsive medical therapy.3438
These studies were excluded from the final meta-analysis
because none of them had a true control group. Specifically,
Borghi and colleagues34 randomly assigned patients nifedipine and corticosteroids versus corticosteroids alone.
Dellabella and co-workers36,37 did two studies examining
the ecacy of medical therapy. In their first,36 patients
with urolithiasis were randomly assigned tamsulosin and
corticosteroids versus corticosteroids alone. 2 years later,
in their second study,37 patients were randomly assigned
tamsulosin or nifedipine and corticosteroids versus
corticosteroids alone. Additionally, the control groups in
Results
See Online for webtable 1
Study
Risk ratio
(95% CI)
Weight
(%)
Controlled
Cooper40
Porpiglia42
Skrekas45
Porpiglia43
Kupeli41
Tekin53
Yilmaz46
Resim44
Taghavi452
Subtotal
163 (115232)
224 (149336)
146 (110195)
193 (124301)
267 (087815)
169 (115247)
145 (101209)
118 (091153)
180 (114284)
165 (145188)
61
55
84
52
10
56
73
71
44
507
No control group
Borghi34
Staerman38
Cervenakov35
Dellabella36
Dellabella37
Subtotal
142 (104193)
143 (104196)
133 (103172)
142 (112180)
136 (113163)
138 (123154)
78
50
102
70
194
493
Overall
152 (139165) 1000

01
03
05
15
25
Risk ratio
Figure 3: Forest plot of risk ratios of stone passage, stratified by presence of control group
Sizes of data markers are proportional to the weight of each study in the meta-analysis. Horizontal bars=95% CI.
main analysis. Indeed, corticosteroids have been shown to

increase stone passage rates.39 Although these studies did
not meet the strict inclusion criteria, we did a separate
sensitivity analysis in which their data were used to
examine the eect of their inclusion on the overall risk
ratio.
In seven of the studies pooled, both treatment and
control groups received scheduled or on-demand doses of
non-steroidal anti-inflammatory drugs (NSAIDs).4046 These
drugs are highly eective in the symptomatic relief of acute
renal colic.47,48 Additionally, NSAIDs might augment
urinary stone expulsion.49,50 Yet the only randomised,
double-blind, placebo-controlled trial to investigate the
eect of NSAIDs on stone-passage rates showed no
dierence between NSAIDs and control.51 None of the
studies that we pooled were designed to examine the eect
of NSAIDs on our primary outcome; however, we did a
post-hoc subgroup analysis for the studies that included
NSAIDs in both treatment and control groups, as well as
for the two studies in which no NSAIDs were used.52,53
We then reviewed the remaining 38 articles in detail to
determine if they met inclusion criteria. The final study
population consisted of nine relevant trials that examined
the use of calcium-channel blockers or blockers to
augment urinary-stone passage.4046,52,53
693 patients were randomised into the nine trials
included in the meta-analysis (table 1). All patients were
treated on an outpatient basis. The mean age of
participants ranged from 344 years to 465 years, and
the percentage of women in the studies varied from 25%
to 60%. Mean stone size ranged from 39 mm to 78 mm.
In all but one study,40 treated patients had stones located
in the distal third of the ureter. There were 12 dropouts
across all nine trials; seven patients from the intervention
groups and five from the control groups.
The medical treatments and follow-up as well as the
primary and secondary outcomes and recorded sideeects are shown in webtable 1. Treatment duration
ranged from 7 days to 6 weeks, or until stone passage if
before than 6 weeks. Follow-up varied from 15 days to
48 days. In some trials, several drugs were given to the
treatment groups; for three studies, corticosteroids were
given to the treatment groups in addition to the calciumchannel blocker nifedipine.40,42,43 The treatment and
control groups received NSAIDs in seven trials.4046
12-06-06
Pooled risk ratio

1.65 (95%CI 1.45-1.88)
NNT 3-16
Benefit of adding
corticosteroids is small
No difference between
alpha blockers and
CCBs
1174
www.thelancet.com Vol 368 September 30, 2006
AUA Guidelines - MET

Alpha
blockers better than control
RR 29% (95% CI: 20% to 37%)
CCBs
have no benefit
9% (95% CI: -7% to 25%)
No
difference between different alpha

blockers
Preminger et al, J Urol, 178: 2418-2434, 2007
12-06-06
Medical Therapy - New Areas

Do
alpha blockers improve outcomes of

SWL?
Do
alpha blockers have any role in

management of stent related
symptoms?
Table 2. Lithotripsy outcomes
Endourology and Stones
Characteristic
ESWL
ESWL Plus
Tamsulosin
Efficacy of Tamsulosin Oral Controlled

Patients (n)
87
99
Absorption System After
Extracorporeal
Median applied
energy during
Shock Wave LithotripsyESWL
to(J) Treat Urolithiasis
Ureteral
101
109
Marin I. Georgiev, Dimitar I. Ormanov, Vasil D.
Vassilev, Plamen D. Dimitrov,
Renal
68
71
Vladislav D. Mladenov, Elenko P. Popov, Petar P. Simeonov, and Petar K. Panchev
Repeat ESWL (n)
22
24
OBJECTIVE
To determine the efficacy of the tamsulosin
controlled absorption
system as4an adjuvant therapy
Auxiliaryoral
procedures
(n)
4
to extracorporeal shock wave lithotripsy (ESWL) for the expulsion of ureteral and renal stones.
A consecutive sample of 248 patients with ureteral or renal stones who underwent ESWL in an
ESWL " extracorporeal shock wave lithotripsy.
academic hospital was included in a 12-week, prospective, open-label, randomized clinical trial.
Of the 248 patients, 186, including 77 with ureteral stones (mean size 9 mm) and 109 with renal
stones (mean size 13 mm) completed the study. After successful ESWL, the patients were
randomized to standard medical care (corticosteroids and analgesics) or standard care plus the
tamsulosin oral controlled absorption system 0.4 mg/d for 1 month. The stone clearance rate,
interval to the elimination of stone fragments, incidence of renal colic, and the need for
rehospitalization were assessed at 4, 8, and 12 weeks.
The stone clearance rate was significantly greater for the patients treated with tamsulosin than
for those in the standard care group at 4 (73.4% vs 55.9%, respectively; P ! .001) and 12 (91.3%
vs 74.6%, respectively; P ! .05) weeks. Tamsulosin treatment was also associated with a
significantly lower interval to the elimination of stone fragments (P ! .001), a significantly lower
rehospitalization rate (P ! .001), and a significantly lower proportion of patients with acute renal
colic (P ! .05) than standard care alone. No severe adverse events leading to treatment
discontinuation were observed.
Adjuvant treatment with tamsulosin, in addition to standard treatment with steroids and analgesics,
improved the outcome of ESWL. UROLOGY 78: 10231028, 2011. 2011 Published by Elsevier Inc.
Flomax (0.4mg) + steroids + analgesics vs. steroids + analgesics

186 patients
Mean stone size
9-10mm (ureteral)
RESULTS
12-14mm (renal calculi)
METHODS
Less Renal colic (68 vs. 22%)

CONCLUSION
Less Re-hospitalization
(25 vs. 7%)
n Europe and North America, an estimated 5%-10%

Evidence that medical treatment with an "1-adrenoof the population develop urinary tract stones at least
ceptor (AR) antagonist or a calcium antagonist could
once in their life, and about one half develop recurimprove the clearance of stone fragments generated with
rent disease.1 Thus, stone disease is 1 of the most comESWL is growing.4 Thus, medical expulsive therapy admon problems in urologic practice.
juvant to ESWL could potentially decrease they costs
A stone !5 mm in diameter has a 68% chance of
related to repeat ESWL or other treatment options such
passing spontaneously compared with only 47% of the
as retrograde ureteroscopic lithotripsy or percutaneous
1. Stone-free rate
at 4, 8, and
weeks after
ESWL
stones "5 and !10 mm.2 When active removal is nec-Figure
nephrolithotomy.
In addition,
this12
treatment
approach
essary, extracorporeal shock wave lithotripsy (ESWL) isin patients
fits withreceiving
current clinical
practice,
more
standard
care (ncharacterized
" 87) and by
patients
the first choice of treatment for most patients, with a
and more patients requesting a conservative and/or mintamsulosin
oral controlled
absorption system 0.4
reported clearance rate for kidney stones of 66%-99% inreceiving
imally
invasive therapeutic
approach.
patients with stones !20 mm3. However, the success ratemg/d combined
Because ofwith
this standard
first evidence,
we "
designed
care (n
99). a prospecof ESWL depends on a number of factors, including the
tive clinical study in Bulgaria. The aim of the present
location and composition of the stone, the lithotripter
randomized trial was to evaluate the efficacy and safety of
used, and the body mass index of the patient.3
the "1-AR antagonist tamsulosin oral controlled absorption system as adjuvant therapy to ESWL for expulsion of
renal and ureteral stones.
Funding Support: Astellas Pharma International funded independent medical
Georgiev, Urology, 78:1023-28, 2011
At 4 and 12 weeks after ESWL, complete elimination

MATERIAL
AND had
METHODS
of the
stone fragments
occurred significantly more
Inclusion
Criteria
frequently
in
the
tamsulosin
group than in the standard
Patients aged 18-80 years with ureterolithiasis along the entire
length group
of the ureter
nephrolithiasis
lower pole
care-only
(P !or.001
and P !(excluding
.05, respectively).
writing support but had no role in the design or conduct of the study, analyzing
the data, or in the preparation or approval of the manuscript.
From the Department of Urology, University Hospital Alexandrovska, Medical
University Sofia, Sofia, Bulgaria
Reprint requests: Marin I. Georgiev, M.D., Department of Urology, University
Hospital Alexandrovska, Medical University Sofia, 1 G. Sofiiski Street, Sofia 1431
Bulgaria. E-mail: marinbg64@gmail.com
Submitted: October 12, 2010, accepted (with revisions): January 21, 2011
calices) were included in the present prospective randomized
Table 3. Proportion of patients with re

pitalization rate at 12 weeks after e
wave lithotripsy
Variable
Patients (
ESW
ESWL
Tam
Renal colic
Rehospitalization
Hematuria #7 d
Fever #38C
Renal hematoma
68.4
24.6
13.8
6.9
0
ESWL " extracorporeal shock wave litho

cant.
COMMENT
The present study examined the be

safety of tamsulosin in patients wit
stones after successful ESWL. In b
addition to standard therapy was sign
tive in enhancing the clearance of s
ESWL than standard care alone and s
the interval to the complete eliminat
4 weeks after treatment, 73% of p
tamsulosin were free of stone fragm
only 56% of those allocated to standa
By week 12, the stone-free rate had in
the tamsulosin group and about 75%
group. The median interval to ston
days for the patients receiving tamsul
those receiving standard care only.
These results are in line with thos
7 effect of med
ous studies assessing the
apy on stone expulsion.5,6 The intere
sive therapy for urolithiasis has inc
during the past few years. Recently,
12-06-06
Urol Res
DOI 10.1007/s00240-011-0410-x
ORIGINAL PAPER
Tamsulosin and doxazosin as adjunctive therapy following

shock-wave lithotripsy of renal calculi: randomized
controlled trial
Urol Res
Table 2 Results
Osama
M. Zaytoun Rachid Yakoubi
Abdel Rahman M. Zahran

Group AKhaled Fouda
Group B
Group C
Essam Marzouk Salah(control)
Gaafar Khaled
Fareed
(tamsulosin)
(doxazocin)
Stone free (%)
42 (84%)
p value
A versus B
0.23
A versus C
B versus C
0.38
0.73
46 (92%)
45 (90%)
Received:
11 June
2011 / Accepted:
Mean expulsion
time (weeks)
7.3 2.730 July 2011
5.3 2.6
! Springer-Verlag 2011
6.8 2.8
0.002
0.685
0.026
Steinstrasse
5 (10%)
2 (4%)
3 (6%)
0.26
0.47
0.65
Number of SWL sessions
2.08 0.9
2.02 1.0
2.12 0.9
0.32
0.58
0.60
Steinstrasse
in0.028
10 (6.7%) patients with no
Abstract
Alpha-blockers
have
been established
as medical
Diclofenac consumption
(mg)
546.0
194.0
311.9 145.5
409.5 197.1
\0.001 was encountered
0.001
significant
difference
between
the
groups. 16 patients on
expulsive
therapy
for
urolithiasis.
We
aimed
to
assess
the
Colic episodes
5.7 2.0
3.0 2.2
4.5 2.1
\0.001
0.015
0.003
effect of tamsulosin and doxazosin as adjunctive therapy tamsulosin and 21 on doxazosin experienced adverse effects
Adverse effects (%)
0 (0%)
18 (36%)
21 (42%)
0.005
0.003
0.54
following SWL for renal calculi. We prospectively included related to postural hypotension. Moreover, 2 (4%) patients in
150 patients who underwent up to four SWL sessions for the tamsulosin group reported ejaculatory complaints. In
renal stones from June 2008 to 2009. Patients were ran- conclusion, adjunction of tamsulosin or doxazosin after
Zaytoun et al, Urol Res, 2011
SWL for
renal calculi
decreases
the time for stone expulsion,
domized
into terazosin,
three groups
of 50 patients
A randomized
controlled
trial (RCT)
on 139 patients,
Tamsulosin,
and doxazosin
have all each,
been groupIn an
amount
the analgesics
and tamsulosin
number colic episodes. There
(phloroglucinol
240efficacious
mg daily),
(tamsulosin
whomg
underwent
repeatedof SWL
for renal stones,
reported to be equally
in group
ureteralBstone
expul- 0.4
was noexpulsion
benefit rate
regarding
overall
once
phloroglucinol),
groupcolic.
C (doxazosin
group had a higher
than thethe
control
groupstone
at expulsion rate. The
sion, asdaily
well asplus
in reducing
the intensityand
of ureteral
side-effects
of
these
agents
are
common
and should be
4Among
mg plus
phloroglucinol).
The
treatment
continued
up
to
these agents, tamsulosin has been heavily studied 3 weeks (p = 0.016), but the difference at 3 months was
weighted
against
the
benefits
of
their
usage.
maximum
12
weeks.
Patients
were
evaluated
for
stone
as an adjunct therapy after SWL for ureteral and renal not statistically significant (94.1 vs. 84.6%, p = 0.14) [13].
expulsion, colic attacks, amount of analgesics and sidethe study by clearance
Gravina et al. [14] the
stone clearance at
stones [1316].
-Blockers
tosignificant
assistIndifferstone
after
Keywords Alpha-adrenergic
antagonists ! Tamsulosin !
effects of alpha-blockers.
There were no
was lithotripsy:
in favor of tamsulosin (78 vs. 60%,
The current study aimed in assessing the additive role
of 3 months
shock
wave
Doxazosin ! Calculi ! Lithotripsy
ences between theextracorporeal
groups regarding stone expulsion
rates
p = 0.04)
tamsulosin
doxazosin
when usedThe
in conjugation
with time
a meta-analysis
(84;
92 andand90%,
respectively).
mean expulsion
of following a single session of SWL. Similarly in
another
study, the expulsion rate at 3 months was signifithe
standard
medical
therapy
for
up
to
12
weeks
after
SWL
tamsulosin was significantly

shorter
than bothDuijvesz
control group
Yefang Zhu*,
Diederick
, Maroeska M. Rovers and Tycho M. Lock*
*Department of Urology, Julius Center for Health
Sciences
Care, University
Center
cantly
higher
inPrimary
tamsulosin
group (73Medical
vs. 55%,
p =Utrecht,
0.008)
treatment
of
renal
calculi.
(p = 0.002) and doxazosin
= 0.026).
Both Hospital,
numberUtrecht,
of and
Introduction
Department of(p
Urology,
Central Military
and
Department of Urology, Erasmus Medical Center,
Rotterdam,
the
Netherlands
Weepisodes
opted not to
patientsdosage
with lower
stones [15].
colic
andinclude
analgesic
werepole
significantly
lower
Accepted for publication 13 August 2009
FalahatkarUrolithiasis
et al. [22] conducted
a placebo-RCT
on 12% of the world
as theretamsulosin
is a great controversy
about thetoefficacy
of SWL
is a disease
that trial,
affects
with
as compared
control
and indoxazosin.
and the pooled mean difference was 8
extracted data. All data were analysed using
150
patients
with
one
SWL
session
for
renal
(90%)
or (SWL) is considthe treatment
the lower
pole calculi and
they
would
Study Type ofTherapy
(meta-analysis)
population
[1].
Shock-wave
lithotripsy
(320) days in favour of the tamsulosin
RevMan 5.
of Evidence 1a
group. Pain and analgesic usage was
Level
7 RCTs
ered
the
standard
of
care
for
renal
calculi
less than 20 mm
ureteral
stones
(10%).
The
overall
expulsion
rate
was
probably
have gained less benefit from any medical
therapy
reported to be lower with tamsulosin.
RESULTS
Adverse
effects of tamsulosin,
mainly
OBJECTIVE
484 patients
[2].
After
application
of
SWL
for
renal
calculi,
the clear71.4%
in
the
tamsulosin
group
and
60.5%
in
the
control
[9].
dizziness, were reported in eight patients
Of the 29 identified papers, seven trials with
(3%).stone fragments depends on various factors,
a total of 484 patients met the predefined
review the evidence for the use of
ance
of
ToOur
5
ureteric,
1
renal,
1
both
group, but
studyafter
demonstrated
thatshock
tamsulosincriteria.
and doxazosin
These studies evaluated
the this difference did not score any statistically
-blockers
extracorporeal
effectiveness of the -blocker tamsulosin,
CONCLUSIONS
wave lithotripsy (ESWL) in enhancing the
including
significant
difference
(p =stone
0.116).size, location and renal collecting system
significantly
shortened
the
time
needed
for
successful
stone
Mean
stone
size
8.5-12mm
and
studied
clearance
rate
as
the
primary
effectiveness
of
renal
and
ureteric
stone
O. M. Zaytoun ! K. Fareed
outcome. There was large heterogeneity
Treatment
with as
tamsulosin
afteredema
ESWL and spasm [3].
clearance.
anatomy,
as
ureteral
In the current study,
thetowell
patients
and
fragments
expulsion and
a significant
difference
in their methodological
Glickman
Urological
and2with
Kidney
Institute,
trials, but
appears
be effectiveinin tamsulosin
assisting stone
Follow-up
weeks
between
3 months
Medical
expulsive
therapy
for
urolithiasis has gained
quality
was
adequate.
The
pooled
absolute
clearance
in
patients
with
renal
and
ureteric
METHODS
Cleveland
Clinic, Cleveland,
OH,
USA
doxazosin
groups
experienced
less
attacks
of
renal
colic
favor
tamsulosin.
Conversely,
there
were
no
statistically
risk difference
of clearance rate was 16%
calculi. To make a definite clinical
WeDornier
and Siemens
Lithostar
increasing
attentiontoinusethe
last decade
[4]. Various agents
(95% confidence interval 527%) in favour
recommendation
tamsulosin
after
searched MEDLINE, Embase and the
intuitively
usedESWL
less foranalgesic
than incalculi,
the control
significant
differences
among
the three
groups
regardinggroup,and
of the! tamsulosin
i.e. an
average of six
renal and ureteric
a high
Cochrane
Library
up to
2009.
All
O.
M. Zaytoun
! A.
R.January
M. Zahran
! K. Fouda
have
been
investigated
including
calcium
channel blockers,
have to be treated with tamsulosin
quality confirmatory trial is warranted.
controlled trials in which group. This
can be interpreted
by the fact that administherandomized
ultimatewerestone
expulsion
rates.were patients
E.
Marzouk
! S.evaluated
Gaafar
after ESWL to achieve clearance
in one.
blockers
after ESWL
alpha-adrenergic
antagonists,
corticosteroids
and smooth
Subgroup analysis for the six studies that
KEYWORDS
eligible for the
analysis. Outcome
measures
Department
of Urology,
Faculty
of Medicine,
tration ofshowed
alpha-blockers
decreases[4,the5].frequency
of periOur results
time
needed
used a expulsion
dose of 0.4 mg tamsulosin
a
assessed
were regarding
clearance rate
(primary)
andfor stone
muscle
relaxants
The
goal
of
medical
therapy
is to
University
of
Alexandria,
pooled risk difference of 19 (1029)%. The
timeAlexandria,
(secondary). Two
authors Egypt
meta-analysis, lithotripsy, adrenergic
stalticin three
contractions
accompanying
the calculi
stone
expulsion
areexpulsion
consistent
with
the study
previous
reports
the efficacy
of analysed
time was
studies
independently
assessed
quality
and on expulsion
-antagonists,
urinary
enhance
stone
expulsion
with
a
parallel
decrease
in
the
Zhu et al, BJUI, 106: 256-61, 2011
superiority ofpain.
tamsulosin
decreaseperistalsis is mediated
tamsulosin,
doxazosin and terazosin in distal ureteral process. The associated
R.
Yakoubi (&)
Givenregarding
that ureteral
pital Huriez,a statistically sig- of colic episodes may be related to its more selectivity to
Department
of Urology,
stones. Yilmaz
et al. [17]Hodemonstrated
by alpha-adrenergic receptors, it was demonstrated that
CHRU, University of Lille 2,
thewhich
last years,
new
have been
primary treatment
for most
patients
with
INTRODUCTION
a1A
?
nificant
advantage
of
any
of
these
drug
groups
over
the
1D-adrenoceptor,
arecan
thetreatments
most prevalent
alpha-1Indeveloped
blockers
decrease
the frequency of colics
59037 Lille, France
aiming to further improve the
uncomplicated calculi [4]. ESWL has many
success
rate stone
after
ESWL.
-blockers [6].
were
advantages,
e.g.
patientsreceptor
can be treated
in an in the
Urinary group,
stone disease
is one
ofdifference
the most between
control
but
with
no
any
of
these
subtypes
ureteral
wall
[23].
associated
with
expulsion
e-mail:
rachid.yakoubi@gmail.com
introduced as a treatment for LUTS suggestive
outpatient setting (with no anaesthesia), a
common reasons for patients visiting a
2009 THE AUTHORS. JOURNAL COMPILATION

Upper Urinary Tract
2009 BJU INTERNATIONAL
-BLOCKERS TO ASSIST STONE CLEARANCE AFTER ESWL

ZHU
et al.
BJUI
BJU INTERNATIONAL
BPH [13],with
and later
effectiveness
of low morbidity rate, and high
urology practice, affecting 510% of the
drugs.
In patient
a study on 104ofblockers
patients
distaltheureteral
stones,
to facilitate urinary stone passage
compliance.
population [1]. An even higher frequency has
was
reported
in
several
studies
[1416].
More
been
reported
from
other
parts
of
world
(soOn the other hand, out of 11 trials on tamsulosin,
0.4 mg tamsulosin significantly
increased the stone expulsion rate
innovative studies also evaluated -blockers
Success rates of ESWL depend on the type of
called stone belts) and there are only a few
after
ESWL, but
the evidence
their
lithotripter
used, stone from
size and
location
[5]. with
geographical
areas
in which stone
disease
is found
included
in
a
meta-analysis,
6
did
not
any
benefits
62
to
80.4%
a
parallel
decrease
in theforassociated
effectiveness in assisting stone clearance
With the first-generation HM3 (Dornier
rare, e.g. in Greenland and in the coastal areas
conflicting.
A meta-analysis
MedTech,
Wessling, Germany)
stone-freeand theremains
Japan [2]. in increasing the expulsion rate
forof tamsulosin
[6, 10, 1821].
colic episodes
total amount
of analgesic
used [24].
combining the studies reported to date would
rates were 7299% [3,610]. Current
offer a unique opportunity to produce an
lithotripters are considered more comfortable
Since its introduction in the early 1980s [3],
However,
the
overall
pooled
effect
was
in
favor
of
tamsulosin
Some
studies
explored
the
effect
of
doxazosin
on
overall effect estimate of -blockers. The
for both user and patient, due to smaller focal
ESWL has become the initial treatment for
direction and magnitude of this effect will
zones and balloon coupling. However, newer
patients with kidney and ureteric calculi. Even
(RR
= 1.29, 95% CI 1.14, 1.47) [5].
clearance of ureteral stones
[17, 25, 26]. Ukhal et al. [25]
help in guiding decisions about clinical
generation machines never reproduced the
with the refinement of current endourological
methods for stone removal, ESWL remains the
high success rate of the Dornier HM3 [11,12].
practice.
123
-BLOCKERS TO ASSIST STONE CLEARANCE AFTER ESWL
12-06-06
FIG. 3. Forest plots with: a, stone clearance as the outcome; b, stone clearance as the outcome for tamsulosin 0.4 mg; and c, expulsion time as the outcome.
a
Tamsulosin
Events
Total
Weight
Risk Difference
M-H, Random, 95% CI
16.6%
11.2%
16.8%
10.2%
10.6%
21.0%
13.7%
0.17 [0.01, 0.33]

0.09 [0.16, 0.33]
0.04 [0.20, 0.12]
0.38 [0.11, 0.64]
0.25 [0.00, 0.50]
0.10 [0.01, 0.20]
0.33 [0.12, 0.53]
Total (95% CI)

240
244 100.0%
Total events
199
164
Heterogeneity: Tau2 = 0.01; Chi2 = 13.74, df = 6 (P = 0.03); I2 = 56%
Test for overall effect: Z = 2.96 (P = 0.003)
0.16 [0.05, 0.27]
Study or Subgroup
[24]
[25]
[26]
[27]
[28]
[29]
[30]
28
20
32
17
23
48
31
29
30
38
24
28
51
40
Control
Events
Total
23
18
30
8
12
55
18
29
31
34
24
21
65
40
Results
b
Tamsulosin
Events
Total
Risk Difference
M-H, Random, 95% CI
20.6%
12.1%
10.7%
11.2%
29.7%
15.7%
0.17 [0.01, 0.33]

0.09 [0.16, 0.33]
0.38 [0.11, 0.64]
0.25 [0.00, 0.50]
0.10 [0.01, 0.20]
0.33 [0.12, 0.53]
Total (95% CI)

202
210 100.0%
Total events
167
134
Test for overall effect:
Z = 3.88 (P < 0.001)
0.19 [0.10, 0.29]
[24]
[25]
[27]
[28]
[29]
[30]
c
Study or Subgroup
[25]
[26]
[29]
28
20
17
23
48
31
29
30
24
28
51
40
Tamsulosin
Mean
SD Total
13.22
4.73
30
15.66
6.14
38
35.53 19.47
51
Control
Events
Total
0.5 0.25
0
0.25
0.5
Favours control Favours tamsulosin
Weight
Study or Subgroup
23
18
8
12
55
18
Mean
12.95
35.47
47.22
29
31
24
21
65
40
Control
SD
6.92
53.7
23.64
Total
31
34
65
Risk Difference
M-H, Random, 95% CI
Weight
42.9%
20.7%
36.4%
Risk Difference
M-H, Random, 95% CI
0.5 0.25
0
0.25
0.5
Favours control Favours tamsulosin
Mean Difference
IV, Random, 95% CI
0.27 [2.70, 3.24]
19.81 [37.97, 1.65]
11.69 [19.54, 3.84]
Mean Difference
IV, Random, 95% CI
OR 1.19 (1.10 1.29)

NNT = 6
Faster expulsion time (Mean reduction 8 days)
Side-effects 3%
However, only Schuler et al. [33] also
tamsulosin
dosage of 0.2 mg to
is accepted
in
adversenon-compliance
effects of tamsulosin were
The
No
secondary
side-effects
conducted a meta-analysis, but at the time of
Japan and South Korea, in Europe and the
evaluated in five studies [24,25,27,29,30] and
119
130 100.0%
Total (95% CI)
were reported for eight patients (3%) from

three different studies. Six patients reported
dizziness [25,30], one postural hypotension
[29], and one retrograde ejaculation [29].
DISCUSSION
The results of this meta-analysis show that
tamsulosin appears to be effective in
enhancing stone clearance. There was an
absolute risk difference of 16% in clearance
rate in favour of the tamsulosin group, based
on seven studies. The I-square statistic of 56%
implied that there is medium heterogeneity
among these studies. Whereas only a
8.24 [19.54, 3.07]
50
25
0
25
Favours tamsulosin Favours control
USA a dose of 0.4 mg is common, as a result

of a higher body mass. Due to this significant
dose difference, a subgroup analysis was done
for tamsulosin 0.4 mg, which showed an
improvement of the absolute risk difference
to 19%, i.e. five patients have to be treated
with 0.4 mg tamsulosin after ESWL to achieve
clearance in one. The I-square statistic of 37%
implied that these six studies are relatively
homogeneous. For our secondary outcome,
expulsion time, there was a mean difference
of 8 days in favour of the tamsulosin group,
based on three studies.
their review only two studies with a total of
Our results are in agreement with earlier

reported reviews on this topic [11,3133].
First, publication bias cannot be completely

excluded, as the funnel plot suggests that
94 patients treated with tamsulosin and 94

Zhu et al, BJUI, 106:
256-61, 2011
controls could be included.
To our knowledge, the present is the first
meta-analysis with enough power to study
the effectiveness of -blockers after ESWL.
Besides the clearance rate, we also evaluated
expulsion time, which also is a clinically
relevant outcome. Moreover, we consider that
the methodological quality of the included
studies is adequate. Nevertheless, there are
some possible limitations.
Meta-analyses on MET + SWL
50
2009 THE AUTHORS
JOURNAL COMPILATION
2009 BJU INTERNATIONAL
Seitz et al, Eur Urol, 56: 455-71, 2009

Tamsulosin, Alfuzosin, Doxazosin, Nifedipine vs.
placebo
Both renal and ureteric calculi
Alpha blockers: OR 1.29 (1.16-1.43)
Nifedipine: 1.57 (1.21-2.04)
Zheng et al, Scan J Urol Nephrol, 44: 425-32, 2010.

Tamsulosin vs. placebo
OR 1.83 (1.20-2.78) for upper ureteral calculi
Faster expulsion time
Less post op pain/analgesic requirement
259
12-06-06
Conclusion
MET
should be offered to all patients

being observed with ureteral calculi
There
is strong evidence that alpha

blockers should be prescribed to
patients undergoing SWL for both renal
and ureteral calculi
Stent Related Symptoms

Ureteral stents
commonly used in
management of
ureteral calculi
What is the evidence
for medical therapy in
managing stent related
symptoms?
10
12-06-06
Stent Symptoms Pathophysiology

Ureteric
smooth muscle spasm around
stent
Trigone irritation (contains alpha 1 D
receptors)
Detrusor muscle spasm around
intramural ureter
High pressure transmitted to renal pelvis
during voiding
Lamb et al, BJUI, 108: 1894-1902, 2010
0022-5347/03/1693-1060/0
THE JOURNAL OF UROLOGY
Copyright 2003 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 169, 1060 1064, March 2003

Printed in U.S.A.
DOI: 10.1097/01.ju.0000049198.53424.1d
URETERAL STENT SYMPTOM QUESTIONNAIRE: DEVELOPMENT AND

VALIDATION OF A MULTIDIMENSIONAL QUALITY OF LIFE MEASURE
H. B. JOSHI, N. NEWNS, A. STAINTHORPE, R. P. MACDONAGH, F. X. KEELEY, JR.
AND A. G. TIMONEY
From the Bristol Urological Institute, Southmead Hospital, Bristol, and Taunton and Somerset National Health Service Trust, Taunton,
United Kingdom
Developed and validated theABSTRACT

USSQ in 309 patients
Purpose: We developed the ureteral stent symptom questionnaire (USSQ), a psychometrically

valid measure to evaluate symptoms and impact on quality of life of ureteral stents.
Questionnaire
with A6total
domains
Materials and Methods:
of 309 patients were asked to participate during different
of our study. In phase 1 a structured literature search, 9 patient interviews and studies
phases
Urinary
symptoms
35%formed the foundation for the initial draft of our new
of 90 patients using existing instruments
In phase40%
2 the USSQ was pilot tested, reviewed by experts and field tested in 40
questionnaire.
Body
pain
patients to produce a final 38-item draft. In phase 3 formal validation studies were performed in
patients to assess
validity,17%
reliability and sensitivity
to change.
validation was
55
General
health
Giannari
et al,Discriminant
BJUI, 107:648-54,
2010
performed by administering the questionnaire to 3 groups of patients without stents.
Work
performance
7%
Results: The final draft addressed various domains of health (6 sections and 38 items) affected
stents covering
urinary symptoms, pain, general health, work performance, sexual matters
by
Sexual
matters
6%
and additional problems. The validation studies showed the questionnaire to be internally
(Cronbachs
! !0.7) with good
6%test-retest reliability (Pearsons coefficient !0.84). The
consistent
Additional
problems
questionnaire demonstrated good construct validity and sensitivity to change shown by significant changes in the score with and after removal of stents. The new USSQ discriminated patients
with stents from healthy controls (p "0.001) and patients with urinary calculi without stents and
lower
Joshi
eturinary
al, J tract
Urol,symptoms.
169: 1060-64, 2002
Conclusions: Indwelling ureteral stents have a significant impact on health related quality of
life. The new USSQ is a valid and reliable instrument that is expected to become a standard
outcome measure to evaluate the impact and compare different types of stents.
KEY WORDS: stents, ureter, quality of life, questionnaires, treatment outcome
Placement of a ureteral stent is a common urological intervention. It has been more than 3 decades since the first
description of a cystoscopically placed temporary ureteral
stent,1 and indications and use have continued to expand.
However, side effects and patient morbidity associated with
stents have been identified as major problems.29 Despite
improvements in stent designs and composition, in an effort
to improve patient comfort and little or no morbidity, structured in-depth assessment of symptoms due to stents and
naire. The developmental phase included qualitative research methods. Only adults with unilateral ureteral stents
placed for urinary calculi or ureteropelvic junction obstruction were included in this phase.
Phase 1. We performed a structured literature review using electronic data bases, hand searches and cross referencing to identify issues related to the use, symptoms and complications of ureteral stents.
We then conducted detailed interviews of 6 men and 3
11
12-06-06
Agents Studied
Alpha
blockers
Anticholinergics
Intravesical
Drug
agents
eluting stents
Is There a Role for !-Blockers in Ureteral Stent Related

Symptoms? A Systematic Review and Meta-Analysis
Rachid Yakoubi,* Mohamed Lemdani, Manoj Monga, Arnaud Villers
and Philippe Koenig
From the Department of Urology, Hpital Huriez, Centre Hospitalier Rgional Universitaire (AV, PK) and Department of Biomathematics,
Faculty of Pharmacy and Biology (ML), University of Lille 2 (RY), Lille, France, and Glickman Urological and Kidney Institute, Cleveland Clinic
(RY, MM), Cleveland, Ohio
12 RCTs (2008-2010)
Purpose: We evaluated the efficacy of !-blockers to improve ureteral stent re-
Abbreviations
912 patients
and Acronyms
lated morbidity and quality of life.

Materials and Methods: We performed a search of MEDLINE, Embase and
The Cochrane Library plus a hand search of conference proceedings from JanuRCT ! randomized,
controlled
Tamsulosin
0.2mg
or 0.4mg OD (7 trials)
ary 2000 to October 2010 to identify randomized, controlled trials comparing
trial
Alfuzosin 10mgtreatment
OD (4 trials)
for ureteral stent symptoms with !-blockers. Two reviewers indepenUSSQ ! ureteral stent symptom
Both
(1
trial)
dently screened studies and extracted data. Trial methodological quality was
questionnaire
Indications for stentassessed by The Cochrane Collaboration quality assessment tool. Placebo randomized, controlled trials with the ureteral stent symptom questionnaire as the
Ureteroscopy
for
calculi
Submitted for publication
January 24, 2011.
outcome were eligible for meta-analysis. Meta-analysis was done using the mean
Supplementary
material
for
this
article
can
Following
endourological
difference to procedures
determine the aggregate effect size.
be obtained at http://ea2694.univ-lille2.fr/
Pyeloplasty Results: A total of 12 randomized, controlled trials including 2 !-blockers in a
publications/data-j-urology.html.
* Correspondence: Department of Urology,
total of 946 patients were eligible, including 4 (33%) presented only as an
Hospitalier
Obstructing
Hpital Huriez, Centre
Rgional Uni- calculus
abstract at a urological meeting and 4 (33%) eligible for meta-analysis. Metaversitaire,
59037,
Lille,
France
(telephone:
("1)
Follow-up: 1-6 weeks
216-444-3272; FAX: ("1) 216-445-2267; e-mail:
analysis using a random effects model showed that !-blockers were associated
rachid.yakoubi@gmail.com).
Yakoubi
et al,
Urol, 186:
928-34,
2011
with a significant
decrease
in Jurinary
symptoms
(MD
#6.76, 95% CI #11.52 to
#2.00, p ! 0.005), a significant decrease in pain (MD #3.55, 95% CI #5.51 to
#1.60, p ! 0.0004) and significant improvement in general health (MD #1.90,
95% CI #3.05 to #0.75, p ! 0.001). However, they were not associated with a benefit
in work (MD 2.41, 95% CI #1.62 to 6.44, p ! 0.24) or sexual matters (MD 0.20, 95% CI
#1.06 to 1.45, p ! 0.33). Eight studies were not included in the meta-analysis, of which
7 showed a significant clinical decrease in urinary symptoms and pain.
Conclusions: Existing evidence from randomized, controlled trials shows that
!-blockers are associated with improvement in ureteral stent symptoms and
supports their use in routine clinical practice.
Interventions
QOL !quality
of life
Key Words: ureter, ureteral obstruction, adrenergic alpha-antagonists, stents,

quality of life
12
12-06-06
932
Results
!-BLOCKER ROLE IN URETERAL STENT RELATED SYMPTOMS
Side effects
- 0 10% dizziness
- 0 10% heaaache
- 6% hypotension
- 5% nausea
- 2 syncope
- No discontinuation
Figure 2. Pooled data analysis of USSQ urinary symptoms, pain and general health scores
symptoms and pain assessment. 2) There was considtive trial in 42 patients randomized to intravesical
erable heterogeneity in the instruments used to
instillation of 1 of 3 chemicals (ketorolac, alkalinmeasure outcomes. Only 6 trials (50%) used USSQ.
ized lidocaine or oxybutynin) vs saline as the conFurther refinement of USSQ to shorten the questrol immediately after stent placement during
tionnaire may facilitate its wider use in future studshock wave lithotripsy.8 No side effects were reies. 3) A
possible
could be the heterogeneported. Ketorolac was associated with a significant
JOURNAL
OF limitation
ENDOUROLOGY
General Research
Volume 23, Number
11, November
ity of treatment
duration
(1 to2009
6 weeks), outcome
decrease in irritative symptoms 1 hour after inter Mary Ann Liebert, Inc.
assessment
timing (3 days to 6 weeks) and the use of
vention.
Pp. 19131917
DOI: 10.1089=end.2009.0173
2 drugs.
Gupta et al postulated that many stent related
A recent study revealed that patients with uresymptoms may be caused by detrusor muscle
teral stents frequently reported bothersome urinary
spasm in and around the intramural ureter. 9
The Effects of Tolterodine Extended
Release and Alfuzosin
symptoms (78%), stent related pain (80%), sexual
Thus, in an RCT of 51 patients they evaluated the
theand
Treatment
of capacity
Double-Jeffect
StentRelated
Symptoms
dysfunctionfor
(32%)
decreased work
of ipsilateral periureteral
injection of botu4
(58%). Different approaches were tried to decrease
linum toxin type A at a concentration of 10 U/ml at
this morbidity.
3 sites around the ureteral orifice after unilateral
Seung
Chol Park,
Sung Won Jung,
M.D., Jea Whan
Lee, stent
M.D., and
Joung Sik
Rim,
M.D., Ph.D.
Norris et
al reported
an M.D.,
RCT comparing
extended
ureteral
insertion.
They
administered
USSQ
release of the anticholinergic oxybutynin with the
7 days after stent insertion. They reported a sigoral topical analgesic phenazopyridine and placebo
nificant decrease in postoperative pain and nar Abstract
52 patients
for ureteral
stent discomfort in 60 patients.7 They
cotic requirements
to find23(11):
a significant
Park et but
al, Jfailed
Endourol,
did not
use USSQ
and
failed
to note differences
impact in any USSQ score.
Aim:ToGroup
evaluate1:
the
effects of tolterodine
extended
release (ER) and alfuzosin for the treatment of Double-J
Alfuzosin
10mg
OD
x
6
weeks
1913-17,
2009
between
active treatments
and
placebo
to relieve
Several groups have attempted to explain stent
stentrelated
lower urinary
tract
symptoms.
Materials
and Methods:
Fifty-twoER
patients
men
19 women;
mean age
years) who
underwent
stent related
symptoms.
related
morbidity
by 52.0
considering
stent
character Group
2: Tolterodine
4mg(33
OD
x 6and
weeks
insertion
of a
Double-J
stent after urological
surgery
prospectively
randomized
intoand
three construction.
groups. Group 1HowOthers
have
tried
intravesical
instillation
of were istics,
including
design
Group
3:
Placebo
included
20 patients
who received 10 mg of alfuzosin, once daily for 6 weeks; group 2 included 20 patients who
chemical
agents. Beiko et al performed a prospecever, to our knowledge the ideal biomaterial has
received 4 mg of tolterodine ER, once daily for 6 weeks; group 3 included 12 patients who received a placebo for
the same protocol. All patients completed a validated Ureteral Stent Symptom Questionnaire at 6 weeks after the
stent placement.
Results: The mean urinary symptom index was 22.1 in group 1, 22.1 in group 2, and 28.1 in the placebo group
( p 0.032). The mean pain scores were 8.2, 11.7, and 16.2, respectively ( p 0.020). There were no significant
differences in urinary symptoms and pain between the alfuzosin and tolterodine ER groups. In addition, there
was no significant difference in the general health, work performance, and sexual performance scores among the
groups.
Conclusions: Tolterodine ER and alfuzosin improve stent-related urinary symptoms and body pain.
Introduction
t has been more than three decades since the first description of a cystoscopically placed indwelling endoluminal stent by Zimskind et al.1 Ureteral stenting has
become a part of routine clinical practice for the treatment of
ureteral obstruction. Indwelling ureteral stents produce
varying degrees of complications and discomforts.24 Ureteral
stents may cause significant lower urinary tract symptoms
(LUTS), ranging from frequency and urgency to hematuria or
infection, in addition to patients forgetting there is a catheter
in place.5 Such complications may significantly impact the
quality of life, and cause discomfort, pain, and anxiety.
The assessment of symptoms caused by indwelling ureteral
stents is difficult in the clinical setting. The International
Prostate Symptom Score is the most widely used questionnaire for the assessment of LUTS; however, it is not specific for
stent-related symptoms. Joshi et al6 first developed and
validated a questionnaire for the evaluation of stent-related
symptoms, the Ureteral Stent Symptom Questionnaire (USSQ),
which is self-administered and designed for use in the clinical
and research settings. The USSQ evaluates ureteral stent
related morbidity in six domainsurinary symptoms, body
pain, general health, work performance, sexual performance,

and other problems. The domain about urinary symptoms has
11 questions. The domain about body pain consists of pain
experience, visual analog scale, and six questions. The domains of general health, work performance, and sexual performance have six, seven, and four questions, respectively.
Each question has 4 to 7 scores. The scoring system for the
questionnaire consists of a simple sum of the scores for individual questions in each domain, and high score means more
bothersome.
The pathophysiology of stent-related symptoms requires
further study. Thomas7 suggested that the high pressure transmitted to the renal pelvis during voiding is an important
factor. In addition, stent-related pain and LUTS might be
related to lower ureter spasm or local trigonal irritation by
the intravesical portion of the ureteral stent. Many investigators have attempted to improve stent-related symptoms
by using intravesical anticholinergics, analgesics, antiinflammatory drugs, and oral alpha-1 antagonists.810 Among
these agents, the alpha-1 antagonists have been most useful
for stent-related symptoms and improving the quality of
life of patients with ureteral stents.9,10 Therefore, we conducted a randomized controlled study to evaluate the effect
Department of Urology, Wonkwang University School of Medicine and Hospital, Iksan, Korea.
1913
13
12-06-06
Conclusion
Good
evidence that alpha blockers

reduce bothersome stent symptoms
Unclear
whether combination therapy

(alpha blocker + anticholinergic) is
superior
Implications for drug eluting stents
Management Options:
Observation
Medical
expulsive therapy (MET)
SWL
Ureteroscopy
14
12-06-06
Emergency SWL
Rationale
Ureteral
edema develops over initial

24-48 hours
Hyperplastic stone bed mucosa with
increased mitosis @ 48hrs
Obliteration of stone-liquid interphase
Kim et al, J Urol, 104: 390-4, 1970
Mueller et al, J Urol, 135: 831-4, 1986
Deliveliotis et al, Urol Int, 70: 269-72, 2003
european urology 49 (2006) 10991106
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Stone Disease
Rapid Extracorporeal Shock Wave Lithotripsy Treatment

after a First Colic Episode Correlates with Accelerated
Ureteral Stone Clearance
zsoy,
Christian Seitz *, Harun Fajkovic, Mesut Remzi, Matthias Waldert, Mehmet O
Gero Kramer, Michael Marberger
Department of Urology, Medical University of Vienna, Wa
hringer Gu
rtel 1820, 1090 Vienna, Austria
Prospective non-randomized study

94 patients
Solitary proximal ureteral calculi
Mean stone size 7.9 2.3mm (range 3-15mm)
Patients schedule for shock wave lithotripsy ASAP
Wolf Piezolith 3000
Article info
Abstract
Article history:
Accepted December 1, 2005
Published online ahead of
print on December 28, 2005
Objectives: To investigate the relationship between delay in extracorporeal shock wave lithotripsy (ESWL) after a first colic and subsequent time
to complete stone clearance.
Methods: This prospective, non-randomized study included 94 patients
treated with ESWL for unilateral solitary proximal ureteral stones after at
least one episode of colic pain. Time between the first onset of colic pain
and ESWL and stone clearance was recorded. The pretherapeutic degree
of hydronephrosis has been assessed using ultrasound.
Results: Mean stone size was 7.9 ! 2.3 mm and mean time before ESWL
after a first colic was 93.4 ! 143.5 h. At 3 months, 3 patients were lost to
follow-up. In 76.9% of patients stones were completely cleared and a
further 3.3% harbored residual fragments "3 mm. Delay in treatment
after a first colic correlated with subsequent time to stone clearance
( p < 0.0001). Mean time to stone clearance in patients treated within 24 h
was 6.4 ! 6.3 days compared with 16.0 ! 17.8days for those treated later
( p = 0.008). Maximum stone diameter correlated with time to stone
clearance ( p = 0.031), but the degree of hydronephrosis did not.
Conclusions: Rapid ESWL after a first onset of colic pain resulted in
accelerated stone clearance independent of the degree of hydronephrosis but had no impact on the need for auxiliary procedures.
# 2005 Elsevier B.V. All rights reserved.
Keywords:
ESWL
Proximal ureter
Colic
Stone clearance
Success = no residual calculi
* Corresponding author. Medical University of Vienna, Wa

hringer Gu
rtel 1820, 1090 Vienna,
Austria. Tel.: +43 1 40 400 2616; fax: +43 1 408 9966.
E-mail address: drseitz@gmx.at (C. Seitz).
Seitz et al, Euro Urol, 49: 1099-1106, 2006

1.
Introduction
Since its introduction in the early 1980s [1] extracorporeal shock wave lithotripsy (ESWL) has become
an effective treatment for urinary tract stones. The

goal of the management of ureteral calculi is to
achieve fast, complete stone clearance with minimal morbidity. Factors affecting stone clearance
0302-2838/$ see back matter # 2005 Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2005.12.003
15
12-06-06
Results
76.9%
SFR (3 month F/U)

Mean time to SWL 94 hours
No
correlation between time to SWL and

overall SFR
Less SWL sessions if treated in first 24
hrs vs. 96 hrs (1.6 vs. 2.4)
Faster clearance if treated in first 24 hrs
(6.4 days vs. 16 days)
Extracorporeal Shockwave Lithotripsy
JOURNAL OF ENDOUROLOGY
Volume 24, Number 12, December 2010
Mary Ann Liebert, Inc.
Pp. 20592066
DOI: 10.1089=end.2010.0066
A Prospective Randomized Comparison

Between Early (<48 Hours of Onset of Colicky Pain)
Versus Delayed Shockwave Lithotripsy for Symptomatic
Upper Ureteral Calculi: A Single Center Experience
Anup Kumar, M.S., M.Ch., Nayan K. Mohanty, M.S., M.Ch., Manoj Jain, M.S.,
Sanjay Prakash, M.S., and Rajender P. Arora, M.S.
160 consecutive patients

Upper ureteral calculi <1cm
Dornier Alpha Compact
Abstract
Background and Purpose: The role of early=emergency shockwave lithotripsy (SWL) in symptomatic upper
ureteral calculi has still not been established. We have performed a randomized comparison between early (<48
hours) vs delayed (>48 hours) SWL for symptomatic upper ureteral stones less than 1 cm to evaluate the
feasibility, safety, and efficacy of early SWL in these patients.
Patients and Methods: One hundred and sixty consecutive patients with a single radiopaque upper ureteral stone
<1 cm, who presented with an episode of colicky pain and who were undergoing treatment between July 2008 and
June 2009 in our department were included. The patients were hospitalized and randomized into two groupsgroup
A: SWL was performed within 48 hours of onset of colicky pain (early SWL) using the electromagnetic lithotripter
(Dornier Alpha Compact) along with analgesics and hydration therapy; group B: SWL was performed after 48 hours
(delayed SWL) along with analgesics and hydration therapy. The statistical analysis was performed in two groups
regarding the patient demographic profile, presence of hydronephrosis, time to stone clearance, success rates, number
of sessions needed, auxiliary procedures, modified efficiency quotient (EQ), and complications.
Results: Eighty patients were enrolled in each group. The mean stone size was 7.3 mm in group A vs 7.5 mm in
group B (P 0.52). The stone fragmentation rate was 88.75% in group A vs 91.2% in group B (P 0.35). The
overall 3-month stone-free rate was 86.3% (69=80) for group A vs 76.2% (61=80) for group B (P 0.34). The mean
time taken for stone clearance was significantly less in group A than in group B (10.2 days vs 21.1 days; P 0.01).
The number of sessions needed in group A were significantly less than in group B (1.3 vs 2.7; P 0.01). The
auxiliary procedure rate was also significantly lesser in group A than group B (16.3% vs 32.5%; P 0.001). The
modified EQ (in %) was 67.2 in group A vs 59.4 in group B (P 0.21). The steinstrasse formation and requirement
for percutaneous nephrostomy (PCN) were significantly less in group A (P:0.02 and P:0.01 respectively).
Conclusions: Early SWL (within 48 hours of onset of colicky pain) is feasible, safe, and highly efficacious in the
management of symptomatic proximal ureteral stones <1 cm, resulting in a lesser requirement of number of
SWL sessions, time taken for stone clearance, auxiliary procedure rate, and fewer complications in comparison
with delayed SWL.
Group 1: SWL <48hrs (early)

Group 2: SWL >48hrs (delayed)
Repeat SWL @ 24hrs if residual fragments seen
Introduction
Kumar et al, Jupper

Endourol,
24(12):
2059-66, 2010
ureteral stones
are approximately
90% and 68%, re-
ith the introduction of shockwave lithotripsy

(SWL) in the early 1980s as a management option for
upper ureteral stones, it has become a primary treatment
for most patients with uncomplicated upper urinary tract
stones.14 According to the European Association of UrologyAmerican Urological Association (EAU-AUA) ureteral stones
clinical guideline in 2007, 3-month stone-free rates for SWL in
spectively, for upper ureteral stone size <1 cm and 1 to 2 cm.5

SWL has been one of the standard management options for
upper ureteral stones <1 cm.5 Ureteroscopy has been traditionally considered the surgical treatment of choice for patients with mid and lower ureteral stones.6 With the advances
made in ureteroscopic instruments and techniques, however,
along with an increase in expertise, this modality has also
become an established management option for upper ureteral
Department of Urology, Vardhman Mahaveer Medical College and Safdarjang Hospital, New Delhi, India.
2059
16
12-06-06
Results
JOURNAL OF ENDOUROLOGY
Volume 19, Number 1, January/February 2005
Mary Ann Liebert, Inc.
Emergency Extracorporeal Shockwave Lithotripsy for Acute

Renal Colic Caused by Upper Urinary-Tract Stones
SERGEY KRAVCHICK, M.D.,1 IGOR BUNKIN, M.D.,1 EUGENY STEPNOV, M.D.,1
RONIT PELED, PH.D.,2 LEONID AGULANSKY, M.D.,1 and SHMUEL CYTRON, M.D.1
53 patients
ABSTRACT
5 15mm UPJ (N = 10) and upper ureteral calculi (N = 43)
Purpose: To evaluate emergency SWL for the treatment of upper urinary-tract stones causing renal colic.
Patients
Mean
7.14mm
and stone
Methods:size
Between
January 1999 and June 2003, 53 patients with a mean age of 46.6 years
(range
2265
years)
were
enrolled.
Medispec Econolith The inclusion criteria were acute renal colic, radiopaque 5-mm to 1.5-cm
calculi in the ureteropelvic junction (N ! 10) or upper ureter (N ! 43), and no evidence of urinary-tract infection or acute renal failure. The mean stone size was 7.14 mm (range 513 mm). Patients were randomly
assigned to the control (N ! 28) and study (N ! 25) groups using previously prepared cards in envelopes. Patients in the study group underwent emergency SWL, while patients in the control group underwent scheduled SWL within 30 days. Stone status was evaluated 4 weeks after lithotripsy. There was no significant difference between the control and study groups with respect to age, sex, stone location or volume, renal
obstruction, or days spent in the hospital for pain control. Available fragments of stones were sent for infrared spectroscopy. Preoperative and postoperative data were compared in the two groups using SPSS 10.0
statistical software.
Results: The SWL treatment lasted 50 " 11 minutes. The stone-free rates were 72% and 64% and the efficiency quotients were 53% and 44% in study and control groups, respectively. Patients in the control group
spent more time in the hospital (P ! 0.014) and in recovery at home (P ! 0.011).
Conclusion: Emergency SWL for acute
renal colicet
caused
upper-ureteral
stones
a safe procedure and
Kravchick
al, J by
Endourol,
19(1):
1-4,is2005
offers effective release from pain and obstruction. It also decreases hospitalization days and hastens return
to normal activity.
Control Group: Observation + SWL within 30 days (Mean 26 days)

Study Group: SWL within 48-72hrs (Mean 2 days)
Follow-up with KUB + U/S 4 weeks after lithotripsy
INTRODUCTION
HE MANAGEMENT OF ureteropelvic junction (UPJ) and

upper-ureteral stones tends to be deferred. It is indisputable
that in cases of infection and acute renal failure, prompt renal
drainage followed by definitive treatment is a reasonable approach. In other instances, however, the treatment of stones depends mainly on the clinical symptoms and stone size and location.1 The fact that most stones !4 may be eliminated
spontaneously supports expectant management. However, SWL
and ureteroscopy are sometimes required.2,3
The efficacy of SWL and its low morbidity rate make it a
desirable option in the management of ureteral stones, even
proach may help to resolve the obstruction definitively and

spare the patient from suffering. However, previous studies
dedicated to emergency SWL were performed in a retrospective manner. In addition, they included stones of different sizes
and locations: some of the relatively small calculi in the lower
ureter could have passed without any treatment. Moreover,
these studies did not compare the results of emergency and
scheduled SWL.
We designed a prospective study that included only patients
with stone sizes from 5 mm to 1.5 cm that were located in the
upper urinary tract (UPJ or upper ureter). We compared the results of emergency and scheduled SWL and included in the
analysis the work time lost by the patients during hospitaliza-
17
Upper ureter
Obstruction (%)
Stones resistant to SWL (%)
Stone-free rate (%)
Re-SWL
AuxiResults
liary procedure (%)
EQ
Mean days before SWL (range)
Hospital days for pain control
Hospitalization (days) (range)
Outpatient visits (range)
88
24
33
64
16
28
44
26! 5.85 (1534)
4.84! 1.344 (37)0
7.72! 2.132 (513)
1.6 ! 1.08 (04)0
groups (N " 25) according to sequentially numbered sealed envelopes. Patients in the study group underwent SWL within 48
to 72 hours (emergency SWL); patients in the control group
were discharged from the hospital after conservative treatment
and scheduled for SWL within 30 days. In cases of intractable
pain, an internal stent or nephrostomy tube was inserted and removed only after the definitive treatment. There was no significant difference between the control and study groups with
respect to age, sex, or stone location or size or renal obstruction (Table 1).
Lithotripsy protocol
Stones were fragmented with an Econolith electrohydraulic

lithotripter (focal-point depth 135170 mm; focus area 60/13
mm length/width, spark voltage 1522.5 kV) (Medispec Group,
Israel). In every procedure, 3000 to 3500 shockwaves were de-
72
20
40
72
8
28
53
02! 0.707 (13)
3.44! 1.635 (29)0
5.76! 3.218 (315)
1.04! 1.064 (03)0
The results are expressed as the arithmetic mean ! SD. To

compare patient and disease features such as age, stone size,
days spent for pain control, hospitalization, outpatient visits,
and days spent recovering at home in the two groups, we used
the Student t-test. To assess the difference in categorical variables (sex, stone location, obstruction, stone-free rate, stone
composition, repeat SWL and auxiliary procedures), the subset
!2 test was used. For this purpose, we employed SPSS 10.0 statistical software, and P % 0.05 was considered significant.
RESULTS
0.733b
0.501b
0.37b
0.384b
1.0b
12-06-06
In the study group, SWL was performed within 1 to 3 days

(mean 2 ! 0.7 days; 76% within 48 hours). Patients in the control group were scheduled for SWL within 12 to 30 days (mean
TABLE 1. CLINICAL AND STATISTICAL DATA OF TWO PATIENT GROUPS
Mean age (range)
M/F (%)
Mean stone size (mm) (range
mm)
Calculi #1 cm (%)
Stone site (%)
UPJ
Upper ureter
Obstruction (%)
Stones resistant to SWL (%)
Stone-free rate (%)
Re-SWL
Auxiliary procedure (%)
EQ
Mean days before SWL (range)
Hospital days for pain control
Hospitalization (days) (range)
Outpatient visits (range)
aStudent's t-test.
b!Student's
2 test. t-test.
Control Group
47.92 ! 11.679
(2263)
44/56
6.88 ! 2.421
(513)
17.8
12
88
24
33
64
16
28
44
26 ! 5.85 (1534)
4.84 ! 1.344 (37)0
7.72 ! 2.132 (513)
1.6 ! 1.08 (04)0
Study group
P value
45.20 ! 10.607
(2565)
36/64
7.40 ! 2.398
(512)
28
0.393a
28
72
20
40
72
8
28
53
0 2 ! 0.707 (13)
3.44 ! 1.635 (29)0
5.76 ! 3.218 (315)
1.04 ! 1.064 (03)0
0.564b
0.449a
0.0018
0.014a
0.042a
0.194a
0.157b
0.733b
0.501b
0.37b
0.384b
1.0b
0.0018
0.014a
0.042a
b! 2
test.
Conclusion
Early
SWL may have benefits in

reducing pain and morbidity compared
with observation or delayed SWL
Less
SWL sessions needed
Studies
did not use medical expulsive
therapy
18
12-06-06
Management of Failed SWL

Repeat
SWL referral for failed previous
SWL
Is
this the optimum management?
Is
the success rate of subsequent

procedures equivalent to the initial
procedure?
Studies looking at repeat SWL

Seitz
et al, Euro Urol, 49: 1099-1106,
2006
20% of patients underwent 3rd and 4th SWL
Only 7% improvement in success
Pace
et al, J Urol, 164: 1905-07, 2000
19
12-06-06
0022-5347/00/1646-1905/0
Copyright 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 164, 19051907, December 2000

Printed in U.S.A.
LOW SUCCESS RATE OF REPEAT SHOCK WAVE LITHOTRIPSY FOR

URETERAL STONES AFTER FAILED INITIAL TREATMENT
KENNETH T. PACE, MICHAEL J. WEIR, NAUMAN TARIQ
AND
R. JOHN DA. HONEY
From the Division of Urology, Saint Michaels Hospital and the University of Toronto, Toronto, Ontario, Canada
ABSTRACT
1,593 ureteral calculi (1994
1999)
Purpose:
We
determined
the
number
of
shock
Dornier
MFL 5000 Lithotripter wave lithotripsy treatments that should be given
for a single ureteral stone before alternate modalities are used.
Compared
rate of
vs. re-treatment
Materials andstone
Methods:free
We compared
the initial
stone-freetreatment
rate of initial shock
wave lithotripsy for
ureteral calculi with that of subsequent treatments. We evaluated 1,593 ureteral stones treated
with the Dornier MFL 5000 lithotriptor* from January 1, 1994 to September 1, 1999 using
various parameters
associated with
treatment
Multivariate
analysis
looking
atoutcome.
predictors of stone free status
Results: The stone-free rate after initial treatment was 68% (1,086 of 1,593 stones), which
Stone
size(126 of 273) after re-treatment 1. We observed a further decrease in the
decreased
to 46%
stone-free
rate
after re-treatment 2 to 31% (19 of 61 stones, p ! 0.001). The cumulative stone-free
Stone location
rate increased to 76% (1,212 of 1,593 stones) after 2 treatments and to 77% (1,231 of 1593) after
The
BMI
3.
stone-free rate for stones 10 mm. or less was significantly better than that of stones 11 to
20
mm.
(64% versusstent
43%) and after re-treatment (49% versus 37%). A ureteral stent
Useinitially
of ureteral
decreased the stone-free rate of initial treatment and re-treatment 1 by 12% and 14%, respectively (p ! 0.001). After initial treatment the stone-free rate of the upper and mid ureter was
significantly higher than that of the lower ureter. Patient weight had no significant impact on
success in either group.
Pace etureteral
al, J Urol,
164:
1905-07,
2000
Conclusions: The stone-free rate of re-treating
calculi
with
shock wave
lithotripsy
decreases significantly after the initial treatment. These findings imply that ureteroscopic
management of ureteral stones may be better than shock wave lithotripsy after initial shock
wave lithotripsy fails.
KEY WORDS: ureter, ureteral calculi, lithotripsy, treatment outcome
Shock wave lithotripsy may be done to manage calculi at

any location throughout the urinary tract. However, the success rate of shock wave lithotripsy varies according to stone
size and location. Ureteral stones are known to fragment less
effectively than renal stones but shock wave lithotripsy remains the preferred treatment method for ureteral stones at
many centers due to its minimally invasive nature.1, 2 Advances in technology have resulted in the high success rate of
modern ureteroscopy with a low incidence of complications,
which has led others to question the supremacy of shock
wave lithotripsy for ureteral calculi, especially those at the
lower third of the ureter.3, 4
There is no consensus on the number of shock wave lithotripsy treatments for ureteral calculi that should be administered for a single stone before alternate modalities are
used. Kim et al suggested that no more than 3 treatments
should be given for a particular stone due to minimal improvement in the subsequent cumulative treatment success
rate.5 We compared the success rate of initial shock wave
lithotripsy for ureteral calculi with that of subsequent treatments to determine whether more than 1 treatment is justified for any single ureteral stone. Other parameters of treatment outcome were also studied.
8%
1906
aged by 1,966 shock wave lithotripsy treatments. Patients

were routinely followed 2 weeks and 3 months after lithotripsy with plain abdominal x-ray of the kidneys, ureters and
bladder. Those with an equivocal plain x-ray underwent excretory urography or noncontrast spiral computerized tomography as necessary to confirm stone-free status and exclude
obstruction. Complete followup data were not available on
patients who drove more than 1 hour to and from the lithotripsy unit since they were followed by the referring urologist. They represent a population similar to those followed at
the lithotripsy unit and, thus, we do not believe that there
was any significant effect on treatment results.
We compared the stone-free rate of the initial treatment
and re-treatments given for a single calculus using the last
treatment result available before any further therapy for the
stone. Treatment success rates were stratified according to
stone size and location, ureteral stenting and patient weight.
We performed chi-square analysis using the MantelHaenszel procedure and Fishers 2-tailed exact test to determine significance. Logistic regression techniques were used
to analyze the importance of patient gender, body weight, the
treating urologist, ureteral stenting, initial stone size and
location,1%
shock wave lithotripsy
fluoroscopy time and final
1%
stone-free status. Bonferroni adjustments were made to prevent multiple testing bias.
LOW SUCCESS OF REPEAT SHOCK WAVE LITHOTRIPSY FOR URETERAL STONES

Results
TABLE 1. Stone-free rate for shock wave lithotripsy of ureteral stones
Stone-Free Rate
Individual
Cumulative (1,593 stones)
No. Stones/Total No. (%)
Initial Treatment
Re-Treatment 1
Re-Treatment 2
Re-Treatment 3 or More
1,086/1,593(68)
1,086(68)
126/273(46)
1,212(76)
19/61(31)
1,231(77)
13/39(33)
1,245(78)
MATERIALS AND METHODS
From January 1, 1994 to September 1, 1999 we treated

2,754 ureteral calculi in 2,424 patients with the Dornier MFL
5000 lithotriptor at the Kidney Stone Center at our institution. After excluding uric acid and cystine stones complete
followup data were available on 1,593 ureteral calculi man-
was68%(1,086of1,593stones)butitdecreasedsignificantly
to 46% (126 of 273) after 1 and to 31% (19 of 61) after 2
re-treatments (p ! 0.001). After 2 and 3 treatments the
cumulative stone-free rate increased from 68% to 76% and
77%, respectively. The success rate of initial treatment for
stones10orlessversus11to20mm.was74%versus43%(p
"0.001, table 2). Re-treatment 1 and 2 stone-free rates were
Accepted for publication July 21, 2000.
* Dornier Medical Systems, Inc., Marietta, Georgia.
RESULTS
TABLE 3. Stone-free rate versus ureteral stone location
During 1,966 lithotripsy sessions we treated 1,593 ureteral

calculi in 1,588 patients 5 to 90 years old, including 1,143
males (72%) and 445 (28%) females. Gender information was
Pace et
al, J Urol,
1905-07,
2000that the stone-free
unavailable
in 5164:
patients.
Table 1 shows
rate after initial shock wave lithotripsy for ureteral stones
Ureteral Location
1905
Upper
Mid
Lower
Overall
Initial Treatment
Re-Treatment 1
755/1,071(70)
232/340 (68)
99/182 (54)
1,086/1,593(68)
62/124(50)
25/53 (47)
39/96 (41)
126/273(46)
20
semirigid ureteroscopes and flexible ureterorenoscopes as

well as the introduction of the holmium:YAG laser have
improved the ureteroscopy stone-free rate while decreasing
the risk of complications.710 Advances in endourological calculous management have led others to suggest that ureteroscopy should be offered as an equally viable alternative to
shock wave lithotripsy for treating ureteral stones,11 particularly those of the distal ureter.3, 4
Ureteral stones that fail to clear after initial shock wave
lithotripsy are less likely to clear after subsequent retreatment. In our study the stone-free rate of re-treatment 1
was significantly less than that of initial treatment (46%
versus 68%). We noted a similar trend in the stone-free rate
when comparing re-treatments 2 and 1 (31% versus 46%). An
Results
CCESS OF REPEAT SHOCK WAVE LITHOTRIPSY FOR URETERAL STONES
TABLE 2. Stone-free rate versus ureteral stone size
TABLE 1. Stone-free rate for shock wave lithotripsy of ureteral stones

Stone Size (mm.)
No. Stones/Total
No. (%)
Initial
Treatment
Initial Treatment
1,086/1,593 (68)
1,086 (68)
Re-Treatment
1
10 or Less
1120
126/273
(46)
Greater than 20
1,212 (76)
es) but it decreased significantly

and to 31% (19 of 61) after 2
After 2 and 3 treatments the
ncreased from 68% to 76% and
ess rate of initial treatment for
20 mm. was 74% versus 43% (p
nt 1 and 2 stone-free rates were
n 11 to 20 mm. (49% versus 37%
tively, p ! 0.006).
ee rate based on ureteral calcurate decreased with more distal
uent shock wave lithotripsy sesureteral stone-free rate was 70%
t only 50% for re-treatment 1.
icantly worse for lower ureteral
free rate after initial treatment
eatment 1.
ed the stone-free rate of initial
1 by 12% and 14%, respectively
nts without a stent and with a 0
n 8% better stone-free rate than
ize but with an indwelling stent.
11 to 20 mm. calculi the stonen in the stented group. Logistic
d that initial stone size, initial
versus the upper or mid ureter
ssociated with a lower stone-free
0.03, respectively). Patent body
fluoroscopy time, number of
nd gender were not significant
ome.
USSION
e lithotripsy for urinary calculi

ily renal stones to include those
nary tract.4, 6 However, the sucotripsy for fragmenting ureteral
r renal stones. Advances in urehe introduction of small caliber
d flexible ureterorenoscopes as
the holmium:YAG laser have
stone-free rate while decreasing
Advances in endourological calothers to suggest that ureterosn equally viable alternative to
eating ureteral stones,11 particeter.3, 4
o clear after initial shock wave
Overall
Re-Treatment 1
Re-Treatment
964/1,294
(74) 2
77/178 (43)
19/61 (31)
45/121 (37)
1,231 (77)
1,086/1,593 (68)
Re-Treatment 2
32/4
or More
101/205Re-Treatment
(49)
(50)
16/41 (39)
9/27 (33)
126/273 (46)
11/33 (33)
13/39 (33)
6/24 (25)
1,245 (78)
19/61 (31)
et al observed that stone impaction ne

outcome, possibly because there is less
surrounding these calculi.5
Poorer results have been reported
stones, although the 12-06-06
cumulative stone-fre
ments in the series of Kim et al was not
mal, mid or distal ureteral calculi.5 We
decreased success for initially treated di
than those of the mid and upper urete
continued during subsequent re-treatme
cess rate for distal stones in our series m
the difficulty in targeting calculi in the d
as the passage of shock waves through th
of the buttocks when lithotripsy was do
supine, and through the sigmoid colon wh
empty and the patient was prone. In add
calcium oxalate monohydrate calculi may
ily down the ureter and, thus, be treated
the lower ureter. Data available in 606 o
(38%) indicated that calculi treated in th
more likely to have a primarily calcium o
composition than those treated elsewh
(70.2% versus 64%, p ! 0.005). A prima
TABLE 3. Stone-free rate versus ureteral stone location

Ureteral Location
Upper
Mid
Lower
Overall

Initial Treatment
Re-Treatment 1
755/1,071 (70)
232/340 (68)
99/182 (54)
1,086/1,593 (68)
62/124 (50)
25/53 (47)
39/96 (41)
126/273 (46)
Pace et al, J Urol, 164: 1905-07, 2000

TABLE 4. Stone-free rate versus ureteral stent
Stent
No stent
Overall
Initial Treatment
Re-Treatment 1
177/303 (58)
909/1290 (70)
1,086/1,593 (68)
31/85 (36)
95/188 (51)
126/273 (46)
Explanation and Criticism
explanation for the decreased stone-free rate for retreatment is that initial shock wave lithotripsy is successful
forThe
softer initial
stones and,
thus, it selects
out a group
harder
treatment
selects
out of
softer
calculi that are less amenable to shock wave lithotripsy fragstones
mentation
when re-treated.
We identified other factors that appeared to affect the
stone-free rate in our patients who underwent shock wave
lithotripsy.
Large
stone size causedstones
a decreased
stone-freeas
Smooth
monohydrate
present
rate in patients treated 1 to 3 times. This factor is likely most
distalwhen
stones
important
considering repeat shock wave lithotripsy.
Ureteral
stenting
during
also influenced the
Distal stones
70%treatment
monohydrate
stone-free rate in our patients independent of calculous size.
Proximal
monohydrate
Most
others have stones
reported 64%
no difference
in the shock wave
lithotripsy success rate based on ureteral stenting during
treatment as well as no difference in the complication rate
after
shock wave
lithotripsy.
Dornier
MFL
50001215 Although the difference in
our patients was 12% and 14% for initial treatment and
re-treatment 1, each value achieved significance, partially
due to the large numbers in our analysis. Ureteral stenting is
probably done more often for impacted stones, which may
partially explain the lower stone-free rate in this group. Kim
et al observed that stone impaction negatively influenced
outcome, possibly because there is less of a water interface
surrounding these calculi.5
Poorer results have been reported for distal ureteral
stones, although the cumulative stone-free rate after 3 treatments in the series of Kim et al was not different for proximal, mid or distal ureteral calculi.5 We noted significantly
decreased success for initially treated distal ureteral stones
than those of the mid and upper ureter, and this pattern
21
12-06-06
Conclusions
Re-treatment
success rates of SWL are
low
Patients
who fail or have poor response

to initial SWL, should be referred for
ureteroscopy, especially patients with
large distal calculi
Management Options:
Observation
Medical
expulsive therapy (MET)
SWL
Ureteroscopy
22
12-06-06
1997 AUA Guidelines

Poor
quality evidence
Mostly based on retrospective studies
Distal
ureter SWL or URS

Proximal ureter SW if <10mm
Segura et al, J Urol, 158: 1915, 1997
Table 1. Stone-Free Rates for SWL and URS in the Overall Population
2007 AUA/EUA Guidelines
23
12-06-06
Extracorporeal shock wave lithotripsy (ESWL) versus

ureteroscopic management for ureteric calculi (Review)
Aboumarzouk OM, Kata SG, Keeley FX, Nabi G
Aboumarzouk et al, The Cochrane Collaboration, 2011

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2011, Issue 12
http://www.thecochranelibrary.com
Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Results
Identified 7 RCTs
1205 patients
Location
4 distal
1 mid
1 proximal
Only semi-rigid ureteroscopy

Variety of lithotripters (1st to 3rd generation)
Success = stone free @ 3 months
24
12-06-06
Results Stone Free Rate

Analysis 1.1. Comparison 1 ESWL versus ureteroscopy, Outcome 1 Stone-free rate.
Review:
Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi
Comparison:
Outcome:
1 ESWL versus ureteroscopy
1 Stone-free rate
Study or subgroup
Hendrikx 1999
Lee 2006
Pearle 2001
ESWL
Ureteroscopy
n/N
n/N
Risk Ratio
Weight
35/69
79/87
12.0 %
7/22
7/20
2.2 %
0.91 [ 0.39, 2.14 ]
29/32
29/32
15.4 %
1.00 [ 0.85, 1.17 ]
M-H,Random,95% CI
Risk Ratio
M-H,Random,95% CI
0.56 [ 0.44, 0.71 ]
Peschel 1999
36/40
40/40
17.1 %
0.90 [ 0.81, 1.01 ]
Salem 2009
71/100
96/100
16.4 %
0.74 [ 0.65, 0.84 ]
Verze 2010
127/137
129/136
18.7 %
0.98 [ 0.92, 1.04 ]
Zeng 2002
164/210
168/180
18.2 %
0.84 [ 0.77, 0.91 ]
610
595
100.0 %
0.84 [ 0.73, 0.96 ]
Total (95% CI)
Total events: 469 (ESWL), 548 (Ureteroscopy)

Heterogeneity: Tau2 = 0.02; Chi2 = 47.37, df = 6 (P<0.00001); I2 =87%
URS

Test for subgroup differences: Not applicable
0.2
SWL
0.5
Favours ureteroscopy
Favours ESWL
Results Retreatment Rate

Analysis 1.2. Comparison 1 ESWL versus ureteroscopy, Outcome 2 Retreatment rate.
Review:
Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi
Comparison:
Outcome:
1 ESWL versus ureteroscopy
2 Retreatment rate
Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Study or subgroup
Lee 2006
ESWL
Ureteroscopy
n/N
n/N
7/22
0/20
Risk Ratio
M-H,Random,95% CI
29
Risk Ratio
M-H,Random,95% CI
13.70 [ 0.83, 225.43 ]
Pearle 2001
0/32
0/32
0.0 [ 0.0, 0.0 ]
Peschel 1999
0/40
0/40
0.0 [ 0.0, 0.0 ]
Salem 2009
22/100
0/100
45.00 [ 2.77, 731.79 ]
Verze 2010
57/137
10/136
5.66 [ 3.02, 10.61 ]
Zeng 2002
25/210
4/180
5.36 [ 1.90, 15.10 ]
541
508
6.18 [ 3.68, 10.38 ]
Total (95% CI)
Total events: 111 (ESWL), 14 (Ureteroscopy)

Heterogeneity: Tau2 = 0.0; Chi2 = 2.70, df = 3 (P = 0.44); I2 =0.0%
Test for overall effect: Z = 6.88 (P < 0.00001)
SWL
URS
Test for subgroup differences: Not applicable
0.001 0.01 0.1

Favours ESWL
10 100 1000
Favours ureteroscopy
25
12-06-06
Results
Favors SWL
Auxiliary procedures
Complications
Hospital stay/recovery
No conclusions on
Post procedural symptoms
Efficiency quotient
Patient satisfaction
No significant difference
Stone size
Aboumarzouk et al, The Cochrane Collaboration, 2011
Treatment of Ureteral and Renal Stones: A Systematic Review

and Meta-Analysis of Randomized, Controlled Trials
Brian R. Matlaga,*, Jeroen P. Jansen, Lisa M. Meckley, Thomas W. Byrne
and James E. Lingeman
From The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland, Mapi Group, Boston and
Boston Scientific Corp., Natick, Massachusetts, and Indiana Clinic Urology, Indiana University School of Medicine, Indianapolis, Indiana
Abbreviations
and Acronyms
Purpose: We compared the clinical outcomes of patients with ureteral or renal

stones treated with ureteroscopy, shock wave lithotripsy using HM3 (Dornier)
and nonHM3
lithotripters, calculi
and percutaneous nephrolithotomy.
9 RCTs looking
at ureteral
Materials and Methods: A systematic literature search identified 6, 4 and 3
randomized, controlled trials of treatment of distal and proximal ureteral stones,
1375 patients and renal stones, respectively, published between 1995 and 2010. Overall stoneAUA ! American Urological
Association
EAU ! European Association of

Urology
PNL ! percutaneous
nephrolithotomy
RCT ! randomized, controlled
trial
SFR ! stone-free rate
SR ! semirigid
SWL ! shock wave lithotripsy
URS ! ureteroscopy
Submitted for publication October 18, 2011.

Study received institutional review board approval.
Supported by Boston Scientific.
* Correspondence: The James Buchanan Brady
Urological Institute, The Johns Hopkins University
School of Medicine, Park 2, 600 North Wolfe St.,
Baltimore, Maryland 21287 (e-mail: bmatlaga@
jhmi.edu).
Financial interest and/or other relationship
with Boston Scientific.
with Mapi Values.
with Boston Scientific, Lumenis, Olympus, Karl
Storz Endoscopy, Midwest Mobile Lithotripsy and
Midstate Mobile Lithotripsy.
free, re-treatment and complication rates were calculated by meta-analytical

techniques.
Results: Based on the randomized, controlled trials evaluated the treatment of
distal ureteral stones with semirigid ureteroscopy showed a 55% greater probability (pooled RR 1.55, 95% CI 1.132.56) of stone-free status at the initial
assessment than treatment with shock wave lithotripsy. Patients treated with
semirigid ureteroscopy were also less likely to require re-treatment than those
treated with shock wave lithotripsy (nonHM3) (RR 0.14, 95% CI 0.08 0.23). The
risk of complications was no different between the 2 modalities. Only 2 of the 4
randomized, controlled trials identified for proximal ureteral stones evaluated
flexible ureteroscopy and each focused specifically on the treatment of stones 1.5
cm or greater, limiting their clinical relevance. The degree of heterogeneity
among the studies evaluating renal stones was so great that it precluded any
meaningful comparison.
Conclusions: Semirigid ureteroscopy is more efficacious than shock wave lithotripsy for distal ureteral stones. To our knowledge there are no relevant randomized,
controlled trials of flexible ureteroscopy treatment of proximal ureteral calculi of a
size commonly noted in the clinical setting. Collectively the comparative effectiveness of ureteroscopy and shock wave lithotripsy for proximal ureteral and renal
calculi is poorly characterized with no meaningful published studies.
Matlaga et al, J Urol, 188: 130-137, July 2012
Key Words: kidney, ureter, calculi, lithotripsy, ureteroscopy

KIDNEY stones are a common and
costly disease. Recent epidemiological investigations show that approximately
10% of the population in the United
States is affected by kidney stone disease in their lifetime and this rate is
1
a significant economic burden on society. The Urologic Diseases in America

project estimated an annual cost of
more than $2 billion in the United
States alone.2
Most patients with symptomatic
26
12-06-06
Results Distal Stones

URS
55% better than SWL-nonHM3
RR 1.55 (95%CI 1.13-2.56)
fold less re-treatment rates with URS

vs. SWL-nonHM3
RR 0.14 (95%CI 0.08-0.23)
No
difference between URS and SWLHM3

Based on 1 study
More
auxiliary procedures with URS

No difference in complications
Matlaga et al, J Urol, 188: 130-137, July 2012
Results Proximal Stones

URS
better than all SWL modalities
RR 1.35 (1.20-1.56) vs. HM3

RR 1.15 (1.00-1.77) vs. new SWL
URS
lower retreatment rates
More
complication with flexible

ureteroscopy
Based on 1 study
27
12-06-06
Practice Patterns
Bandi
et al, J Endourol, 22(4): 631-5,
2008
Surveyed 790 members of North Central
Section of AUA
167 respondents
Satkunasivam
and Pace, Can Urol

Assoc J, 5(5): 324-7, 2011
131 CUA member respondents
28
12-06-06
Conclusions
URS
better for distal stones
URS
better for proximal stones
Flexible scopes, lower success of new
lithotripters
SWL still very prevalent
Resource availability
Careful patient selection
29
12-06-06
Evolution of Lithotripters - Is the

new technology any better?
Original Dornier HM3
1980 first human

1984 FDA approval
SFR 77-90% for solitary
renal calculi
Draw backs
Large size
Water bath
Need for anesthesia
Miller and Lingeman, Nat Clin Prac
Urol, 3(5): 236-8, 2006
30
12-06-06
Generating Shockwaves
Focal Zone
Wider aperture less
shockwave density
reduced pain no
anesthesia
Wider aperture smaller
focal zone ? Lower
success
Small focal zone of high
energy ?more tissue
injury
31
12-06-06
Have the design modifications

helped?
More
mobile with less analgesia

requirements
Data
suggests that 2nd and 3rd

generation lithotripters are inferior to
original Dornier HM3
UBC Connection
0022-5347/95/1536-1794$03.00/0
Copyright 0 1995 by AMERICAN
UROLOGICAL
A~SOCIATION,
INC.
Vol. 153,1794-1797,June 1995

Printed in U.S.A.
A PROSPECTIVE TRIAL COMPARING THE EFFICACY AND

COMPLICATIONS OF THE MODIFIED DORNIER HM3 AND MFL 5000
LITHOTRIPTORS FOR SOLITARY RENAL CALCULI
S. L. CHAN, L. STOTHERS, A. ROWLEY, Z. PERLER, W. TAYLOR
AND
L. D. SULLIVAN
From the Division of Urology, Department of Surgery and Division of Uroradiology, Department of Radiology, University of British
Columbia, Vancouver, British Columbia, Canada
ABSTRACT
A prospective randomized study of 198 patients was conducted to compare the efficacy of the
et al,lithotriptor.
J Urol, 153:
1794-97,
1995
modified Dornier HM3 lithotriptor to theChan
MFL 5000
Entrance
criteria included
solitary stones at any location within the upper collecting system that had not previously been
treated with lithotripsy. Following lithotripsy the patients were evaluated by a blinded radiologist with a plain abdominal film, tomograms and renal ultrasound at 1 , 4 and 12 weeks. Patients
were classified at 12 weeks after lithotripsy as failing treatment if any stone fragments were
imaged. Of the patients 170 were available for complete 3-month followup. No statistical or
clinical difference in stone-free rates was apparent for calculi in the ureter or renal pelvis in
either group. Of patients with lower caliceal stones 80%had no residual fragments visualized at
12 weeks when treated with the modified HM3 device versus 56%with the MFL 5000 lithotriptor
(p = 0.05). Treatment time on the MFL 5000 unit was significantly prolonged compared with the
modified HM3 device (0.7 hours versus 0.4 hours, respectively) resulting in fewer patients being
treated in a given day (p <0.001).No statistical difference in complication rates could be found
between the 2 machines. Steinstrasse were noted in 10%of the patients treated with the modified
HM3 device and 6% of the MFL 5000 group. Subcapsular hematomas were noted in 4% of the
MFL 5000 treatment arm compared to 1%in the modified HM3 group. Overall, the MFL 5000
lithotriptor was believed to offer no significant clinical advantage over the modified HM3 device
in terms of lithotripsy efficacy, although the multifunctional table did offer more versatility for
32
12-06-06
Bierkens et al, J Urol, 148: 1052-56, 1992

Multi-centre randomized trial, 1800 patients
2nd generation lithotripters
45% stone free rate
20% re-treatment rate
Third-generation
machines
40-80% stone free

7-40% re-treatment
Storz Modulith SLX-F2

Two focal zones
Narrow (6 x 28mm)
Wide (9 x 50mm)
Better stone
fragmentation in vitro
than HM3
(Teichman et al, J Urol, 164:
1259-64)
33
EUROPEAN UROLOGY 59 (2011) 637644
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
12-06-06
Stone Disease
A Prospective Randomised Trial Comparing the Modified HM3

with the MODULITHW SLX-F2 Lithotripter
Pascal Zehnder, Beat Roth, Frederic Birkhauser, Silvia Schneider, Rolf Schmutz,
George N. Thalmann, Urs E. Studer *
Department of Urology, University of Bern, Bern, Switzerland
Article info
Article
820
patients
history:
January
2011
Accepted
HM3
vs. 14,
SLX-F2
Published online ahead of
print
on
January
25,
2011
Wide focus
Keywords:
HM3
Prospective randomised
comparison
Shock wave lithotripsy
SLX-F2
Abstract
Background: The relative efficacy of first- versus last-generation lithotripters is
unknown.
Objectives: To compare the clinical effectiveness and complications of the modified Dornier HM3 lithotripter (Dornier MedTech, Wessling, Germany) to the
MODULITH1 SLX-F2 lithotripter (Storz Medical AG, Tagerwilen, Switzerland) for
extracorporeal shock wave lithotripsy (ESWL).
Design, setting and participants: We conducted a prospective, randomised, singleinstitution trial that included elective and emergency patients.
Interventions: Shock wave treatments were performed under anaesthesia.
Measurements: Stone disintegration, residual fragments, collecting system dilatation, colic pain, and possible kidney haematoma were evaluated 1 d and 3 mo after
ESWL. Complications, ESWL retreatments, and adjuvant procedures were documented.
Results and limitations: Patients treated with the HM3 lithotripter (n = 405)
required fewer shock waves and shorter fluoroscopy times than patients treated
with the MODULITH1 SLX-F2 lithotripter (n = 415). For solitary kidney stones, the
HM3 lithotripter produced a slightly higher stone-free rate ( p = 0.06) on day 1;
stone-free rates were not significantly different at 3 mo (HM3: 74% vs MODULITH1
SLX-F2: 67%; p = 0.36). For solitary ureteral stones, the stone-free rate was higher at
3 mo with the HM3 lithotripter (HM3: 90% vs MODULITH1 SLX-F2: 81%; p = 0.05).
For solitary lower calyx stones, stone-free rates were equal at 3 mo (63%). In patients
with multiple stones, the HM3 lithotripters stone-free rate was higher at 3 mo (HM3:
64% vs MODULITH1 SLX-F2: 44%; p = 0.003). Overall, HM3 lithotripter led to fewer
secondary treatments (HM3: 11% vs MODULITH1 SLX-F2: 19%; p = 0.001) and fewer
kidney haematomas (HM3: 1% vs. MODULITH1 SLX-F2: 3%; p = 0.02).
Conclusions: The modified HM3 lithotripter required fewer shock waves and shorter
fluoroscopy times, showed higher stone-free rates for solitary ureteral stones and
multiple stones, and led to fewer kidney haematomas and fewer secondary treatments than the MODULITH1 SLX-F2 lithotripter. In patients with a solitary kidney
and solitary lower calyx stones, results were comparable for both lithotripters.
Zehnder et al, Euro Urol, 59: 637-44, 2011
Endourology and Stones
# 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Factors Determining Stone-free Rate in

Shock Wave Lithotripsy Using Standard
Focus of Storz Modulith SLX-F2 Lithotripter
* Corresponding author. Department of Urology, University Hospital of Bern, Inselspital, 3010 Bern,
Switzerland. Tel. +41 31 632 3641; Fax: +41 31 632 2180.
E-mail address: urs.studer@insel.ch (U.E. Studer).
0302-2838/$ see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2011.01.026
Mohamed A. Elkoushy, Jacob A. Hassan, Douglas D. Morehouse, Maurice Anidjar, and

Sero Andonian
OBJECTIVES
To calculate the efficiency quotient (EQ) of the latest mobile Storz Modulith SLX-F2 lithotripter
and to identify the factors determining the stone-free rate.
METHODS
Retrospective
review,review
553
patients
A retrospective
of aconsecutive
prospectively collected
database of the first consecutive 533 patients
undergoing shock wave lithotripsy (SWL) from June 2009 to February 2010 was performed. A total
Mean stoneofsize
8.7mm
16 patients
with radiolucent stones and 43 patients with incomplete follow-up were excluded. The
patients were followed up with plain radiography to assess the stone-free status. Univariate and
Narrow focus
multivariate analyses were performed to identify the factors determining the stone-free rates.
RESULTS
Follow-up was complete for 474 patients, with a mean age of 54.2 ! 14.5 years. The success rate
after a single SWL session was 82.7% (renal 82.2% and ureteral 83.3%; P " .81). The
retreatment rate was 14.7% (renal 15.2% and ureteral 14.2%; P " .79). The stone-free rate was
77% (renal 74.1% and ureteral 80.9%; P " .10). Of the 474 patients, 43 had pre-SWL ureteral
stents, and 13 required post-SWL ureteral stenting; 35 patients required post-SWL curative
procedures. The EQ was 0.66, and the modified EQ was 0.62. On multivariate analysis, the
stone-free patients had a smaller stone size (9.5 vs 10.3 mm, P " .02), younger age (53.1 vs 58.0
years, P " .002), right-sided stones (83.6% vs 71.0% P " .001), and the absence of a ureteral
stent (78.7% vs 64.3%; P " .001).
The mobile Storz Modulith SLX-F2 lithotripter has an acceptable EQ of 0.66. In the present
study, smaller stones (#10 mm), younger age, right-sided stones, and the absence of ureteral
stents were associated with significantly greater stone-free rates. UROLOGY 78: 759 763, 2011.
2011 Elsevier Inc.
Stone free rate: 80.9%

Re-treatment rate: 14.2%
Efficiency quotient: 66%
CONCLUSIONS
Factors associated with higher stone free rate

Younger age
inceSize
<10mm
its invention,
shock wave lithotripsy (SWL)
human model 3 (HM3) lithotripter is 0.64-0.67, there is a
remains one of the first-line options for the manwide variation among the reported EQs of the EM Storz
of upper urinary tract calculi. However,
Modulith lithotripters (0.57-0.67). Therefore, the first obagement
No stent
the latest generation of electromagnetic (EM) shock wave
jective of the present study was to calculate the EQ of the
lithotripters
with smaller
preslatest fourth-generation mobile Storz Modulith SLX-F2
Right
sidefocal areas and greater peak
Elkoushy et al, Urology, 78: 759-63, 2011
sures has been criticized for lower stone-free rates and

greater retreatment rates owing to the difficulty in keeping
the stone in the smaller focal zone.2 One such lithotripter is
the mobile Storz Modulith SLX-F2 lithotripter, which has
an EM cylindrical shock wave generator with dual focal
zones (Table 1). It has been reported to have a success rate
of 83%-86% and a stone-free rate of 70%-76%.3,4 Although
the efficiency quotient (EQ) of the original electrohydraulic
Funding Support: This work was supported in part by the Northeastern American
Urological Association Young Investigator Award and Montreal General Hospital
Foundation Award to S. Andonian.
From the Division of Urology, Department of Surgery, McGill University Health
Centre, McGill University, Montreal, Quebec, Canada
Reprint requests: Sero Andonian, M.D., M.Sc., F.R.C.S.C., Division of Urology,
Royal Victoria Hospital, McGill University Health Centre, 687 Avenue des Pins
Ouest, Suite S6.92, Montreal, QC H3A 1A1 Canada. E-mail: sero.andonian@
muhc.mcgill.ca
Submitted: January 2, 2011, accepted (with revisions): March 7, 2011
2011 Elsevier Inc.
lithotripter using its standard focus.

In addition to the type of lithotripter used, other factors,
such as stone size (burden), location, and composition have
been found to influence the stone-free rates after SWL.6,7
Recent efforts in identifying factors affecting the stone-free
rates have concentrated on the computed tomography (CT)
findings of the stone density measured in Hounsfield units
and skin-to-stone distance.8,9 However, not all patients
have undergone CT scans before referral to SWL. Therefore, the second objective of the present study was to identify the factors determining the stone-free rate after SWL.
PATIENTS AND METHODS

A retrospective review of a prospectively collected SWL database was performed for 533 consecutive patients undergoing
SWL using the standard focus of the mobile Storz Modulith
SLX-F2 (Storz Medical, Kreuzlingen, Switzerland) from June
0090-4295/11/$36.00
759
34
12-06-06
Wide vs. Narrow
Multicentered, Randomized Control Trial

Comparing Narrow Versus Wide Focal Zones
for Shock Wave Lithotripsy of Renal Calculi
Vancouver, Edmonton, London, Toronto, Montreal
Conclusions
? Modulith SLX-F2 better than 3rd
generation machines
Success rate 80%
Advantage of dual focus system not clear
Must emphasize patient selection
Large stones
Obese
Skin to stone distance
Stone density
Location
Prior failed SWL for same stone
35

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12-06-06

Management of Ureteral Calculi:

risk 5-12% (13% men, 7% women)

Bader et al, Eur Urol, 61: 764-772, 2012

/ Medical expulsive therapy

2007 EUA/AUA Nephrolithiasis

observation + offer MET

Preminger et al, J Urol, 178: 2418-2434, 2007

stones 57 mm in diameter was 60%. The

clinical follow-up. This confirmatrospectively. Of these 440 pandings on CT of acute ureteral

oints), distal (below the sacroiliac

ws the relationship of stone

No prior studies, to our knowledge, have

Natural History Size Matters

Spontaneous Passage Rate of

Stones in Mid Ureter

Stones in Distal Ureter

Stones in Ureterovesical Junction

Note.Proximal ureter = above sacroiliac joints, mid ureter =

Coll et al, AJR, 178: 101-103, 2001

AJR:178, January 2002

passage based on size were statistically signifi-

xcept the ureterovesical junction, no sta-

Stones in Mid Ureter

Stones in Distal Ureter

Stones in Ureterovesical Junction

Note.Proximal ureter = above sacroiliac joints, mid ureter =

Medical Expulsive Therapy

Medical therapy to facilitate urinary stone passage:

these drug classes stems from our understanding of

Lancet 2006; 368: 117179

as editorials or commentaries, or studies on the wrong

152 (139165) 1000

main analysis. Indeed, corticosteroids have been shown to

Pooled risk ratio

www.thelancet.com Vol 368 September 30, 2006

AUA Guidelines - MET

blockers better than control

RR 29% (95% CI: 20% to 37%)

9% (95% CI: -7% to 25%)

difference between different alpha

Medical Therapy - New Areas

alpha blockers improve outcomes of

alpha blockers have any role in

Table 2. Lithotripsy outcomes

Endourology and Stones

Efficacy of Tamsulosin Oral Controlled

Flomax (0.4mg) + steroids + analgesics vs. steroids + analgesics

Less Renal colic (68 vs. 22%)

n Europe and North America, an estimated 5%-10%

Georgiev, Urology, 78:1023-28, 2011

At 4 and 12 weeks after ESWL, complete elimination

calices) were included in the present prospective randomized

Table 3. Proportion of patients with re

ESWL " extracorporeal shock wave litho

The present study examined the be

Tamsulosin and doxazosin as adjunctive therapy following

Abdel Rahman M. Zahran