Extracorporeal shockwave lithotripsy (ESWL) is more effective for treating distal ureteral stones if patients are placed in a supine rather a prone position, according to a new review and meta-analysis. Tao Li, MD, and colleagues from West China Hospital, Sichauan University, in Chengdu, China, pooled data from 4 randomized and case-control trials of 647 patients. (Patients with multiple stones were excluded.) According to results published online ahead of print by Urologia Internationalis, supine ESWL was associated with more than 4 times the stone-free rate of prone ESWL at the first treatment session and triple the rate at the final session. The researchers found no significant differences between the supine and prone procedures in the average number of shocks per ESWL session, percentage of power used in the first session, or the average number of sessions per patient. “In the supine position, the lithotripter treatment head is in contact with the patient's posterior abdomen and shockwaves entering the body traverse homogenous muscle tissues, reaching the stone with attenuation of only 20% of its power; however, in the prone position, shockwaves entering the body would be significantly decreased because they traverse the air-filled bowel,” the researchers explained. The distance between the skin and stone is also greater in the prone position. No major complications were reported. Most patients experienced transient hematuria and skin reddening; colic developed in 6 patients, and urinary tract infection with fever developed in 3 patients. The researchers acknowledged that certain factors may have affected the comparison, such as the size and location of ureteral calculi, ureteral tube diameter, and surgeon experience.
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Silodosin may aid the passage of a unilateral distal ureteral stone 4 to 10 mm in diameter, a new study suggests. Researchers found an 8 mg daily dose to be “well tolerated and beneficial” for up to 4 weeks of treatment. Results were similar for men and women. The distal ureter is an area of interest for medical expulsive therapy with alpha-blockers such as silodosin because the location contains the highest concentration of alpha-1 adrenergic receptors. “The mechanism of action of silodosin presumably includes blockage of the alpha-adrenergic receptors, thereby relaxing the ureter and potentially providing a spasmolytic effect,” according to lead investigator Roger L. Sur, MD, of the University of California, San Diego, and colleagues. Silodosin performed no better than placebo, however, at eliminating ureteral stones generally, including medial and proximal stones, according to results published online by European Urology. There were also no significant advantages in patient use of pain relievers, emergency room visits, or hospital admissions. The study was a randomized, double-blind, placebo-controlled trial conducted over 4 weeks at 27 locations in the U.S. from 2010 to 2012. The researchers studied 239 men and women with a single ureteral stone 4 to 10 mm in diameter; 6 discontinued due to adverse effects, which included retrograde ejaculation, nausea, dizziness, headache, and nasal congestion. Most effects were considered mild and unrelated to treatment, however. The rate of stone passage was about 23% higher with silodosin compared with placebo. Use of selective alpha-blockers for medical expulsive therapy is cost-effective compared with some other therapies for ureteral stones. Both the American Urological Association and the European Association of Urology list alpha blockers among recommended treatments. The researchers suggested future studies investigate the treatment of mid and proximal ureteral stones, larger stones, and the efficacy of silodosin versus tamsulosin. |
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