Abstract

Introduction: Urinary calculi are a common complaint, affecting the cases in a ratio of 3 men to 1 woman, with advanced incidence between 40 to 50 years of age. Size of the calculus influences the rate of spontaneous calculus passage. Medical expulsive therapy (MET) has been described as an effective conservative treatment option in the initial management of small distal ureteral/ Vesico-Ureteric Junction (VUJ). Ureteroscopy (URS) is indicated in unsuccessful cases of MET. Current European Association of Urology advocates the use of URS as first line treatment for distal ureteric calculus larger than 10 mm. Methods: The study was conducted at a tertiary care hospital in Gujarat, India, nvolving both outpatient and inpatient cases. Patients underwent radiological, blood, and urine evaluations. They were instructed to take silodosin, deflazacort, diclofenac, and maintain supra-hydration. Follow-ups were scheduled every 7 days with X-ray KUB to monitor spontaneous calculus passage. If stone passage was unsuccessful after 28 days, patients underwent planned URS with or without lithotripsy and DJ stenting under anaesthesia. Results: In a cohort of 170 patients with small distal ureteral stones, 89% were successfully managed with medical expulsive therapy (MET), while 11% required ureteroscopy (URS) after unsuccessful MET. Comparative analyses considered factors such as patient demographics, stone characteristics, medical history, lab results, and URS findings, leading to the study’s conclusions. Conclusion: Our study has 170 patients with mid and distal ureteric calculi with size ranging from 4 to 10 mm with mild or no backpressure changes, which were subjected to MET with tablet silodosin, tablet deflazacort, tablet diclofenac and supra-hydration. We documented 88.8% MET success and 11.2% unsuccessful cases of MET. MET success is unaffected by age, gender of the patient, history of prior surgical procedure, diabetic status, hypertension or recurrent stone former status. For calculus size between 4 to 10 mm stone-free rate was achieved with medical therapy in 88.8% of patients with no overt complications. Size of the calculus is a significant predictor of expulsion rate. In our study all cases with unsuccessful MET underwent ureteroscopy for calculus clearance.

• 1.   Johnston W., Low R., Das S. The evolution and progress of ureteroscopy. Urol Clon North Am. 2004; 31: 5-13. doi: 10.1016/S0094- 0143(03)00100-9.
• 2.   Miller N.L., Lingeman J.E. (March 2007). “Management of kidney calculuss”. BMJ. 334 (7591): 468–72. doi:10.1136/ bmj.39113.480185.80. PMC 1808123. PMID 17332586.
• 3.   Gettman M.T., Segura J.W. (March 2005). “Management of ureteric calculuss: issues and controversies”. BJU International. 95 (Suppl 2): 85–93. doi:10.1111/j.1464-410X.2005.05206.x. PMID 15720341. S2CID 36265416.
• 4.   Knudsen B.E., Beiko D.T., Denstedt J.D., Ch. 16: “Uric Acid Urolithiasis”. In Stoller & Meng 2007, pp. 299–308.
• 5.   Macaluso J.N. Jr. Management of calculus disease--bearing the burden. J Urol. 1996 Nov; 156(5): 1579-80. doi: 10.1016/s0022- 5347(01)65452-1. PMID: 8863542.
• 6.   Rahman M.J., Faridi M.S., Mibang N., Singh R.S. Comparing tamsulosin, silodosin versus silodosin plus tadalafil as medical expulsive therapy for lower ureteric calculuss: A randomised trial. Arab J Urol. 2017 Dec 24; 16(2): 245-249. doi: 10.1016/j.aju.2017.11.012. PMID: 29892490; PMCID: PMC5992261.
• 7.   Kumar S., Jayant K., Agrawal M.M., Singh S.K., Agrawal S., Parmar K.M. Role of tamsulosin, tadalafil, and silodosin as the medical expulsive therapy in lower ureteric calculus: a randomized trial (a pilot study). Urology. 2015 Jan; 85(1): 59-63. doi: 10.1016/j. urology.2014.09.022. PMID: 25530364.
• 8.   Wang C.J., Tsai P.C., Chang C.H. Efficacy of Silodosin in Expulsive Therapy for Distal Ureteral Calculuss: A Randomized Doubleblinded Controlled Trial. Urol J. 2016 Jun 28; 13(3): 2666-71. PMID: 27351320.
• 9.   Huang W., Xue P., Zong H., Zhang Y. Efficacy and safety of silodosin in the medical expulsion therapy for distal ureteral calculi: a systematic review and meta-analysis. Br J Clin Pharmacol. 2016 Jan; 81(1): 13-22. doi: 10.1111/bcp.12737. Epub 2015 Sep 21. PMID: 26255996; PMCID: PMC4693578.
• 10.   Sharma G., Pareek T., Kaundal P., Tyagi S., Singh S., Yashaswi T., Devan S.K., Sharma A.P. Comparison of efficacy of three commonly used alpha-blockers as medical expulsive therapy for distal ureter calculuss: A systematic review and network meta-analysis. Int Braz J Urol. 2022 Sep-Oct; 48(5): 742-759. doi: 10.1590/ S1677-5538.IBJU.2020.0548. PMID: 34003612; PMCID: PMC9388169.
• 11.   Gürel K., Gürel S., Kalfaoğlu M., Yilmaz O and Metin A: Does an extra kidney-ureter-bladder radiograph taken in the upright position during routine intravenous urography provide diagnostic benefit? Diagn Interv Radiol 14: 205-211, 2008.
• 12.   Wells I.T., Raju V.M., Rowberry B.K., Johns S., Freeman S.J. and Wells IP: Digital tomosynthesis-a new lease of life for the intravenous urogram? Br J Radiol 84: 464-468, 2011.
• 13.   F. Ahmed, A.M. Zafar, N. Khan, Z. Haider, M.H. Ather, A paradigm shift in imaging for renal colic e is it time to say good bye to an old trusted friend? Int. J. Surg. 8 (3) (2010) 252e256.
• 14.   Coursey C.A., et al. ACR Appropriateness Criteria(R) acute onset flank pain-suspicion of calculus disease. Ultrasound Q. 2012; 28: 227–233.
• 15.   Jendeberg J., Geijer H., Alshamari M., Cierzniak B, Lidén M. Size matters: The width and location of a ureteral calculus accurately predict the chance of spontaneous passage. Eur Radiol. 2017 Nov; 27(11): 4775-4785. doi: 10.1007/s00330-017-4852-6. Epub 2017 Jun 7. PMID: 28593428; PMCID: PMC5635101.
• 16.   Bokka S., Jain A. Hounsfield unit and its correlation with spontaneous expulsion of lower ureteric calculus. Ther Adv Urol. 2019 Dec 3; 11: 1756287219887661. doi: 10.1177/1756287219887661. PMID: 31832102; PMCID: PMC6891007.
• 17.   Gücük A., Uyetürk U. Usefulness of hounsfield unit and density in the assessment and treatment of urinary calculuss. World J Nephrol. 2014 Nov 6; 3(4): 282-6. doi: 10.5527/ wjn.v3.i4.282. PMID: 25374823; PMCID: PMC4220362.
• 18.   Türk C., Knoll T., Petrik A., Sarica K., Skolarikos A, Straub M, Seitz C. EUA Guidelines on Urolithiasis p26, 2015.
• 19.   Yilmaz E., Batislam E., Basar M.M., Tuglu D, Ferhat M., Basarr H. The comparison and efficacy of 3 different α1-adrenergic blockers for distal ureteral calculuss J Urol. 2005; 173: 2010-2.

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