STONE DISEASE

Role of adjunctive medical therapy with nifedipine and deflazacort after extracorporeal shock wave lithotripsy of ureteral stones
Porpiglia F, Destefanis P, Fiori C, Scarpa RM, Fontana D
Divisione Universitaria di Urologia, Dipartimento di Scienze Cliniche e Biologiche, Azienda Ospedaliera S. Luigi, Orbassano, Torino, Italy
Urology 2002; 59:835-8

• Objectives: To increase the success rate of the first treatment of ureteral stones through extracorporeal shock wave lithotripsy (ESWL), we tested the efficacy of a medical therapy with nifedipine and deflazacort administered to patients who had undergone ESWL for ureteral stones.
• Methods: This prospective study lasted from October 1998 to September 2000 and involved 80 patients. All the patients underwent ESWL with Sonolith 4000+. The patients were randomly divided into two groups: 40 patients (group 1) received an “adjunctive” treatment with oral medical therapy (nifedipine and deflazacort); the other 40 patients (group 2) were used as the control group.
• Results: Complete fragment expulsion occurred in 30 (75%) of the 40 patients of group 1 and in 20 (50%) of the 40 patients of group 2 at the endpoint. A statistically significant difference was observed in the stone-free rate (P = 0.02). Concerning the symptomatic therapy, the average diclofenac use was 37.5 mg per patient in group 1 and 86.25 mg per patient in group 2 (P = 0.02).
• Conclusions: The results of this study have shown the role that adjunctive medical therapy with nifedipine and deflazacort given after an ESWL procedure can play in increasing the success rate of ureteral stone treatment. Furthermore, these results would suggest that adjunctive medical therapy can reduce total analgesic consumption after the ESWL procedure.
  
  
• Editorial Comment
  Based on previous studies demonstrating facilitated spontaneous passage of ureteral stones with the use of corticosteroids and calcium channel blockers, the authors performed a prospective, randomized trial evaluating a similar medical regimen in patients with ureteral stones undergoing shock wave lithotripsy. Patients in the group receiving adjuvant medical therapy were treated with a 10-day regimen of nifedipine and deflazacort while the control group received no adjuvant therapy. The study group demonstrated improved rates of fragment discharge and reduced narcotic requirements compared with the control group (75% versus 50% stone free, respectively, and 37.5 mg versus 86.3 mg of diclofenac, respectively).
  This study adds to the mounting evidence that pharmacologic manipulation of ureteral physiology can be used to facilitate the passage of ureteral stones, whether intact or fragmented. Consequently, consideration should be given to instituting a similar medical regimen in eligible patients (those in whom the use of corticosteroids or calcium channel blockers is not contraindicated) presenting to the emergency room with renal colic due to a ureteral stone or in patients undergoing shock wave lithotripsy for ureteral stones. Use of this regimen in patients undergoing shock wave lithotripsy for renal stones has yet to be studied, and therefore it is not clear if improved stone clearance rates can be expected from the kidney.

Dr. Margaret S. Pearle
Associate Professor of Urology
University of Texas Southwestern Med Ctr
Dallas, Texas, USA