STONE DISEASE

Nifedipine versus tamsulosin for the management of lower ureteral stones
Propiglia F, Ghignone G, Fiori C, Fontana D, Scarpa RM
From the Division of Urology, University of Turin, Orbassano, Turin, Italy
J Urol. 2004; 172: 568-571

• Purpose: We evaluate and compare the effectiveness of 2 different medical therapies during watchful waiting in patients with lower ureteral stones.
• Materials and Methods: A total of 86 patients with stones less than 1 cm located in the lower ureter (juxtavesical or intramural tract) were enrolled in the study and were randomly divided into 3 groups. Group 1 (30) and 2 (28) patients received daily oral treatment of 30 mg deflazacort, (maximum 10 days). In addition group 1 patients received 30 mg nifedipine slow-release (maximum 28 days) and group 2 received 1 daily oral therapy of 0.4 mg tamsulosin (maximum 28 days), Group 3 patients (28) were used as controls. Statistical analyses were performed using Student’s test, ANOVA test, chi-square test and Fisher’s exact test.
• Results: The average stone size for groups 1 to 3 was 4.7, 5.42 and 5.35 mm, respectively, which was not statistically significant. Expulsion was observed in 24 of 30 patients in group 1 (80%), 24 of 28 in group 2 (85%) and 12 of 28 in group 3 (43%). The difference in groups 1 and 2 with respect to group 3 was significant. Average expulsion time for groups 1 to 3 was 9.3, 7.7 and 12 days, respectively. A statistically significant difference was noted between groups 2 and 3. Mean sodium diclofenac dosage per patient in groups 1 to 3 was 19.5, 26, and 105 mg, respectively. A statistical significant difference was observed between groups 1 and 2 with respect to group 3.
• Conclusions: Medical treatments with nifedipine and tamsulosin proved to be safe and effective as demonstrated by the increased stone expulsion rate and reduced need for analgesic therapy. Moreover medical therapy, particularly in regard to tamsulosin, reduced expulsion time.
  
  
• Editorial Comment
  A number of trials have demonstrated the utility of pharmacologic therapy in promoting spontaneous ureteral stone passage and in reducing the time for and pain associated with stone expulsion. The efficacy of calcium channel blockers (nifedipine) in conjunction with corticosteroids has now been proven in several prospective, randomized clinical trials, and recently the combination of an alpha-1 receptor antagonist (tamsulosin) and a corticosteroid has likewise demonstrated benefit in the medical management of distal ureteral calculi. Propiglia and colleagues performed a head-to-head comparison of the 2 medical regimens (nifedipine/deflazacort versus tamsulosin/deflazacort) compared with a control, no-treatment arm and found that both treatment groups demonstrated a significantly higher rate of stone expulsion, a shorter time to spontaneous passage (only the tamsulosin arm was statistically significant compared with control) and a reduced need for analgesics.
  Although adverse effects associated with the use of nifedipine and tamsulosin are low, all trials involving these drugs have reported a small number of patient drop-outs as a result of perceived side effects from the medication. Given the perhaps greater potential for problems due to nifedipine compared with tamsulosin, as well the proven benefit of the tamsulosin regimen in reducing time to stone passage, the combination of tamsulosin/corticosteroid may provide the best chance of spontaneous passage for distal ureteral stones. It remains to be seen if pharmacological therapy will prove to be as effective in promoting the spontaneous passage of stones located in the middle and proximal ureter as well as stones in the distal ureter. Furthermore, these studies have not separated the effect of the corticosteroid from that of the calcium channel blocker or alpha-1 blocker. Hopefully, future study will define the role of each agent in reducing symptoms and promoting stone passage. However, for now, there is ample evidence supporting the use of these agents in appropriate patients with < 1 cm distal ureteral stones.

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