ENDOUROLOGY & LAPAROSCOPY

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
  This group from Italy has contributed much to the active pharmacologic management of ureteral stones. They and others have demonstrated the effectiveness of nifedipine (calcium-channel blocker) or tamulosin (alpha-1 blocker) in combination with corticosteroids and non-steroidal anti-inflammatory agents to facilitate stone passage from the ureter. Spontaneous ureteral stones and ureteral fragments after extracorporeal shock wave litotripsy both have been shown to pass more frequently, sooner, and with less pain compared to controls. Unfortunately, all of the randomized studies have included corticosteroids and non-steroidal anti-inflammatory agents in the treatment arms, and the distinct effects of the calcium-channel blocker or alpha-1 blocker alone cannot be ascertained. Nonetheless, at our institution we have used the combination of calcium-channel blockers and non-steroidal anti-inflammatory agents for the treatment of ureteral colic. We have been unwilling to subject stone patients, with potential upper urinary tract obstruction and risk for infection, to the risks of corticosteroids. Anecdotally we have seen favorable results, but we cannot make any statement as to the comparative effectiveness to a treatment also including corticosteroids. This new study, however, leads us to believe that the alpha-1 blocker tamulosin may have even greater effectiveness than nifedipine. Although the incidence of adverse effects was low in this study (only one patient in each of the treatment groups had to suspend therapy owing to adverse effects), one would expect tamulosin to have fewer adverse effects in general. The use of tamulosin and non-steroidal anti-inflammatory agents (plus corticosteroids if the studied treatment is to be applied exactly) should be considered the current best pharmacologic management of ureteral colic.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA