STONE DISEASE

Efficacy of tamsulosin in the medical management of juxtavesical ureteral stones
Dellabella M, Milanese G, Muzzonigro G
Department of Urology, A. O. Umberto I-Torrette, University of Ancona, Italy
J Urol. 2003; 170: 2202-5

• Purpose: We evaluated the efficacy of the alpha1-adrenergic antagonist tamsulosin for conservative expulsive therapy in patients with ureteral colic due to juxtavesical stones.
• Materials and Methods: A total of 60 consecutive symptomatic patients with stones located in the juxtavesical tract of the ureter were randomly divided into group 1-30 who received oral floroglucine-trimetossibenzene 3 times daily and group 2-30 who received 0.4 mg tamsulosin daily. The 2 groups received 30 mg deflazacort daily for 10 days plus cotrimoxazole 2 times daily for 8 days and 75 mg diclofenac injected intramuscularly on demand. Ultrasound followup and medical visits were performed weekly for 4 weeks. Stone passage rate and time, analgesic use, hospitalization and endoscopical intervention were evaluated. Statistical analysis was performed using the Student t test.
• Results: The stone expulsion rate was 70% for group 1 and 100% for group 2. Mean stone size was 5.8 and 6.7 mm, respectively (p = 0.001). Mean expulsion time was 111.1 hours for group 1 and 65.7 hours for group 2 (p = 0.020). The mean number of diclofenac injections was 2.83 for group 1 and 0.13 for group 2 (p < 0.0001). Ten group 1 patients were hospitalized, of whom 9 underwent ureteroscopy, compared with none in group 2 (p < 0.0001 and 0.001, respectively).
• Conclusions: Tamsulosin used as a spasmolytic drug during renal colic due to juxtavesical calculi increased the stone expulsion rate and decreased expulsion time, the need for hospitalization and endoscopic procedures, and provided particularly good control of colic pain.
  
  
• Editorial Comment
  The likelihood of spontaneous passage of stones in the ureter depends primarily on the size and location of the stone at the time of diagnosis. Although most ureteral stones pass spontaneously, the pain and cost associated with repeated episodes of renal colic is substantial. A number of investigators have evaluated the use of pharmacologic agents to enhance the rate and reduce the pain of spontaneous passage of ureteral calculi and demonstrated a beneficial effect of some medications (references 4 and 6 in the article). The efficacy of corticosteroids and calcium channel blockers has been attributed to their ability to reduce ureteral edema and spasm.
  In the current study, Dellabella and colleagues theorized that the use of an alpha-adrenergic antagonist would reduce ureteral peristalsis around an obstructing ureteral stone, thereby increasing urine flow and improving the likelihood of spontaneous passage. In a prospective, randomized trial, these investigators compared tamsulosin with an anti-spasmotic agent (floroglucine-trimetossibenzene) in 60 patients with stones in the intramural ureter. After 4 weeks, all patients in the tamsulosin group successfully passed their stones compared with only 70% in the anti-spasmotic group. Furthermore, patients in the tamsulosin group passed their stones in less time (66 hours vs. 111 hours, respectively) and required less pain medication (0.13 vs. 2.83 injections diclofenac, respectively) than the anti-spasmotic group.
  These findings again suggest that pharmacotherapy aimed at decreasing ureteral peristalsis associated with an obstructing stone can reduce pain and enhance spontaneous stone passage. Although few adverse effects from drug therapy have been reported in the current and previous trials, one must still weigh the risks of pharmocotherapy against the benefit of spontaneous stone passage for each patient. The efficacy of alpha-blocker therapy for the management of ureteral stones will need to be confirmed in future trials; however, the use of adjunctive drug therapy in patients electing to manage their ureteral stones conservatively should be considered.

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