UroToday - Over the past decade, the most significant advance, in my mind, with regard to the treatment of the distal ureteral stone, has been the advent of medical expulsive therapy as described by Porpiglia and colleagues in 2000, and corroborated by many subsequent studies. Savings with this approach, according to work by Lotan and colleagues, is around $1100/patient in addition to the benefits of decreased renal colic. Stone passage rates increase anywhere from 40-100% of controls within 10 days of starting medical expulsive therapy. While a variety of medications have been used (e.g. alpha blockers, steroids, calcium channel blockers), the alpha blockers (i.e. tamsulosin and alfuzosin) appear to be effective and well tolerated.

Is medical expulsive therapy worthwhile in the post SWL patient who has multiple stone fragments to pass? The answer appears to be: YES. In this meta-analysis of four randomized trials, the authors noted a 17% absolute increase in stone free rates (i.e. < 3mm fragments) overall; this effect was more marked (i.e. 26%) when stones larger than 10 mm were considered. The time points were usually at 30-45 days post SWL. The treatment lengths varied from 10-90 days; however there were no significant differences among the four studies leading me to conclude that a short course (i.e. 10 days) would likely be sufficient as it is for the single distal ureteral stone.

Schuler TD, Shahani R, Honey RJ, Pace KT
J Endourol. 2009 Mar;23(3):387-93
doi: 10.1089/end.2008.0216

UroToday Medical Editor Ralph V. Clayman, MD

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