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Management of ureteral calculi and medical expulsive therapy in emergency departments  [cached]
Stefano Picozzi C,Marenghi Carlo,Casellato Stefano,Ricci Cristian
Journal of Emergencies, Trauma and Shock , 2011,
Abstract: Introduction : Ureteral stones are a common problem in daily emergency department practice. Patients may be offered medical expulsive therapy (MET1) to facilitate stone expulsion and this should be offered as a treatment for patients with distal ureteral calculi, who are amenable to waiting management. Emergency department clinicians and family practitioners are often in the front line regarding the diagnosis and treatment of symptomatic nephrolithiasis and this commentary is dedicated to them because their decisions directly influence the outcome of the acute stone episode and appropriate referral patterns. Materials and Methods : The aim of this systematic review and meta-analysis was to understand the role of MET in the treatment of obstructing ureteral calculi. A bibliographic search covering the period from January 1980 to March 2010 was conducted in PubMed, MEDLINE and EMBASE. The searches were restricted to publications in English. This analysis is based on the 21 studies that fulfilled the predefined inclusion criteria. Results : A metaregression analysis of expulsion time showed a statistically significant advantage in the experimental group, in which the mean expulsion time was 6.2 days compared to 10.3 days in controls. The treatment effect on expulsion rate (P = 0.53) was partially lost as the size of the stones decreased because of the high spontaneous expulsion rate of small stones and the expulsion time was not influenced by pharmacological treatment (P = 0.76) if the stone size was smaller than 5 mm. Analysis of the tamsulosin database : A total of 1283 participants were included in the 17 studies. These studies showed that compared to standard therapy or placebo, tamsulosin had significant benefits, being associated with both a higher stone expulsion rate (P < 0.001) and reduction of the expulsion time (P = 0.02). Reductions in the need for analgesic therapy, hospitalization and surgery are also shown. Analysis of the nifedipine database : The number of participants in each trial ranged from 25 to 70. Compared to standard therapy, the use of nifedipine significantly improved the spontaneous stone expulsion rate (P < 0.001). The mean expulsion time was slightly, but not statistically significantly, different (P = 0.19) between the treatment and control groups. A possible benefit of nifedipine, in terms of significantly reducing the doses of analgesics required, was reported in three studies. There was no difference between the tamsulosin- and nifedipine-treated groups with regard to expulsion time (P = 0.17) or expulsion rate (P = 0.79).
The efficacy of tamsulosin in lower ureteral calculi  [cached]
Griwan M,Singh Santosh,Paul Himanshu,Pawar Devendra
Urology Annals , 2010,
Abstract: Context: There has been a paradigm shift in the management of ureteral calculi in the last decade with the introduction of new less invasive methods, such as ureterorenoscopy and extracorporeal shock wave lithotripsy (ESWL). Aims: Recent studies have reported excellent results with medical expulsive therapy (MET) for distal ureteral calculi, both in terms of stone expulsion and control of ureteral colic pain. Settings and Design: We conducted a comparative study in between watchful waiting and MET with tamsulosin. Materials and Methods: We conducted a comparative study in between watchful waiting (Group I) and MET with tamsulosin (Group II) in 60 patients, with a follow up of 28 days. Statistical Analysis: Independent ′t′ test and chi-square test. Results: Group II showed a statistically significant advantage in terms of the stone expulsion rate. The mean number of episodes of pain, mean days to stone expulsion and mean amount of analgesic dosage used were statistically significantly lower in Group II (P value is 0.007, 0.01 and 0.007, respectively) as compared to Group I. Conclusions: It is concluded that MET should be considered for uncomplicated distal ureteral calculi before ureteroscopy or extracorporeal lithotripsy. Tamsulosin has been found to increase and hasten stone expulsion rates, decrease acute attacks by acting as a spasmolytic, reduces mean days to stone expulsion and decreases analgesic dose usage.
Efficacy of three different alpha 1-adrenergic blockers and hyoscine N-butylbromide for distal ureteral stones
Gurbuz, M. Cenk;Polat, Haci;Canat, Lutfi;Kilic, Mert;Caskurlu, Turhan;
International braz j urol , 2011, DOI: 10.1590/S1677-55382011000200006
Abstract: purpose: to evaluate hyoscine n-butyl bromide (hbb) and three different alpha-1 blockers in the treatment of distal ureteral stones. materials and methods: a total of 140 patients with stones located in the distal tract of the ureter with stone diameters of 5 to 10mm were enrolled in the present study and were randomized into 4 equal groups. group 1 received hbb, group 2 received alfuzosin, group 3 received doxazosin and group 4 received terazosin. the subjects were prescribed diclofenac injection (75 mg) intramuscularly on demand for pain relief and were followed-up after two weeks with x-rays of the kidneys, ureters, bladder and urinary ultrasonography every week. the number of pain episodes, analgesic dosage and the number of days of spontaneous passage of the calculi through the ureter were also recorded. results: the average stone size for groups 1, 2, 3 and 4 was comparable (6.13, 5.83, 5.59 and 5.48 mm respectively). stone expulsion was observed in 11%, 52.9%, 62%, and 46% in groups 1, 2, 3 and 4 respectively. the average time to expulsion was 10.55 ± 6.21 days in group 1, 7.38 ± 5.55 days in group 2, 7.85 ± 5.11 days in group 3 and 7.45 ± 5.32 days in group 4. alpha blockers were found to be superior to hbb (p < 0.05). conclusions: medical treatment of distal ureteral calculi with alfuzosin, doxazosin and terazosin resulted in a signi?cantly increased stone-expulsion rate and decreased expulsion time when compared with hbb. hbb seems to have a negative effect on stone-expulsion rate.
Ureteral Calculi in Children: What is Best as a Minimally Invasive Modality?
Abbas Basiri,Samad Zare,Nasser Shakhssalim,Seyed Mohammadmehdi Hosseini Moghaddam
Urology Journal , 2008,
Abstract: Introduction: Minimally invasive treatment of ureteral calculi in children is a challenging topic. In an evidence-based review, we evaluated the efficacy and safety of extracorporeal shock wave lithotripsy (SWL) and ureteroscopic modalities for this group of patients. Materials and Methods: In this study, we performed a comprehensive systematic review on articles appeared in the PubMed from 1998 to March 2008. We selected all papers addressing SWL or ureteroscopic management of the ureteral calculi in children and determined the level of evidence of the presenting data. Results: Thirty-nine articles were reviewed and 24 with valid information on SWL or ureteroscopic management of the pediatric ureteral calculi were analyzed. Six articles (25%) were randomized controlled trials and 18 (75%) were retrospective case-controls or case series. The following data were extracted from the 24 articles: in SWL groups, overall success rate was 84.1% (range, 71% to 100%) for the upper ureteral calculi and 76.2% (range, 19% to 91%) for the lower ureteral calculi. Only 61% of the patients had only 1 treatment course, while 8% and 31% of the cases required 2 and more than 2 sessions of treatment, respectively. With ureteroscopic management, the overall success rates were 93.2% (range, 81% to 100%) and 74.4% (range, 20% to 100%) in the lower and upper ureteral calculi, respectively. Conclusion: The main limitations of the series on minimally invasive treatment of pediatric ureteral calculi are lack of powerful randomized controlled trials or prospective data and insufficient patient numbers. Therefore, it is difficult to draw absolute conclusions about successful treatment based on current knowledge.
Ureteroscopic pneumatic lithotripsy of impacted ureteral calculi
Brito, Artur H.;Mitre, Anuar I.;Srougi, Miguel;
International braz j urol , 2006, DOI: 10.1590/S1677-55382006000300006
Abstract: introduction: this work evaluates the results of ureteroscopic treatment of impacted ureteral stones with a pneumatic lithotripter. materials and methods: from march 1997 to may 2002, 42 patients with impacted ureteral stones were treated by retrograde ureteroscopic pneumatic lithotripsy. twenty-eight patients were female and 14 were male. the stone size ranged from 5 to 20 mm. the ureteral sites of the stones were distal in 21, middle in 12 and proximal in 9. results: considering stones with distal location in the ureter, 1 patient had ureteral perforation and developed a stricture in the follow-up (4.7%). as for stones in the middle ureter, 2 perforations and 1 stricture were observed (8.3%) and regarding stones located in the proximal ureter, 5 perforations and 4 strictures occurred (44%). in the mid ureter, 1 ureteral avulsion was verified. in 34 patients without ureteral perforation, only 1 developed a stricture (2.9%). of 8 patients who had perforation, 6 developed strictures. the overall incidence of stricture following treatment of impacted ureteral calculi was 14.2%. conclusions: ureteroscopy for impacted ureteral calculi is associated with a higher incidence of ureteral perforation and stricture. ureteroscopy of proximal ureteral calculi is associated with a high risk of perforation, when compared to mid or distal ureteral calculi. ureteral perforation at the site of the stone seems to be the primary risk factor for stricture formation in these cases.
Spontaneous Ureteral Rupture Diagnosis and Treatment  [PDF]
E. Pampana,S. Altobelli,M. Morini,A. Ricci,S. D'Onofrio,G. Simonetti
Case Reports in Radiology , 2013, DOI: 10.1155/2013/851859
Abstract: Rupture of the urinary collecting system associated with perinephric or retroperitoneal extravasation of the urine is an unusual condition and it is commonly associated with renal obstructing disease. Perforation could occur at any level from the calix to the bladder but it is usually seen at the fornices and upper ureter. It may lead to several serious consequences including urinoma, abscess formation, urosepsis, infection, and subsequent irreversible renal impairment. We report a case of a 69-year-old woman who presented at the emergency department of our institution with severe abdominal pain. Due to symptomatology worsening, complete laboratory evaluation was performed and the patient underwent abdominal contrast enhanced computed tomography (CT) evaluation which showed contrast agent extravasation outside the excretory system without any evidence of renal calculi at basal acquisition. It was decided to perform a double-J stent placement which was followed by complete healing of the ureter and its removal was performed 8 weeks later. Diagnosis and therapeutic approaches are discussed. 1. Introduction Obstruction of the genitourinary system is followed by an increase of intraluminal pressure which may lead to rupture of the collecting system and consequently urine extravasation with urinoma formation. Spontaneous rupture of the ureter is rare and can be traumatic or nontraumatic. Calculi represent the most frequent cause of ureteral and pelvis rupture in the nontraumatic group. Urine extravasation may be clinically occult or may lead to symptoms of acute abdomen. We report a rare case of spontaneous ureteric rupture in a patient with a clinical history of recurrent renal colics in the younger age treated with double-J stent placement. We further describe this minimally invasive interventional approach. 2. Case Presentation A 69-year-old woman was admitted to the emergency department of our institution with a severe right-sided flank pain that started 6 hours before, nausea, and history of renal calculi in the younger age. In suspicion of an episode of renal colic, analgesic drugs therapy and complete laboratory evaluation were performed. Her vital signs were as follows: heart ratio: 89 beats per minute and regular; blood pressure: 145/90?mmHg; respiration: 18 per minute; and body temperature: 36,8°C. She had leukocytosis in the blood (9,300/mm3), with 48,2% of neutrophils. Urine analysis showed the presence of leukocytes and erythrocytes. Other values were within the normal limits. The patient reported a previous episode of colic pain 6 weeks before
Ureteral fibroepithelial polyps with calculi: a case series
Tahsin Turunc, Baris Kuzgunbay, Tuba Canpolat
Journal of Medical Case Reports , 2008, DOI: 10.1186/1752-1947-2-280
Abstract: We present three cases of fibroepithelial polyps associated with calculi in the distal part of the ureter. The patients were all women, aged 20, 45 and 52 years. Two patients were suffering from flank pain and dysuria while one patient was asymptomatic at the time of diagnosis. The patients were fully treated with endoscopic resection. To the best of our knowledge, this is the fourth report of adult ureteral fibroepithelial polyps associated with ureteral calculi in the English literature. The etiology, clinical features, diagnosis, and management of fibroepithelial polyps are discussed in this report.Whenever polypoid lesions are detected especially at the distal part of the ureter, benign fibroepithelial polyps should be kept in mind for differential diagnosis. Additionally, although rarely seen, the co-existence of ureteral calculi with fibroepithelial polyps should be borne in mind.Fibroepithelial polyps (FEPs) are the most common benign lesions of the ureter. Most occur in the ureter and renal pelvis in adult patients, while a few occur in the posterior urethra or bladder, generally in children [1]. However, FEPs of the ureter accompanied by calculi are rare. We review our experiences with three patients having FEP associated with calculi in the distal ureter to define this entity more clearly and its outcome following treatment.A 20-year-old woman presented to our clinic with intermittent right flank pain and dysuria. She had undergone an extracorporeal shockwave lithotripsy for a kidney stone 5 months before the current admission. Urine analysis showed mild microscopic hematuria. Intravenous urography demonstrated a 12-mm calculus in the right distal ureter, focal ureteral dilatation in the proximal part of the ureter, smoothly marginated tubular filling defects, and mild hydronephrosis. Also, there was another irregular filling defect at the level of the right ureteral orifice (Fig. 1). On cystoscopic examination of her bladder, there were two polypoid masse
Comparison of Computerized Spiral Tomography with Ultrasonography for Detection of Ureteral Calculi
Turkish Journal of Emergency Medicine , 2010,
Abstract: Objectives: We aimed to compare accuracy levels of ultrasonography and spiral computerized tomography for detection of the ureteral calculi in patients admitted to the emergency department with flank pain. Methods: The patients presented with either unilateral or bilateral flank pain to the emergency department over a four-month period and who were suspected to be renal colic were included into the study. All of the study patients with distended bladder after hydration had ultrasonography (USG) and unhanced helical computerized tomography (UHCT) performed by two independent radiologists. Results: Of the 76 patients with flank pain, CT detected ureteral calculi in 47 out of 48 patients (97.9%) and USG detected ureteral calculi in 34 out of the 48 patients (70.83%). CT detected uretral calculi in 14 patients which was not detected by USG. CT also detected renal calculi in 7 patients which was not detected by USG. A kappa value of 0.62 (p<0.001) was determined, indicating a moderate concordance between CT and USG in detecting ureteral calculi. Also a kappa value of 0.65 (p<0.001) was determined in the overall diagnostic performance of the both imaging tools in detecting renal calculi. Conclusions: Computerized tomography is better than ultrasonography in detecting urinary calculus in patients presented to the emergency department with flank pain. However, as a bedside, non-invasive and non-ionized tool, USG should be preffered as the first line diagnostic choice in ED for detecting urinary calculus. CT should be used as an second choice in patients with negative USG exam in ED.
Prospective randomized trial comparing the efficacy of tamsulosin and tamsulosin combined with nifedepine for the management of lower ureteral stones
Tapas Maitra
Turkish Journal of Urology , 2012,
Abstract: Objective: To evaluate the efficacy of tamsulosin compared to the combination of tamsulosin with nifedepine for the management of lower ureteral calculi less than 1 cm in size. Material and Methods: This study included 150 patients with stones <1 cm in size located in the lower ureter. The patients were divided into three groups. Group 1- Patients (N-50) received 0.4 g tamsulosin once daily. Group 2- Patients (n-50) received 0.4 g tamsulosin once daily with cap. nifedepine (5 mg) twice daily. Group 3- Patients (n-50) received placebo treatment (control group). The patients received an injection of diclofenac/injected hyoscine butyl bromide as necessary. Follow-up was performed at 6 weeks.Results: The average stone size was similar among the three groups (6.40, 6.75 and 6.25 mm in Groups 1, 2 and 3, respectively). After treatment with medication, stone expulsion was noted in 37 of 50 patients in group 1 (74%), 43 of 50 patients in group 2 (86%), and 15 of 50 patients in group 3 (30%). The average time required for expulsion of the stone in groups 1, 2, and 3 was 28.5 days, 20.5 days, and 37.7 days, respectively. The results were superior in group 1 and group 2 compared to group 3 (placebo). A significantly higher rate of expulsion was noted in group 2 compared to group 1 (12% more expulsion compared to group 1). However, postural hypotension was noted in 3 patients in group 2 but was not so severe as to require dropping these patients from the study. Conclusion: Study reveals that lower ureteral stones less than 1 cm. can be effectively managed by medical management. We have found that for this purpose combination therapy by tamsulosin with nifedipine is more effective than monotherapy by tamsulosin.
The Comparison of Ultrasonography and Non Enhanced Helical Computed Tomography in the Diagnosis of Ureteral Calculi  [PDF]
?lhan K?l?n?,Cihan Akgül ?zmen,Hatice Akay,A?ur Uyar
Dicle Medical Journal , 2007,
Abstract: Intravenous urography, ultrasonography, and non-contrast spiral computed tomography have been used to diagnose ureteral calculi. We aimed to compare the accuracy of non-contrast spiral computed tomography with ultrasonography in the evaluation of patients with renal colic.Fourty-one patients with flank pain were examined with both computed tomography and ultrasonography over a period of 11 months. Findings of ultrasonography and computed tomography of 28 patients in whom üreteral stones were confirmed by standart methods were comparedUreteral calculi were diagnosed in 28 of 41 patients. Ureteral stones could be demonstrated in 18 patients by ultrasonography and in 27 patients by computed tomography. Ultrasonography showed 64.3% sensitivity and 100% specificity in the diagnosis of ureterolithiasis; computed tomography showed 96.4% and 100%, respectively. Spiral computed tomography is superior to ultrasonography in the demonstration of ureteral calculi in patients with renal colic. But because of higher cost and higher radiation dose, it should be reserved for symptomatic cases in whom ultrasonography is non-diagnostic.
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