Editing CUA: Ureteral Calculi (2015) (section)

== Conservative management ==

* Not appropriate in presence of infectious or intolerable symptoms, or compromised renal function
* '''Observation'''
** '''Spontaneous stone passage rate:'''
*** '''2-4mm: 95%'''
*** '''<5mm: 68%'''
*** '''5-10mm: 47%'''
** Axial diameter on CT, as opposed to length, is closely correlated with stone passage rate
** '''Ultrasound overestimates stone size, particularly for stone ≤ 5mm''', compared with CT. [Stones >10mm are underestimated§] Therefore, '''CT-based measurement of stone size should be relied upon for determining treatment plan'''
** “Conservative management” '''[Observation] appropriate for stones <5mm; >5mm should consider treatment options'''
* '''Medical expulsive therapy (MET)'''
** Several RTCs
** '''Sur et al. European Urology 2015'''
*** Population: 239 patients from multiple centers with a unilateral calculus of any ureteral location, 4-10mm
*** Randomized to silodosin 8mg or placebo for up to two weeks
*** Primary outcomes: spontaneous stone passage, based on imaging or history
*** Results:
**** No different in stone free rate at 4 weeks (52% silodosin vs. 44% placebo). In subgroup of distal stones, significant difference in favour of silodosin. Silodosin improved pain scores. No difference in time to stone passage, stone-related ER visits, hospital admissions, surgical interventions, nonsurgical interventions, or use of outpatient analgesics between groups.
*** Silodosin to Facilitate Passage of Ureteral Stones: A Multi-institutional, Randomized, Double-blinded, Placebo-controlled Trial. Sur et al. European Urology 2015.
** '''SUSPEND Lancet 2015'''
*** '''Population: 1167 patients from multiple centers with a unilateral calculus ≤ 10mm in any ureteral location'''
*** '''Randomized to tamsulosin 4mg, nifedipine 30mg, or placebo for up to 4 weeks'''
*** '''Primary outcome was spontaneous stone passage, defined as the proportion of participants who did not need further intervention for stone clearance within 4 weeks of randomization.'''
*** '''Results:'''
**** '''At 4 weeks, no difference in need for further intervention (no intervention in 80% placebo vs. 81% tamsulosin vs. 81% nifedipine).''' '''Trend towards benefit in larger or distal stones for tamsulosin vs. placebo'''.
**** No difference in time to stone passage, pain, or analgesic use.
*** Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial (SUSPEND). Pickard et al. Lancet 2015.
** '''Furyk et al. Annals of ER 2016'''
*** Population: 316 patients with a unilateral distal ureteric calculus <10mm
*** Randomized to tamsulosin 4mg or placebo for 28 days
*** Coprimary outcomes were stone expulsion, based on CT and time to stone expulsion, based on history or first day of pain-free 48-hour period with stone-free CT
*** Results:
**** No significant difference in stone expulsion rate (87% tamsulosin vs. 82% placebo) or time to stone expulsion. Benefit in stones 5-10mm.
*** Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial. Furyk et al. Annals of ER 2016.
** '''2018 Cochrane Review'''
*** 15 RCTs, with 5,878 participants overall to assess the effects of alpha-blockers compared to standard therapy or placebo for ureteral stones 1 cm and less confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease.
*** '''Result'''s: '''Treatment with an alpha-blocker may result in a large increase in stone clearance''' (RR 1.45, 95% CI 1.36 to 1.55; low quality evidence), '''corresponding to 278 more stone clearances per 1000 participants'''. Treatment with an alpha-blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low quality evidence); this corresponds to '''5 more major adverse events per 1000 participants. Patients treated with alpha-blockers may also experience shorter stone expulsion times''' (MD -3.40 days, 95% CI: -4.17 to -2.63), '''use less diclofenac and likely require fewer hospitalizations''' (RR 0.51, 95% CI 0.34 to 0.77). '''Meanwhile, the need for surgical intervention appears similar.''' '''There may be a different effect of alpha-blockers based on stone size''' with RRs of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or less versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones greater than 5 mm. '''We did not find evidence for possible subgroup effects based on stone location or alpha-blocker type.'''
*** '''Conclusions: In patients with ureteral stones, alpha-blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha-blockers may be less effective in smaller (≤5 mm) than larger stones (> 5 mm)'''
*** Alpha-blockers as medical expulsive therapy for ureteral stones: a Cochrane Systematic Review.
* '''Recommendation: MET with alpha-antagonists potentially shortens the duration and increases the likelihood of spontaneous stone passage. Consideration should be given to offer it to patients with distal ureteral stones < 10mm in size'''