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Urolithiasis plays a major role in Urological practice and has contributed to increased office visits, emergency room visits, hospitalizations and annual expenditures. Prolonged ureteral obstruction by stones may be associated with serious complications including renal failure, infection, sepsis, pyelonephritis and ureteral stricture.
Spontaneous passage of ureteral stones was found to be dependent on factors such as size, location and degree of impaction. Simple watchful waiting approach has been advocated for small ureteral stones with high probability to pass. However it may result in complications such as urinary tract infection and renal function loss therefore it is recommended to not exceed 4 to 6 weeks.
Medial expulsive therapy (MET) has emerged as an appealing option for the management of ureteral stones up to 10 mm in size. Several pharmacological agents have been studied and of these agents, a blockers have been demonstrated to augment stone passage.
Since a1 receptors are abundant in distal ureteral smooth muscle, blockage of these receptors using a1 antagonists, inhibits basal tone, peristalsis and ureteral contraction therefore facilitating stone passage.
Tamsulosin , a selective a1a and a1d receptor antagonist, has been the most commonly studied a1 blocker for MET. Alfuzosin, an a1 antagonist with similar efficacy as tamsulosin in treating obstructive uropathy due to benign prostatic hypertrophy was found to have a lower incidence of retrograde ejaculation than tamsulosin and has not been adequately studied in MET for distal ureteral stones up to 10 mm.
The current study was conducted to assess the clinical efficacy of alfuzosin on expulsion of ureteral stones of the distal ureter of size up to 10 mm. Additionally, the effect of alfuzosin on the clinical outcome of the patient in terms of colic pain, analgesic need and hospitalization was evaluated. The study was conducted on 54 patients presenting to the Outpatient Urology Department and diagnosed with distal
ureteral stones of size up to 10 mm. The included patients were randomized into one of 2 groups:
٠ The Control group received standard of care therapy of maintained hydration via 2 L daily water intake and diclofenac 75 mg IM injection on demand.
٠ The Alfuzosin group received the same therapy as the control group in addition to alfuzosin 5 mg twice daily.
The treatment duration was 28 days or until stone expulsion and all patients were followed up weekly through the outpatient clinic in addition to phone call interviews on the 2nd and 5th day of each week. The primary outcomes assessed at the end of the study included stone expulsion frequency and stone passage time while the secondary outcomes included occurrence of complications, occurrence of adverse drug events, occurrence of colicky pain episodes, requirement for analgesia, pain intensity & scores, hospitalization rate and need for ureteroscopic intervention.
The current study showed that:
٠ Stone passage rate was significantly higher and stone passage time was significantly shorter in the alfuzosin group than in the control group.
٠ No significant difference was found in both groups in terms of the number of pain episodes experienced and the pain scores recorded using the 10 cm VAS (Visual analogue scale).
٠ There was no significant difference between both groups with regards to the analgesic injections required to achieve pain control.
٠ Patients in the alfuzosin group required significantly lower ureteroscopic interventions than in the control group.
٠ Results suggest that the administration of alfuzosin improves stone passage rate and reduces stone expulsion time for distal ureteral stones of size < 10mm.
٠ Use of alfuzosin therapy can significantly help in reducing the need of ureteroscopic intervention for stone removal.
٠ Medical expulsive therapy using alfuzosin had no effect on reducing pain episodes or colic pain intensity.
٠ Alfuzosin administration by patients with uncomplicated distal ureteral stones failed to reduce analgesic consumption.
٠ Use of alfuzosin was tolerable and reported adverse effects were minor, reversible and didn’t demand treatment discontinuation.
Large multicenter trials should be conducted to include patients with stones along the entire length of the ureter. Additionally, trials should be conducted to investigate the adjunctive use of steroids with alfuzosin that could further relieve edema and pain associated with stone obstruction.