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Guidelines for managing stone-related ureteral colic suggest using “medical expulsive therapy” with smooth muscle relaxants such as tamsulosin or nifedipine (e.g., European Association of Urology Urolithiasis Guideline 2015); however, the two meta-analyses supporting these recommendations include primarily small, single-center trials of low-to-moderate quality.
To evaluate the effectiveness of medical expulsive therapy more rigorously, researchers in the U.K. enrolled 1136 symptomatic adults, each with a single ureteral stone <10 mm in diameter identified by computed tomography and without sepsis or an indication for immediate intervention. Participants were randomized to receive once-daily tamsulosin (0.4 mg), nifedipine (30 mg), or placebo for 4 weeks.
During treatment, about 20% of patients in each group required additional interventions to assist with stone passage. In the 8 weeks after treatment, about 7% of patients in each group required interventions. Patients' sex, stone size, and stone location did not affect outcomes. Analgesic use, time to stone passage, and overall health status were similar in all three groups.
Pickard R et al. Medical expulsive therapy in adults with ureteric colic: A multicentre, randomised, placebo-controlled trial. Lancet 2015 May 18; [e-pub]. (http://dx.doi.org/10.1016/S0140-6736(15)60933-3)
Comment
This trial, designed to reflect current recommendations and clinical practice, not only definitively demonstrates the ineffectiveness of medical expulsive therapy for ureteral stones but also reaffirms the essential importance of large, well-designed, randomized trials for assessing clinical interventions and formulating treatment guidelines.