Ureteral calculi: What should you consider before intervening?

Article Type
Changed
Mon, 01/14/2019 - 11:30
Display Headline
Ureteral calculi: What should you consider before intervening?
EVIDENCE-BASED ANSWER

THE SIZE OF THE CALCULI, their location, and complicating factors such as infection should all be considered.

Most ureteral calculi smaller than 5 mm pass spontaneously, as do approximately half of calculi between 5 and 10 mm. Calculi larger than 10 mm are unlikely to pass without intervention. Distal calculi are more likely to pass spontaneously than calculi in mid- or proximal ureteral locations; most spontaneous passage occurs within 4 to 6 weeks (strength of recommendation [SOR]: A, prospective cohort studies).

All patients with calculi complicated by such factors as obstruction, infection, renal injury, or a single kidney require surgical consultation (SOR: C, expert opinion).

Medical expulsion therapy with alpha-blockers (usually tamsulosin) and nifedipine improves passage rates, including for some calculi larger than 10 mm (SOR: A, meta-analysis of prospective cohort studies).

 

Evidence summary

A meta-analysis of 5 prospective cohort studies evaluated the rate of spontaneous passage of ureteral calculi according to size. Calculi smaller than 5 mm passed spontaneously in 68% of patients (5 studies, N=224). Calculi between 5 and 10 mm passed spontaneously in 47% of patients (3 studies, N=104).1

A prospective cohort study evaluated spontaneous passage rates of ureteral calculi by size in 172 patients who were diagnosed by unenhanced helical computed tomography.2 Investigators found spontaneous passage rates of 87% for 1-mm calculi, 76% for 2- to 4-mm calculi, 60% for 5- to 7-mm calculi, 48% for 7- to 9-mm calculi, and 25% for calculi larger than 9 mm.

Spontaneous passage rates differed significantly for calculi 1 to 4 mm in size compared with calculi 5 to 7 mm in size (P<.001) and for calculi 5 to 7 mm in size compared with calculi 8 mm or larger (P<.001). Calculi in either the distal ureter or ureterovesicular junction were more likely to pass that those in the mid- or proximal ureter (75% to 79% vs 48% to 60%; P<.001).

Most smaller calculi pass in 4 to 6 weeks
Another prospective cohort study (N=75) found that most calculi pass spontaneously within 4 to 6 weeks. In 95% of patients, calculi passed within 31 days (2 mm or smaller), 40 days (2-4 mm), or 39 days (4-6 mm).3

Some cases require prompt surgery
The American Urological Association (AUA) expert panel recommends early surgical intervention, regardless of calculus size, under the following circumstances: obstruction with high-grade hydronephrosis, infection, impending renal deterioration, intractable pain, nausea and vomiting, or obstruction in a solitary or transplanted kidney.1

Medical expulsion therapy trumps waiting for distal calculi to pass
A meta-analysis comparing rates of calculus passage found that medical expulsion therapy was more effective than expectant management for patients with distal ureteral calculi. Sixteen RCTs (N=1235) evaluated alpha-antagonists (mostly tamsulosin), and 9 RCTs (N=686) evaluated nifedipine. Treat ment periods for medical expulsion therapy ranged from 30 to 60 days.

Alpha-antagonists increased expulsion rates over expectant management for calculi ranging in size from 3 to 18 mm with a mean diameter greater than 5 mm (relative risk [RR]=1.59; 95% confidence interval [CI], 1.44-1.75; number needed to treat [NNT]=3). The mean time until passage ranged from 2.7 to 14.2 days. Nifedipine also increased expulsion rates for calculi with a mean diameter larger than 5 mm, ranging in size from 3.9 to 12.8 mm (RR=1.50; 95% CI, 1.34-1.68; NNT=4).4

Recommendations

The Joint European Association of Urology/ AUA Nephrolithiasis Guideline Panel recommends observation with periodic evaluation for patients newly diagnosed with ureteral calculi smaller than 10 mm.1 Patients may be offered medical expulsion therapy to facilitate calculus passage. Surveillance should be maintained until calculi pass; intervention should be considered if calculi don’t pass spontaneously within about 30 days.

The Panel states that patients with ureteral calculi larger than 10 mm could be observed (with or without medical expulsion therapy); however, most cases will require surgical intervention.1

Acknowledgements

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Medical Department of the United States Army or the US Army Service at large.

References

1. European Association of Urology/American Urology Association Nephrolithiasis Guideline Panel. 2007 Guideline for the management of ureteral calculi. Available at: www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=uc. Accessed August 16, 2010.

2. Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to calculus size and location as revealed by unenhanced helical CT. Am J Roentgenol. 2002;178:101-103.

3. Miller OF, Kane CJ. Time to calculus passage for observed ureteral calculi: a guide for patient education. J Urol. 1999;162:688-691.

4. Singh A, Alter HJ, Littlepage A. A systematic review of medical therapy to facilitate passage of ureteral calculi. Ann Emerg Med. 2007;50:552-563.

Article PDF
Author and Disclosure Information

Jonathan C. Taylor, MD
Robert Gauer, MD
Womack Family Medicine Residency Clinic, Fort Bragg, NC

Stacy Rideout, MLIS, MA
Wake Area Health, Education Center Medical, Library, Raleigh, NC

ASSISTANT EDITOR
Gary Kelsberg, MD
Valley Family Medicine, Renton, Wash

Issue
The Journal of Family Practice - 60(04)
Publications
Topics
Page Number
232-233
Legacy Keywords
Jonathan Taylor; uteral calcul; spontaneous passage; smaller calculi; medical expulsion therapy
Sections
Author and Disclosure Information

Jonathan C. Taylor, MD
Robert Gauer, MD
Womack Family Medicine Residency Clinic, Fort Bragg, NC

Stacy Rideout, MLIS, MA
Wake Area Health, Education Center Medical, Library, Raleigh, NC

ASSISTANT EDITOR
Gary Kelsberg, MD
Valley Family Medicine, Renton, Wash

Author and Disclosure Information

Jonathan C. Taylor, MD
Robert Gauer, MD
Womack Family Medicine Residency Clinic, Fort Bragg, NC

Stacy Rideout, MLIS, MA
Wake Area Health, Education Center Medical, Library, Raleigh, NC

ASSISTANT EDITOR
Gary Kelsberg, MD
Valley Family Medicine, Renton, Wash

Article PDF
Article PDF
EVIDENCE-BASED ANSWER

THE SIZE OF THE CALCULI, their location, and complicating factors such as infection should all be considered.

Most ureteral calculi smaller than 5 mm pass spontaneously, as do approximately half of calculi between 5 and 10 mm. Calculi larger than 10 mm are unlikely to pass without intervention. Distal calculi are more likely to pass spontaneously than calculi in mid- or proximal ureteral locations; most spontaneous passage occurs within 4 to 6 weeks (strength of recommendation [SOR]: A, prospective cohort studies).

All patients with calculi complicated by such factors as obstruction, infection, renal injury, or a single kidney require surgical consultation (SOR: C, expert opinion).

Medical expulsion therapy with alpha-blockers (usually tamsulosin) and nifedipine improves passage rates, including for some calculi larger than 10 mm (SOR: A, meta-analysis of prospective cohort studies).

 

Evidence summary

A meta-analysis of 5 prospective cohort studies evaluated the rate of spontaneous passage of ureteral calculi according to size. Calculi smaller than 5 mm passed spontaneously in 68% of patients (5 studies, N=224). Calculi between 5 and 10 mm passed spontaneously in 47% of patients (3 studies, N=104).1

A prospective cohort study evaluated spontaneous passage rates of ureteral calculi by size in 172 patients who were diagnosed by unenhanced helical computed tomography.2 Investigators found spontaneous passage rates of 87% for 1-mm calculi, 76% for 2- to 4-mm calculi, 60% for 5- to 7-mm calculi, 48% for 7- to 9-mm calculi, and 25% for calculi larger than 9 mm.

Spontaneous passage rates differed significantly for calculi 1 to 4 mm in size compared with calculi 5 to 7 mm in size (P<.001) and for calculi 5 to 7 mm in size compared with calculi 8 mm or larger (P<.001). Calculi in either the distal ureter or ureterovesicular junction were more likely to pass that those in the mid- or proximal ureter (75% to 79% vs 48% to 60%; P<.001).

Most smaller calculi pass in 4 to 6 weeks
Another prospective cohort study (N=75) found that most calculi pass spontaneously within 4 to 6 weeks. In 95% of patients, calculi passed within 31 days (2 mm or smaller), 40 days (2-4 mm), or 39 days (4-6 mm).3

Some cases require prompt surgery
The American Urological Association (AUA) expert panel recommends early surgical intervention, regardless of calculus size, under the following circumstances: obstruction with high-grade hydronephrosis, infection, impending renal deterioration, intractable pain, nausea and vomiting, or obstruction in a solitary or transplanted kidney.1

Medical expulsion therapy trumps waiting for distal calculi to pass
A meta-analysis comparing rates of calculus passage found that medical expulsion therapy was more effective than expectant management for patients with distal ureteral calculi. Sixteen RCTs (N=1235) evaluated alpha-antagonists (mostly tamsulosin), and 9 RCTs (N=686) evaluated nifedipine. Treat ment periods for medical expulsion therapy ranged from 30 to 60 days.

Alpha-antagonists increased expulsion rates over expectant management for calculi ranging in size from 3 to 18 mm with a mean diameter greater than 5 mm (relative risk [RR]=1.59; 95% confidence interval [CI], 1.44-1.75; number needed to treat [NNT]=3). The mean time until passage ranged from 2.7 to 14.2 days. Nifedipine also increased expulsion rates for calculi with a mean diameter larger than 5 mm, ranging in size from 3.9 to 12.8 mm (RR=1.50; 95% CI, 1.34-1.68; NNT=4).4

Recommendations

The Joint European Association of Urology/ AUA Nephrolithiasis Guideline Panel recommends observation with periodic evaluation for patients newly diagnosed with ureteral calculi smaller than 10 mm.1 Patients may be offered medical expulsion therapy to facilitate calculus passage. Surveillance should be maintained until calculi pass; intervention should be considered if calculi don’t pass spontaneously within about 30 days.

The Panel states that patients with ureteral calculi larger than 10 mm could be observed (with or without medical expulsion therapy); however, most cases will require surgical intervention.1

Acknowledgements

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Medical Department of the United States Army or the US Army Service at large.

EVIDENCE-BASED ANSWER

THE SIZE OF THE CALCULI, their location, and complicating factors such as infection should all be considered.

Most ureteral calculi smaller than 5 mm pass spontaneously, as do approximately half of calculi between 5 and 10 mm. Calculi larger than 10 mm are unlikely to pass without intervention. Distal calculi are more likely to pass spontaneously than calculi in mid- or proximal ureteral locations; most spontaneous passage occurs within 4 to 6 weeks (strength of recommendation [SOR]: A, prospective cohort studies).

All patients with calculi complicated by such factors as obstruction, infection, renal injury, or a single kidney require surgical consultation (SOR: C, expert opinion).

Medical expulsion therapy with alpha-blockers (usually tamsulosin) and nifedipine improves passage rates, including for some calculi larger than 10 mm (SOR: A, meta-analysis of prospective cohort studies).

 

Evidence summary

A meta-analysis of 5 prospective cohort studies evaluated the rate of spontaneous passage of ureteral calculi according to size. Calculi smaller than 5 mm passed spontaneously in 68% of patients (5 studies, N=224). Calculi between 5 and 10 mm passed spontaneously in 47% of patients (3 studies, N=104).1

A prospective cohort study evaluated spontaneous passage rates of ureteral calculi by size in 172 patients who were diagnosed by unenhanced helical computed tomography.2 Investigators found spontaneous passage rates of 87% for 1-mm calculi, 76% for 2- to 4-mm calculi, 60% for 5- to 7-mm calculi, 48% for 7- to 9-mm calculi, and 25% for calculi larger than 9 mm.

Spontaneous passage rates differed significantly for calculi 1 to 4 mm in size compared with calculi 5 to 7 mm in size (P<.001) and for calculi 5 to 7 mm in size compared with calculi 8 mm or larger (P<.001). Calculi in either the distal ureter or ureterovesicular junction were more likely to pass that those in the mid- or proximal ureter (75% to 79% vs 48% to 60%; P<.001).

Most smaller calculi pass in 4 to 6 weeks
Another prospective cohort study (N=75) found that most calculi pass spontaneously within 4 to 6 weeks. In 95% of patients, calculi passed within 31 days (2 mm or smaller), 40 days (2-4 mm), or 39 days (4-6 mm).3

Some cases require prompt surgery
The American Urological Association (AUA) expert panel recommends early surgical intervention, regardless of calculus size, under the following circumstances: obstruction with high-grade hydronephrosis, infection, impending renal deterioration, intractable pain, nausea and vomiting, or obstruction in a solitary or transplanted kidney.1

Medical expulsion therapy trumps waiting for distal calculi to pass
A meta-analysis comparing rates of calculus passage found that medical expulsion therapy was more effective than expectant management for patients with distal ureteral calculi. Sixteen RCTs (N=1235) evaluated alpha-antagonists (mostly tamsulosin), and 9 RCTs (N=686) evaluated nifedipine. Treat ment periods for medical expulsion therapy ranged from 30 to 60 days.

Alpha-antagonists increased expulsion rates over expectant management for calculi ranging in size from 3 to 18 mm with a mean diameter greater than 5 mm (relative risk [RR]=1.59; 95% confidence interval [CI], 1.44-1.75; number needed to treat [NNT]=3). The mean time until passage ranged from 2.7 to 14.2 days. Nifedipine also increased expulsion rates for calculi with a mean diameter larger than 5 mm, ranging in size from 3.9 to 12.8 mm (RR=1.50; 95% CI, 1.34-1.68; NNT=4).4

Recommendations

The Joint European Association of Urology/ AUA Nephrolithiasis Guideline Panel recommends observation with periodic evaluation for patients newly diagnosed with ureteral calculi smaller than 10 mm.1 Patients may be offered medical expulsion therapy to facilitate calculus passage. Surveillance should be maintained until calculi pass; intervention should be considered if calculi don’t pass spontaneously within about 30 days.

The Panel states that patients with ureteral calculi larger than 10 mm could be observed (with or without medical expulsion therapy); however, most cases will require surgical intervention.1

Acknowledgements

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Medical Department of the United States Army or the US Army Service at large.

References

1. European Association of Urology/American Urology Association Nephrolithiasis Guideline Panel. 2007 Guideline for the management of ureteral calculi. Available at: www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=uc. Accessed August 16, 2010.

2. Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to calculus size and location as revealed by unenhanced helical CT. Am J Roentgenol. 2002;178:101-103.

3. Miller OF, Kane CJ. Time to calculus passage for observed ureteral calculi: a guide for patient education. J Urol. 1999;162:688-691.

4. Singh A, Alter HJ, Littlepage A. A systematic review of medical therapy to facilitate passage of ureteral calculi. Ann Emerg Med. 2007;50:552-563.

References

1. European Association of Urology/American Urology Association Nephrolithiasis Guideline Panel. 2007 Guideline for the management of ureteral calculi. Available at: www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=uc. Accessed August 16, 2010.

2. Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to calculus size and location as revealed by unenhanced helical CT. Am J Roentgenol. 2002;178:101-103.

3. Miller OF, Kane CJ. Time to calculus passage for observed ureteral calculi: a guide for patient education. J Urol. 1999;162:688-691.

4. Singh A, Alter HJ, Littlepage A. A systematic review of medical therapy to facilitate passage of ureteral calculi. Ann Emerg Med. 2007;50:552-563.

Issue
The Journal of Family Practice - 60(04)
Issue
The Journal of Family Practice - 60(04)
Page Number
232-233
Page Number
232-233
Publications
Publications
Topics
Article Type
Display Headline
Ureteral calculi: What should you consider before intervening?
Display Headline
Ureteral calculi: What should you consider before intervening?
Legacy Keywords
Jonathan Taylor; uteral calcul; spontaneous passage; smaller calculi; medical expulsion therapy
Legacy Keywords
Jonathan Taylor; uteral calcul; spontaneous passage; smaller calculi; medical expulsion therapy
Sections
PURLs Copyright

Evidence-based answers from the Family Physicians Inquiries Network

Disallow All Ads
Article PDF Media