The Use of Alpha-Blockers for the treatment of Nephrolithiasis

1. ALPHA-BLOCKER THERAPY FOR UROLOGICAL DISORDERS
The Use of Alpha-Blockers for the
Treatment of Nephrolithiasis
Michael Lipkin, MD, Ojas Shah, MD
Department of Urology, New York University School of Medicine, New York, NY
Medical expulsion therapy has been shown to be a useful adjunct to observa-
tion in the management of ureteral stones. Alpha-1-adrenergic receptor an-
tagonists have been studied in this role. Alpha-1 receptors are located in the
human ureter, especially the distal ureter. Alpha-blockers have been demon-
strated to increase expulsion rates of distal ureteral stones, decrease time to
expulsion, and decrease need for analgesia during stone passage. Alpha-
blockers promote stone passage in patients receiving shock wave lithotripsy,
and may be able to relieve ureteral stent–related symptoms. In the appropri-
ate clinical scenario, the use of -blockers is recommended in the conserva-
tive management of distal ureteral stones.
[Rev Urol. 2006;8(suppl 4):S35-S42]
© 2006 MedReviews, LLC
Key words: Alpha-blockers • Ureteral stones • Kidney stones
R
ecent advances in endoscopic stone management have allowed kidney
stones to be treated using minimally invasive techniques, which have
increased success rates and decreased treatment-related morbidity. These
advances include shock wave lithotripsy (SWL), ureteroscopy, and percutaneous
nephrostolithotomy. Although these approaches are less invasive than traditional
VOL. 8 SUPPL. 4 2006 REVIEWS IN UROLOGY S35

2. Alpha-Blockers for Nephrolithiasis continued
open surgical approaches, they are ex- Physiology ureters were exposed to different com-
pensive and have inherent risks. Con- The human ureter contains -adrener- pounds, including agonists and an-
sequently, observation has been advo- gic receptors along its entire length, tagonists, phentolamine caused a 67%
cated for small ureteral stones with a with the highest concentration in the prolongation of ureteral peristaltic
high probability to pass that do not distal ureter.3,4 Stimulation of the re- discharge intervals, an 84% increase
have absolute indications for surgical ceptors increases the force of ureteral in ureteral fluid bolus volume, and an
intervention. The rate of spontaneous contraction and the frequency of 18% increase in the rate of fluid
passage with no medical intervention ureteral peristalsis, whereas antago- transportation.6
for a stone of 5 mm or smaller in the nism of the receptors has the opposite More recently, Sigala and col-
proximal ureter is estimated to be 29% effects. Malin and colleagues first leagues4 studied 1-adrenergic recep-
to 98%, and in the distal ureter, 71% demonstrated the presence of - tor gene and protein expression in
to 98%. The most important factors in adrenergic receptors in the human the proximal, middle, and distal
predicting the likelihood of sponta- ureter in 1970.3 These investigators ob- ureter. They demonstrated that the
neous stone passage are stone location tained specimens containing all levels distal ureter expressed the greatest
and stone size.1 of the human ureter. In the lower third quantity of 1 messenger ribonucleic
acid (mRNA). The 1d mRNA was ex-
pressed in all portions of the ureter,
The most important factors in predicting the likelihood of spontaneous stone
and it was expressed in significantly
passage are stone location and stone size. greater amounts than the 1a or 1b
receptor subtype in both the proxi-
Recently, medical expulsion therapy of the ureter, exposure to adrenaline or mal and distal ureter. Using ligand
(MET) has been investigated as a sup- noradrenaline increased the tone and binding, they were able to show that
plement to observation in an effort to frequency of contractions, whereas ex- the distal ureter had the highest den-
improve spontaneous stone passage posure to isoproterenol decreased the sity of receptors, and 1d was the
rates, which can be unpredictable. amplitude and frequency of contrac- most common receptor present in all
Because ureteral edema and ureteral tions. Similar results were seen when portions of the ureter (Figure 1). An
spasm have been postulated to affect the entire length of the ureter was ex-
stone passage, these effects have been posed to adrenaline and noradrenaline.
Figure 1. Representation of the kidney and ureter with
targeted for pharmacologic interven- This demonstrated the presence of - density of receptors as studied by Sigala et al.4
tion. Therefore, the primary agents adrenergic receptors along the entire Alpha-1d receptor is the most common in all segments
of the ureter. The highest overall density of 1 recep-
that have been evaluated for MET are length of the ureter, as well as the tors is in the distal ureter.
calcium channel blockers, steroids, physiologic response of increased
nonsteroidal anti-inflammatory drugs tone and frequency of contractions in
(NSAIDs), and 1-adrenergic receptor the ureter when exposed to -
antagonists. A recent meta-analysis adrenergic agonists.3
was performed, looking at studies that In a study using dog and rabbit
compared stone passage rates in pa- ureters, Weiss and associates demon-
tients who were given calcium chan- strated that -adrenergic agonists
nel blockers or 1-adrenergic receptor have a stimulatory effect on the
antagonists versus controls who did ureteral smooth muscle, whereas -
not receive these medications. The adrenergic agonists have an inhibitory 1d 1b 1a
analysis demonstrated a 65% greater affect. Phenylephrine was found to
chance of passing a ureteral stone in significantly increase the contractile
patients who received either medica- force of ureteral segments. This effect
tion.2 The use of these drugs for the was blocked by pretreatment of the
1d 1a 1b
purposes of facilitating stone passage, segment with phentolamine, an -
however, is investigational and off adrenergic antagonist. Additionally,
label. This article will focus on the use when rabbit ureters were exposed to
of -blockers in the management of electrical stimuli in the presence of 1d 1a 1b
stone disease and other stone-related phentolamine, there was a decrease in
processes. maximum force generated.5 When dog
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3. Alpha-Blockers for Nephrolithiasis
in vitro study comparing the effects has been to reduce ureteral spasm, in- Tamsulosin has been the most com-
of nifedipine, a calcium channel crease pressure proximal to the stone, monly studied 1-blocker in the treat-
blocker; diclofenac, an NSAID; and and relax the ureter in the region of ment of ureteral stones; however, the
5-methylurapidil (5-MU), an 1a an- and distal to the stone.14 The rationale data have been extrapolated and clin-
tagonist, demonstrated that both in using 1 antagonists in MET has ically tested on other -blockers as
nifedipine and 5-MU decreased the been that they are capable of decreas- well. Tamsulosin has equal affinity
force of contraction in ureteral seg- ing the force of ureteral contraction, for 1a and 1d receptors.16 The 1d
ments. The predominant affect of 5- decreasing the frequency of peristaltic receptor is the most common receptor
MU was found to be in the distal contractions, and increasing the fluid in the ureter and is most concentrated
ureter.7 bolus volume transported down the in the distal ureter.4 Cervenakov and
ureter.5-7 associates17 performed one of the first
Treatment of Distal In 1972, Kubacz and Catchpole15 double-blind, randomized studies
Ureteral Stones compared the effectiveness of treating comparing their standard MET with
MET has been aimed at modifiable ureteral colic with meperidine, phen- and without tamsulosin (Table 1).
factors that can affect stone passage. tolamine, and propanolol. They found Their standard therapy included an
These factors are mucosal edema/ that 85.5% of patients receiving injection of a narcotic and diazepam
inflammation, infection, and ureteral meperidine, 63.5% of patients receiv- on presentation, followed by a daily
spasm. Several agents have been ing phentolamine, and only 6% of NSAID. They found that the sponta-
studied as potential MET. Steroids patients receiving propanolol had sig- neous passage rates with and without
have been used to reduce mucosal nificant relief of pain. Interestingly, tamsulosin were 80.4% versus 62.8%,
edema and aid in stone passage. A re- they found that in 4 patients receiv- respectively. The majority of patients
cent study by Porpiglia and associ- ing phentolamine, their renal obstruc- receiving tamsulosin passed their
ates8 failed to demonstrate that tion was corrected, as depicted by stone within 3 days. There were fewer
steroids alone promote stone passage. intravenous pyelography, as was their instances of recurrent colic with tam-
However, Dellabella and colleagues9 pain. The investigators concluded that sulosin, and the tamsulosin was well
did show that steroids are a useful ad- -adrenergic blockade may have the tolerated.
junct to induce more rapid stone ex- advantage of relieving obstruction as Tamsulosin increases rates of spon-
pulsion. They found similar expulsion well as pain. taneous stone expulsion and decreases
rates when tamsulosin was used alone
or with deflazacort (90% vs 96.7%),
but found significantly reduced time
to expulsion in the group of patients Table 1
who also received steroids (120 hours Rates of Stone Expulsion for Distal Ureteral Stones in Patients Treated
vs 72 hours; P .036). NSAIDs also With Alpha-1-Blocker Versus Patients Treated With Standard Medical
have the potential to decrease inflam- Expulsion Therapy Without Alpha-1-Blocker
mation and mucosal edema and are
useful for analgesia during stone pas- Distal Ureteral Stone Expulsion Rates (%)
sage, but have not been proven to be
With Alpha-1- Without Alpha-1-
successful in stone passage when used
Study Blocker Blocker P Value
alone.10 Nifedipine is the most studied
17
calcium channel blocker used to treat Cervenakov I et al 80.4 62.8 N/A
ureteral spasm and promotes stone Dellabella M et al18 100 70 .001
passage.11-13 Resim S et al 19
86.6 73.3 .196
Alpha-1-adrenergic receptor antag- De Sio M et al20 90 58.7 .01
onists have some degree of selectivity
Yilmaz E et al21 79.31 (tamsulosin) 53.57 .03
for the detrusor and the distal ureter
78.57 (terazosin) 53.57 .03
and have therefore been the next 75.86 (doxazosin) 53.57 .04
agents investigated for their potential
Porpiglia F et al22 85 43 .001
to promote stone expulsion and de-
crease pain. The likely mechanism Dellabella M et al23 97.1 64.3 .0001
that -blockers use in stone passage
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4. Alpha-Blockers for Nephrolithiasis continued
and another group that received
Table 2 tamsulosin in addition to tenoxicam.
Time to Stone Expulsion for Distal Ureteral Stones in Patients Treated The stones ranged in size from 5 to
With Alpha-1-Blocker Versus Patients Treated With Standard Medical 12 mm in the group without tamsu-
Expulsion Therapy Without Alpha-1-Blocker losin and from 5 to 13 mm in the
group receiving tamsulosin. Patients
receiving tamsulosin reported signifi-
Distal Ureteral Stone Expulsion Times
cantly less pain using a VAS scoring
Study With Alpha-1 Blocker Without Alpha-1 Blocker P Value from 1 to 10 (5.70 vs 8.30; P .0001).
Dellabella M et al18 65.7 h 111.1 h .02 Patients receiving tamsulosin reported
De Sio M et al 20
4.4 d 7.5 d .005 fewer instances of colic. The sponta-
Yilmaz E et al21 6.31 d (tamsulosin) 10.54 d .04 neous passage rates were 86.6% for
5.75 d (terazosin) 10.54 d .03 patients receiving tamsulosin, com-
5.93 d (doxazosin) 10.54 d .03 pared with 73.3% for those who did
Porpiglia F et al22 7.9 d 12 d .02 not. There were minimal side effects
23 reported from the tamsulosin, and
Dellabella M et al 72 h 120 h .0001
none of the patients had to stop taking
tamsulosin secondary to a side effect.
In a more recent prospective study,
the time to stone expulsion (Tables 1 trimetossibenzene, a spasmolytic De Sio and associates20 showed simi-
and 2). Importantly, it decreases the used in Italy. All patients received an lar results. They enrolled 96 patients
amount of pain patients suffer while oral steroid (deflazacort) for 10 days, with distal ureteral stones smaller
passing their stones (Table 3). Della- clotrimoxazole for 8 days, and di- than 10 mm. The patients were ran-
bella and colleagues18 evaluated clofenac as needed. The expulsion domized into 2 groups: 1 group re-
60 patients with symptomatic rate was 100% for patients receiving ceiving diclofenac and aescin, an
ureterovesical junction stones. They tamsulosin, compared with 70% in anti-edema extract from horse chest-
compared 2 groups of 30 patients the other group. The time to expul- nuts, and the second group receiving
each: 1 group received tamsulosin sion was significantly less in the tamsulosin in addition to diclofenac
and the other received floroglucine- tamsulosin group, 65.7 hours com- and aescin. The stone expulsion rate
pared with 111.1 hours in the group was 90.0% with tamsulosin and
not using tamsulosin. Patients receiv- 58.7% without tamsulosin. The time
Table 3 ing tamsulosin required significantly to expulsion was significantly less
Diminished Pain During Stone fewer injections of diclofenac, 0.13 with tamsulosin: 4.4 days versus 7.5
Passage With Alpha-1 Blocker compared with 2.83. One third of the days. Patients receiving tamsulosin
patients who did not receive tamsu- required significantly less analgesia.
Pain Measure losin needed to be hospitalized, 3 for The rate for rehospitalization for pa-
Significantly uncontrollable pain and 7 for failure tients receiving tamsulosin was 10%,
Improved With to pass their stone in 28 days. Mean and none of the patients required
Study Alpha-1-Blocker* stone size was significantly greater in an endoscopic procedure, whereas in
Dellabella M et al18 Yes the group receiving tamsulosin, 6.7 the group who did not receive tamsu-
19 mm versus 5.8 mm in those who re- losin, 27.5% were rehospitalized
Resim S et al Yes
ceived floroglucine, which further and 13% underwent an endoscopic
De Sio M et al20 Yes points to the effectiveness of - procedure.
21
Yilmaz E et al Yes blockers. Although tamsulosin has been the
Porpiglia F et al22 Yes Patients with distal ureteral stones most commonly studied 1-blocker in
Dellabella M et al 23
Yes given tamsulosin reported decreased the treatment of ureteral stones, other
pain using a visual analogue scale 1 antagonists have been shown to be
*Various measures were used to quantify
pain in the above studies, including visual (VAS). Resim and colleagues19 studied equally effective. In a prospective
analogue scale, dose of diclofenac in mil- 60 patients with lower ureteral stones randomized study, tamsulosin was
ligrams, number of injections of diclofenac
used, and number of episodes of colic. who were divided into 2 groups, 1 of compared with terazosin and doxa-
which received tenoxicam, an NSAID, zosin. A total of 114 patients with
S38 VOL. 8 SUPPL. 4 2006 REVIEWS IN UROLOGY

5. Alpha-Blockers for Nephrolithiasis
distal ureteral stones of 10 mm or In a study of 86 patients with distal losin (97.1%) when compared with
smaller were divided into 4 treatment ureteral stones smaller than 1 cm, both the group receiving nifedipine
groups: those who received either no Porpiglia and associates22 compared (77.1%) and the group receiving
1-blocker (control group), tamsu- the effectiveness of nifedipine and phloroglucinol (64.3%). The median
losin 0.4 mg, terazosin 5 mg, or dox- tamsulosin. All 86 patients received time in hours to stone passage was
azosin 4 mg. All the patients were 10 days of deflazacort. The 86 pa- 72 hours for the group receiving tam-
given diclofenac to take as needed for tients were broken down into 3 sulosin, and this was significantly less
pain. In the control group, only groups: 1 group received only de- than the 120 hours for the groups re-
53.57% passed their stones, whereas flazacort (control group), 1 group re- ceiving nifedipine or phloroglucinol.
the rates for the groups receiving ceived tamsulosin 0.4 mg daily, and None of the patients receiving tamsu-
tamsulosin, terazosin, and doxazosin the third group received 30 mg losin required hospitalization during
were 79.31%, 78.57%, and 75.86%, nifedipine slow release daily. All pa- the study, whereas 15.7% of the pa-
respectively. The patients treated with tients received diclofenac as needed tients receiving phloroglucinol and
1-blockers also reported significantly for pain. The expulsion rates for the 4.3% of the patients receiving
decreased pain and need for analgesia control group, tamsulosin group, and nifedipine required hospitalization
when compared with the control nifedipine group were 43%, 85%, and during the study. The group receiving
group. Finally, the mean times to pas- 80%, respectively. Both tamsulosin tamsulosin required significantly
sage for the control group, and the and nifedipine significantly increased fewer endoscopic procedures, required
groups receiving tamsulosin, tera- stone passage rates. Only tamsulosin less analgesia, and lost fewer work-
zosin, and doxazosin were 10.54 days, had a significantly shorter time to days when compared with the groups
6.31 days, 5.75 days, and 5.93 days, stone passage when compared with receiving nifedipine or phlorogluci-
respectively. The mean time to pas- the control group. The mean time to nol. At the conclusion of the study,
sage was significantly lower in the passage for the control group, tamsu- patients filled out a EuroQuol ques-
groups receiving 1-blockers com- losin group, and nifedipine group was tionnaire to evaluate quality of life,
pared with the control group. Of note, 12 days, 7.9 days, and 9.3 days, re- and tamsulosin was shown to have
there were no instances of hypoten- spectively. Both tamsulosin and significantly improved quality of life
sion in any of the patients receiving nifedipine significantly reduced the variables such as mobility, capacity to
1-blockers, and the patients receiv- need for diclofenac when compared perform usual activities, pain and dis-
ing terazosin and doxazosin were with the control group. The investiga- comfort, and anxiety. Of note, the
started on their therapeutic doses tors concluded that tamsulosin was median stone size in the tamsulosin
upon entrance into the study rather superior to nifedipine because of the group was significantly larger, 7 mm
than being titrated to those doses.21 decreased time to expulsion and compared with 6 mm in the other
slightly higher rate of expulsion, even 2 groups.
Alpha-1-Blockers Compared though the stone size in the tamsu-
With Calcium Channel Blockers losin group was larger, although not Alpha-1-Blockers and SWL
In 1994, Borghi and colleagues statistically significantly so (5.42 mm SWL has been established as an effec-
demonstrated the efficacy of the cal- vs 4.7 mm). tive therapy for the treatment of
cium channel blocker nifedipine in Dellabella and colleagues also re- ureteral and renal stones. Tamsulosin
the treatment of ureteral stones in a cently compared tamsulosin, nifedip- has been studied as an adjunct ther-
randomized, double-blind, placebo- ine, and phloroglucinol, a spasmolytic apy along with SWL. One study com-
controlled study.11 They enrolled agent, in 210 patients with distal pared the stone-free rate in 48 pa-
86 patients to receive methylpred- ureteral stones larger than 4 mm.23 tients who received SWL for distal
nisolone with placebo or nifedipine. The patients were randomly assigned ureteral stones of 6 mm to 15 mm.24
The patients receiving nifedipine had to receive either tamsulosin 0.4 mg, After the patients underwent SWL,
a significantly higher rate of stone nifedipine slow release 30 mg, or they were randomized to receive ei-
passage compared with the placebo phloroglucinol. All patients received ther oral hydration and diclofenac, or
group, 87% versus 65%. Studies com- 10 days of deflazacort 30 mg and oral hydration and diclofenac with
paring nifedipine with tamsulosin 8 days of cotrimoxazole, as well as tamsulosin 0.4 mg. The mean stone
have shown that both are effective in diclofenac as needed. The percentage size for those receiving tamsulosin
aiding in stone passage, but that tam- of stones passed was significantly was 8.6 mm, compared with 8.2 mm
sulosin may be more efficacious.22,23 greater in the group receiving tamsu- for those not receiving tamsulosin.
VOL. 8 SUPPL. 4 2006 REVIEWS IN UROLOGY S39

6. Alpha-Blockers for Nephrolithiasis continued
Patients were evaluated 15 days after those who did not receive tamsulosin, toward improved resolution of the
receiving SWL with abdominal radi- but the difference was not statistically steinstrasse and there is the potential
ography to evaluate for residual stone significant. The mechanism of action benefit of improved analgesia.
burden. The stone-free rate was 70.8% of how -blockers help clear renal
for patients who received tamsulosin, stone burden has yet to be elucidated Alpha-1-Blockers
compared with 33.3% for those who and requires further investigation; and Ureteral Stents
did not (P .019). Only 1 patient re- however, their ability to assist in the Ureteral stents are often used in the
ceiving tamsulosin experienced slight passage of stone fragments when they treatment of renal and ureteral stones.
dizziness. The investigators concluded pass through the ureter is intuitive, The stents can be associated with
that tamsulosin could improve stone- based on previous work as reported. some morbidity, including pain and
free rates after SWL of distal ureteral Steinstrasse is an accumulation of urinary symptoms. Deliveliotis and
stones with minimal side effects. stone fragments in the ureter typi- colleagues studied whether these
Gravina and colleagues studied the cally after SWL, which can lead to symptoms could be improved using
efficacy of tamsulosin as an adjunc- obstruction. It is estimated to occur the 1-blocker alfuzosin.28 Double-J
tive therapy after SWL for renal in 2% to 10% of cases, and there is stents were placed in 100 patients for
stones.25 They included 130 patients increased risk with increasing stone the treatment of ureteral stones
who underwent renal stone SWL, ex- burden.26 Resim and colleagues27 smaller than 10 mm. Patients were
cluding patients with lower pole studied the effect of tamsulosin on randomized after stent placement to
stones. The stones ranged in size from the resolution of steinstrasse. Patients receive either alfuzosin 10 mg daily or
4 mm to 20 mm. After SWL, patients were included in the study if they had placebo for 4 weeks. At the end of the
were randomized to either receive steinstrasse in the lower ureter and if 4-week study, all patients were as-
standard medical therapy, which was the column of stone fragments was sessed for stone-free status and filled
methylprednisolone, 16 mg twice obstructing the ureter, as determined out the validated Ureteral Stent
daily for 15 days and diclofenac as with radiography and renal ultra- Symptom Questionnaire (USSQ). The
needed, or standard therapy plus tam- sound. A total of 67 patients were mean urinary symptom score, as as-
sulosin 0.4 mg. Patients were evalu- included and were randomized to sessed by the USSQ, was significantly
ated with renal ultrasound, radiogra- receive hydration and tenoxicam, an lower in the group receiving alfu-
phy, and/or intravenous urography at NSAID, with or without tamsulosin zosin, 21.6 versus 28.1 (P .001). Pa-
4, 8, and 12 weeks. Clinical success 0.4 mg. Patients were followed for 6 tients receiving alfuzosin reported
was defined as stone-free status or the weeks. The stone passage rates were less stent related pain, 66% versus
presence of clinically insignificant determined by patient report and by 44% (P .027) and also reported a
stone fragments, which were defined imaging with radiography and renal lower mean pain index score, 8 versus
as asymptomatic fragments 3 mm or ultrasound. The passage rates were 11.4 (P .001). Both the mean gen-
less. At 12 weeks, clinical success was 75% with tamsulosin and 65.7% eral health index score and mean sex-
achieved in 78.5% of patients receiv- without, which did not reach statisti- ual matters score were significantly
ing tamsulosin and 60% of patients cal significance. The time to passage better in patients taking alfuzosin.
not receiving tamsulosin (P .037). was also not significantly different. Spontaneous stone passage was simi-
Tamsulosin had a greater effect when However, patients receiving tamsu- lar between the 2 groups. Albeit a
compared with the control group for losin did have significantly fewer single small study, the potential ben-
larger stones. In stones 4 mm to episodes of colic and had signifi- efits of -blockers is demonstrated in
10 mm, the clinical success rates with cantly lower pain scores on a VAS. reducing stent-related symptoms and
and without tamsulosin were 75% Approximately 40% of patients re- should be investigated further.
versus 68% (P .05), and for stones ceiving tamsulosin experienced
11 mm to 20 mm the success rates minor side effects from the medica- Current Recommendations
were 81% versus 55% (P .009). tion, but none were significant When conservative management of a
Tamsulosin significantly reduced the enough for the patient to stop taking ureteral stone is being considered and
amount of diclofenac used and re- the tamsulosin. Although -blockers the patient has no associated signs of
duced the occurrence of flank pain did not reach statistical significance infection, uncontrollable pain, or
after SWL. Patients receiving tamsu- in the previous study, they may be a renal failure, adjuvant pharmacologic
losin required ureteroscopy or a sec- useful adjunct in the management of intervention has proven efficacious
ond SWL less often compared with steinstrasse because there is a trend in improving spontaneous stone pas-
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7. Alpha-Blockers for Nephrolithiasis
sage rate and time interval, and in sage. Alpha-blockers, specifically 1 passage: a meta-analysis. Lancet. 2006;368:
1171-1179.
reducing analgesic requirements. antagonists, are highly effective in in- 3. Malin JM, Deane RF, Boyarsky S. Characterisa-
Many of the studies have adminis- creasing the expulsion rate of distal tion of adrenergic receptors in human ureter. Br
tered the drugs in conjunction with ureteral stones, reducing the time to J Urol. 1970;42:171-174.
4. Sigala S, Dellabella M, Milanese G, et al. Evi-
steroids and/or NSAIDs, which may stone passage, and decreasing the dence for the presence of alpha1 adrenoceptor
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transport: changes in bolus volume, peristaltic
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7. Davenport K, Timoney AG, Keeley FX. A com-
randomized trial, has been shown to vestigation is necessary to define the parative in vitro study to determine the
be more efficient than nifedipine with role of -blockers in the treatment of beneficial effect of calcium-channel and alpha(1)-
a decreased time to expulsion and proximal ureteral and renal stones, adrenoceptor antagonism on human ureteric
activity. BJU Int. 2006;98:651-655.
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Our current treatment regimen for nisms of renal stone clearance after steroids and tamsulosin in the medical expulsive
conservative management of ureteral surgical stone intervention. therapy for symptomatic distal ureter stones:
single drug or association? Eur Urol. 2006;
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receptor antagonist, prescribe anal- or without steroids and/or NSAIDs, expulsive therapy for distal ureterolithiasis:
randomized prospective study on role of corti-
gesics as needed, and follow the pa- -blockers, with their high success costeroids used in combination with tamsulosin-
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10. Laerum E, Ommundsen OE, Gronseth JE, et al.
However, the combination of corti- come the leading candidate in MET Oral diclofenac in the prophylactic treatment of
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11. Borghi L, Meschi T, Amato F, et al. Nifedipine
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Additionally, -adrenergic receptor placebo-controlled study. J Urol. 1994;152:
1095-1098.
Summary antagonists may be considered during 12. Porpiglia F, Destefanis P, Fiori C, Fontanta D. Ef-
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