EAU 2017: Debate Session: The Patient In Pain: How To Approach The Ureteral Stone?

London, England (UroToday.com) Ureteral stones are common and there are multiple treatment modalities including ureteroscopy (URS), shock-wave lithotripsy (SWL) and medical expulsive therapy. The optimal treatment modality as to what modality and when to use remains a topic of debate. During this is exciting session, two stone experts debated on an important topic in the management of ureteral stones.

Dr. Stefano Picozzi, (Milan, Italy) was defending emergency SWL treatmant, and Dr. Juan Galan Llopes from Alicante, Spain was defending emergency URS, and finally Dr. Thomas Lam from Aberdeen, UK was defending the use of alpha-blockers and Dr. Andreas Gross from Hamburg, Germany was defending emergency stenting. The debate was on the effectiveness of all these treatment modalities in the setting of emergency obstructive ureteral stone.

Dr. Picozzi advocated that the ESWL as an emergency treatment of choice for the patient presenting in the emergency department (ED) with an obstructive ureteral stone. He started with the discussion of the meta-analysis that his group published in 2012 that included 570 patients, which demonstrated that the success rates of emergency ESWL are higher than elective ESWL, and more importantly the patient will be pain free faster and will thus return to daily activity sooner5. Although this study is one of the few in this topic, it has significant limitations to conclude a definitive answer to the question and based on their data it is hard to change a clinical practice. Dr. Picozzi did mention that a larger prospective trial would be needed to identify a significant difference and draw a definitive conclusion. Finally, he concluded emergency ESWL is a safe and effective procedure that is generally well tolerated by patients and that earlier treatment may minimize stone impaction.

The next debated in this session was Dr. Galan who started his lecture with the statement that most patients are concerned about their pain at the time of renal colic in the emergency department and urologist’s primary concern must be relieving patients pain and deal with the stone at a later stage. Apparently, 87% of patients would agree with a 4 week trial of MET. When patients are asked about the preference of active treatment, the majority would prefer ESWL, which is considered the least invasive procedure, however patients preference shifts to URS after physicians provide more information on the success rates of both, URS and ESWL procedures. The current state of literature and data on the emergency use URS is poor with only one prospective trial and 1 meta-analysis. Although no big difference in stone free rate, patients can be rendered pain free faster with an emergency procedure. Dr. Galan concluded that although URS is effective, 90% of patients will need a stent post-operatively and subsequent follow up visit to remove the ureteral stent.

The third presenter on this debate session was Dr. Lam who advocated for MET treatment based on the SUSPEND prospective randomized trial published by McClinton and colleauges in 20146. He continued that all meta-analyses on the subject show a benefit of MET over placebo. They also all, expect for the one from Hollingsworth published in 20167, acknowledge that there is a large methodological and statistical heterogeneity, small studies included and publication bias8. Dr. Lam further defined that the current data would indicate that MET is most useful for distal stones >5mm and <10mm. He emphasized that meta-analysis, including only high-quality studies would be useful as well as a nomogram to identify the probable responders to MET.

Final debater of the session, Dr. Gross started off with the a statement that he has a very busy ED department of 50,000 visits per year, in which renal colic is the 9th most common cause of visit. He expressed that as most patients with a renal colic are in pain at the time of ED visit, there is no time for a lengthy discussion with the patient about stone free rates, complication rates, etc. He continued that all URS, SWL and MET are all excellent treatment options; however, he reinforced that ESWL has a high chance of needing retreatment and the limitation of URS is that patients need to be stented and subsequent visits are required to remove the stent. Dr. Gross said he believes that MET does not help in the first 2 weeks of the treatment (no reference provided).

Emergency stenting has multiple benefits. The patient is relieved of pain immediately, gaining access with ureteroscope is more successful in pre-stented patients and pre-stented patients have a lower chance of needing a stent after the URS. He also feels that pre-stented patients have less bleeding during URS. In the discussion, Dr. Picozzi holds true to his principle and would SWL any stone in the ureter of <10mm if there is no indication of infection or contra-indication for SWL. Interestingly, many of the patients in Dr. Galan’s service may have had a trial of MET prior to their first visit to the urologist. Dr. Lam emphasizes that it remains difficult to identify the ideal patient and ideal treatment window for a trial of MET.

Presenter: Beat Roth, MD; Department of Urology, University of Bern, Bern, Switzerland

Written By: Zhamshid Okhunov, MD, University of California, Irvine

at the #EAU17 - March 24-28, 2017- London, England