Emergency room management of ureteral calculi: current practices.

OBJECTIVE: To evaluate current practice patterns in U.S. emergency departments (EDs) for the diagnosis, treatment, and counseling of patients with ureteral calculi. METHODS: Hospital-based ED physicians were invited by e-mail to participate in a Survey-Monkey survey. E-mails were delivered in March 2008 by Direct Medical Data using a listserv provided by the American Medical Association. Of the e-mails sent, 173 e-mails were opened, and 135 physicians responded. Physicians were compensated with a $10 Amazon.com gift card. RESULTS: Ninety percent of ED physicians use noncontrast CT as their initial imaging modality, and 63% use alpha-blockers for medical expulsive therapy. Only 13% of evaluated EDs have guidelines for the management of renal colic, and only 58% of these guidelines that recommend the use of an alpha-blocker. Alpha-blocker use was more common with physicians who have been practicing fewer than 5 years (81%) compared with those with more than 10 years of experience (56%). The majority of physicians used ketorolac and morphine to achieve effective analgesia. Although the average responses concerning the chance of spontaneous stone passage for stones 4 mm (44%) were close to evidence-based values, great variation in the answers was noted (standard deviations: 12% and 22%, respectively). Indeed, 38% of respondents stated that stones 95% chance of passage. Twenty-eight percent of ED physicians would arrange follow-up with a primary care physician, while the remainder would arrange follow-up with a urologist. CONCLUSIONS: This study establishes a need for educational opportunities for ED physicians in the management of renal colic. The development of collaborative practice guidelines between urology and emergency medicine associations may be warranted.

Systematic evaluation of ureteral occlusion devices: insertion, deployment, stone migration, and extraction.

OBJECTIVES: To compare 4 ureteral occlusion devices in terms of insertion force, maneuverability, radial dilation and extraction forces, ability to prevent stone migration, and tip stiffness. METHODS: The devices tested were the PercSys Accordion, Microvasive Stone Cone (7 and 10 mm), and Cook N-Trap. Using a ureteral model with an artificial stone in place, the insertion force, number of attempts, and time to pass the impacted stone were measured. Using a Teflon block model, radial dilation and extraction and axial extraction force were measured with a load cell. Holmium lithotripsy was performed in the ureteral model with a canine stone in place to test the ability of the devices to prevent stone migration. In a similar model, the force applied to retrieve the canine stone was measured. The stiffness of the tip was measured as the force to compress a 5-mm length of the tip in a clamp-clamp configuration on a linear motion stage driven by a stepper motor with a resolution of 8-mum/step. RESULTS: The devices were significantly different statistically from each other in terms of insertion force, number of attempts and time to pass the impacted stone, radial dilation, radial extraction, and axial extraction force in the Teflon block model. No proximal migration of the stones occurred with any of the devices. The devices were similar in terms of preventing proximal stone migration, force applied to retrieve stones, and tip stiffness. CONCLUSIONS: The differences in the physical characteristics of stone migration devices might help to predict their safety and efficacy in clinical use.

Ayurvedic medicine and renal calculi.

OBJECTIVE: To explore the supportive evidence for the use of Ayurvedic medicine in the management of existing and recurrent nephrolithiasis. METHOD: Nine Ayurvedic medicines commonly utilized in the management of nephrolithiasis were identified by discussions with Ayurvedic practitioners in India. Mechanistic and clinical studies evaluating the use of these agents were identified using the Medline database and bibliographies suggested by Ayurvedic practitioners. The articles were then critically reviewed and summarized. RESULTS: Four in vitro mechanistic studies, eight animal studies, and seven human trials were identified. Phyllanthus niruri has undergone mechanistic in vitro, animal, and clinical trials that support its impact on calcium oxalate crystallization. Preliminary clinical trials have evaluated the role of Dolichos biflorus and Orthosiphon grandiflorus in the prevention of urolithiasis and fish stone as a method of stone expulsion, yet the treatment effect and mechanism of action remains to be elucidated. CONCLUSION: Ayurvedic medicine holds promise as a complementary approach to the management and prevention of nephrolithiasis. The best studied compound is P. niruri. Further controlled randomized clinical trials are justified to support or refute the potential benefits demonstrated in these initial studies.