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PD31-04 MEDICAL EXPULSIVE THERAPY, EVIDENCE FROM RANDOMISED TRIALS META-ANALYSIS
THE JOURNAL OF UROLOGYâ
e718
Data from 53 trials (number of patients ¼ 5,611) were pooled. The main outcomes were the proportion of patients who passed their stones and the proportion that required urologic intervention. We calculated the summary estimate of effect associated with alpha blocker therapy using random-effects models, stratifying by ureteral stone size and location. RESULTS: While no benefit was observed in patients with smaller ureteral stones, those with larger ones who were given alpha blockers had a 71% greater likelihood of stone passage than those not given such treatment [pooled risk ratio (RR), 1.71; 95% confidence interval (CI), 1.29 to 2.53]. With respect to stone passage by location, the pooled RRs for upper/middle and lower ureteral stones were 1.65 (95% CI, 1.22 to 2.39) and 1.53 (95% CI, 1.41 to 1.68), respectively. Although alpha blockers did not reduce the likelihood of urologic intervention among patients with upper and middle ureteral stones, as shown in the Figure, the pooled RR for lower ureteral stones, comparing alpha blockers to controls, was 0.46 (95% CI 0.37 to 0.55). CONCLUSIONS: Our findings suggest a continued role of alpha blocker therapy to facilitate ureteral stone passage, particularly in patients with larger stones of the lower ureter who could avoid the need for urological intervention and its attendant risks.
Vol. 195, No. 4S, Supplement, Sunday, May 8, 2016
variance was used. Expressed as Mean difference and risk ratio, respectively, with a 95% confidence interval; p<0.05 considered significant. RESULTS: A total of 5472 patients were in the a-blocker studies (52 studies) and 1372 patients in the Nifedipine studies (9 studies). There was no significant difference between the experimental and control groups in any of the demographic parameters or the medication side effects. The analysis reveals that a-blockers were statistically more likely to lead to stone expulsion (p<0.00001). Subgroup analysis of individual a-blockers also showed statistical significant favouring the a-blocker over a control. However, a subgroup analysis of powered RCTs with low risk of bias (9 trials) reveals no difference between a-blocker and control groups (p¼0.1). Analysis of the Tamsulosin studies (29 trials) also favoured Tamsulosin over a control for stone expulsion (p¼0.00001). However, a subgroup analysis of powered RCTs with low risk of bias (6 trial) reveals no difference between Tamsulosin and control groups (p¼0.09). Analysis of the Nifedipine studies (9 trials) also favoured the CCB over a control for stone expulsion (p¼0.0005). However, a subgroup analysis of powered RCTs with low risk of bias (2 trial) reveals no difference between Nifedipine and control groups (p¼0.38). There was statistical significance, favouring a-blockers for having shorter time to stone expulsion as opposed to the control groups (p<0.00001). This was mirrored in the sub-group analysis of powered RCTs with low risk of bias as well (p¼0.0001). Though no difference was found between the a-blockers and control with regards to stones <5mm in size, either in the general analysis (p¼0.31) or the high quality study sub-analysis (p¼0.68), there was statistical significance favouring a-blockers in stones >5mm in size for both general analysis (p<0.00001) and powered RCTs with low risk of bias sub-analysis (p¼0.02). CONCLUSIONS: Evidence from high quality trials that were powered RCTs with low risk of bias would suggest, although MET does not increase stone expulsion rates in general, their role might be more significant for larger (>5mm) stones and stones in the lower ureter. Furthermore, MET does shorten the expulsion time of stones. Source of Funding: None
Source of Funding: None
PD31-04 MEDICAL EXPULSIVE THERAPY, EVIDENCE FROM RANDOMISED TRIALS META-ANALYSIS Tarik Amer*, Martin Mariappan, Glasgow, United Kingdom; Ameet Gupta, Wolverhampton, United Kingdom; Bhaskar Somani, Southampton, United Kingdom; Frank Keeley, Bristol, United Kingdom; Allan Johnston, Glasgow, United Kingdom; Omar Aboumarzouk, Bristol, United Kingdom INTRODUCTION AND OBJECTIVES: Medical Expulsive Therapy (MET) has been a matter of debate in the last decade with a number of randomised trials that varied in their outcomes from each other. We aimed to conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) investigating the efficacy MET to increase stone expulsion focusing on studies that were powered and have a low risk of bias. METHODS: A Cochrane style systematic review was conducted on published literature from 1990 to 2015 to include studies comparing either an a-blocker or calcium channel blocker to a control. The outcome measures were the patient and stone demographics, expulsion rates, expulsion times, and side effect of the medication. A pooled meta-analysis was conducted. A subgroup meta-analyses was done by excluding trials with risk of bias. For continuous data, a MantelHaenszel chi-square test was used; for dichotomous data, an inverse
PD31-05 TITLE: PAIN FOLLOWING URETERAL STENT REMOVAL: PREVALENCE AND TREATMENT Gabriel Belanger*, Lisa Beaule, Portland, ME INTRODUCTION AND OBJECTIVES: Ureteral stents may cause ureteral edema which can lead to ureteral obstruction after stent removal, with symptoms similar to ureteral colic. The prevalence of this phenomenon has not been characterized. Tadros et al (British Journal of Urology, 111 (1):101-5 (2013)) gave patients Rofecoxib 50 mg (withdrawn from the US market in 2004) or placebo prior to ureteral stent removal and noted a significant reduction in severe pain at 24 hours on the numeric pain rating scale, suggesting post-stent removal obstruction is commonplace. The effect was so pronounced, the study was terminated at interim analysis. As this amount of pain did not seem typical of our patients, we designed a study to assess pain after stent removal and whether prophylactic NSAID use would be a useful treatment. METHODS: A prospective, randomized, double-blind, placebocontrolled trial was performed at our institution following IRB approval. Adults undergoing cystoscopy and stent removal after recent ureteroscopic treatment of nephrolithiasis were randomized to receive either 440 mg Naproxen sodium or placebo just prior to stent removal. Patients completed a visual analogue scale (VAS, 0-100 mm) for their pain level at time of stent removal and 24 hours later. The primary outcome was visual analogue scale at 24 hours. Data was analyzed using
e718
Data from 53 trials (number of patients ¼ 5,611) were pooled. The main outcomes were the proportion of patients who passed their stones and the proportion that required urologic intervention. We calculated the summary estimate of effect associated with alpha blocker therapy using random-effects models, stratifying by ureteral stone size and location. RESULTS: While no benefit was observed in patients with smaller ureteral stones, those with larger ones who were given alpha blockers had a 71% greater likelihood of stone passage than those not given such treatment [pooled risk ratio (RR), 1.71; 95% confidence interval (CI), 1.29 to 2.53]. With respect to stone passage by location, the pooled RRs for upper/middle and lower ureteral stones were 1.65 (95% CI, 1.22 to 2.39) and 1.53 (95% CI, 1.41 to 1.68), respectively. Although alpha blockers did not reduce the likelihood of urologic intervention among patients with upper and middle ureteral stones, as shown in the Figure, the pooled RR for lower ureteral stones, comparing alpha blockers to controls, was 0.46 (95% CI 0.37 to 0.55). CONCLUSIONS: Our findings suggest a continued role of alpha blocker therapy to facilitate ureteral stone passage, particularly in patients with larger stones of the lower ureter who could avoid the need for urological intervention and its attendant risks.
Vol. 195, No. 4S, Supplement, Sunday, May 8, 2016
variance was used. Expressed as Mean difference and risk ratio, respectively, with a 95% confidence interval; p<0.05 considered significant. RESULTS: A total of 5472 patients were in the a-blocker studies (52 studies) and 1372 patients in the Nifedipine studies (9 studies). There was no significant difference between the experimental and control groups in any of the demographic parameters or the medication side effects. The analysis reveals that a-blockers were statistically more likely to lead to stone expulsion (p<0.00001). Subgroup analysis of individual a-blockers also showed statistical significant favouring the a-blocker over a control. However, a subgroup analysis of powered RCTs with low risk of bias (9 trials) reveals no difference between a-blocker and control groups (p¼0.1). Analysis of the Tamsulosin studies (29 trials) also favoured Tamsulosin over a control for stone expulsion (p¼0.00001). However, a subgroup analysis of powered RCTs with low risk of bias (6 trial) reveals no difference between Tamsulosin and control groups (p¼0.09). Analysis of the Nifedipine studies (9 trials) also favoured the CCB over a control for stone expulsion (p¼0.0005). However, a subgroup analysis of powered RCTs with low risk of bias (2 trial) reveals no difference between Nifedipine and control groups (p¼0.38). There was statistical significance, favouring a-blockers for having shorter time to stone expulsion as opposed to the control groups (p<0.00001). This was mirrored in the sub-group analysis of powered RCTs with low risk of bias as well (p¼0.0001). Though no difference was found between the a-blockers and control with regards to stones <5mm in size, either in the general analysis (p¼0.31) or the high quality study sub-analysis (p¼0.68), there was statistical significance favouring a-blockers in stones >5mm in size for both general analysis (p<0.00001) and powered RCTs with low risk of bias sub-analysis (p¼0.02). CONCLUSIONS: Evidence from high quality trials that were powered RCTs with low risk of bias would suggest, although MET does not increase stone expulsion rates in general, their role might be more significant for larger (>5mm) stones and stones in the lower ureter. Furthermore, MET does shorten the expulsion time of stones. Source of Funding: None
Source of Funding: None
PD31-04 MEDICAL EXPULSIVE THERAPY, EVIDENCE FROM RANDOMISED TRIALS META-ANALYSIS Tarik Amer*, Martin Mariappan, Glasgow, United Kingdom; Ameet Gupta, Wolverhampton, United Kingdom; Bhaskar Somani, Southampton, United Kingdom; Frank Keeley, Bristol, United Kingdom; Allan Johnston, Glasgow, United Kingdom; Omar Aboumarzouk, Bristol, United Kingdom INTRODUCTION AND OBJECTIVES: Medical Expulsive Therapy (MET) has been a matter of debate in the last decade with a number of randomised trials that varied in their outcomes from each other. We aimed to conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) investigating the efficacy MET to increase stone expulsion focusing on studies that were powered and have a low risk of bias. METHODS: A Cochrane style systematic review was conducted on published literature from 1990 to 2015 to include studies comparing either an a-blocker or calcium channel blocker to a control. The outcome measures were the patient and stone demographics, expulsion rates, expulsion times, and side effect of the medication. A pooled meta-analysis was conducted. A subgroup meta-analyses was done by excluding trials with risk of bias. For continuous data, a MantelHaenszel chi-square test was used; for dichotomous data, an inverse
PD31-05 TITLE: PAIN FOLLOWING URETERAL STENT REMOVAL: PREVALENCE AND TREATMENT Gabriel Belanger*, Lisa Beaule, Portland, ME INTRODUCTION AND OBJECTIVES: Ureteral stents may cause ureteral edema which can lead to ureteral obstruction after stent removal, with symptoms similar to ureteral colic. The prevalence of this phenomenon has not been characterized. Tadros et al (British Journal of Urology, 111 (1):101-5 (2013)) gave patients Rofecoxib 50 mg (withdrawn from the US market in 2004) or placebo prior to ureteral stent removal and noted a significant reduction in severe pain at 24 hours on the numeric pain rating scale, suggesting post-stent removal obstruction is commonplace. The effect was so pronounced, the study was terminated at interim analysis. As this amount of pain did not seem typical of our patients, we designed a study to assess pain after stent removal and whether prophylactic NSAID use would be a useful treatment. METHODS: A prospective, randomized, double-blind, placebocontrolled trial was performed at our institution following IRB approval. Adults undergoing cystoscopy and stent removal after recent ureteroscopic treatment of nephrolithiasis were randomized to receive either 440 mg Naproxen sodium or placebo just prior to stent removal. Patients completed a visual analogue scale (VAS, 0-100 mm) for their pain level at time of stent removal and 24 hours later. The primary outcome was visual analogue scale at 24 hours. Data was analyzed using