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Role of steroidal anti-inflammatory agent prior to intracorporeal lithotripsy under local anesthesia for ureterovesical junction calculus: A prospective randomized controlled study.

Lodh B, Singh KA, Sinam RS - Urol Ann (2015 Apr-Jun)

Bottom Line: Re-treatment rates in the study group were lower than the control group (4.76% vs. 17.46%) and found to be statistically significant (P - 0.044).It is found that computed tomography (CT) appearance (r - 0.399) and stone size (r - 0.410) strongly correlate with the endoscopic findings of the region of UVJ (P - 0.001).The present study showed the administration of tablet deflazacort (a steroidal anti-inflammatory agent) significantly improves the outcome of URSL under local anesthesia.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Regional Institute of Medical Sciences, Imphal, Manipur, India.

ABSTRACT

Objective: The objective of the following study is to assess the effect of steroidal anti-inflammatory agent on the outcome of ureterorenoscopic lithotripsy (URSL) for ureterovesical junction (UVJ) calculus.

Settings and design: This was a prospective randomized controlled study conducted at the Department of Urology, Regional Institute of Medical Sciences, Imphal.

Subjects and methods: One hundred and twenty-six patients requiring ureteroscopic lithotripsy for UVJ calculus were randomly assigned into two groups. The study group received tablet deflazacort 30 mg once a day for 10 days prior to the procedure, whereas the control group did not receive such treatment. Parameters with respect to the outcome of the procedure were recorded for all patients in both groups.

Statistical analysis used: Fisher's exact and independent t-test was used to compare the outcome between the groups where P < 0.05 was considered to be statistically significant.

Results: There was significant statistical difference (P - 0.016) on the endoscopic appearance of the region of ureteric orifice in patients receiving steroidal anti-inflammatory agent compared with control. Severe procedure related pain and mean operative time was less in the study group compared to control (P - 0.020 and 0.031, respectively). Re-treatment rates in the study group were lower than the control group (4.76% vs. 17.46%) and found to be statistically significant (P - 0.044). It is found that computed tomography (CT) appearance (r - 0.399) and stone size (r - 0.410) strongly correlate with the endoscopic findings of the region of UVJ (P - 0.001).

Conclusions: Inflamed and or obliterated ureteric orifice is the major constraints for stone clearance at ureterovesical junction. The present study showed the administration of tablet deflazacort (a steroidal anti-inflammatory agent) significantly improves the outcome of URSL under local anesthesia. We strongly recommend its use prior to URSL for UVJ calculus, especially for stone size ≥10.24 mm and on CT evidence of prominent soft tissue swelling at the UVJ.

No MeSH data available.


Related in: MedlinePlus

Nonenhance computed tomography scans showing soft tissue eprominence in the region of left uretero vesical junction
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Figure 4: Nonenhance computed tomography scans showing soft tissue eprominence in the region of left uretero vesical junction

Mentions: The incidence of urolithiasis in Manipur (a north east state of India) is alarmingly high as observed by Singh et al.[2] and Marak et al.[3] Therefore, it is not uncommon for us to evident a ureteric and UVJ calculus undergoing ureterorenoscopic lithotripsy (URSL) under local anesthesia. However, occasionally we face difficulties, while dealing UVJ calculus and it is mostly due to inflamed and or obliterated ureteric orifice that resulted in an adverse outcome. In such situation, negotiation of URS through the ureteric orifice is the key predictor of outcome of URSL with respect to UVJ calculus. We prefer to use hydrophilic guidewire 0.035 inches during ureteroscopy. Guidewire access is of paramount importance during difficult cases because it enables the surgeon to negotiate a troublesome spot either to find back the ureter and continue with the ureteroscopy or to deploy a stent and return at a later date.[4] However not surprisingly due to intense inflammation at UVJ secondary to calculus, it is often impossible to access the ureter even with guide wire. Our study was aimed to identify effects of pharmacotherapy on forthcoming events related to URSL for UVJ calculus. In the present study, we have used tablet deflazacort (a glucocorticoid) because of its faster and potent anti-inflammatory effect that is achieved at a low dose compared to nonsteroidal anti-inflammatory drugs. We have avoided the pre-operative use of Diclofenac except for analgesia single shot half-an-hour prior to the procedure, to prevent potential bias that may arise due to its anti-inflammatory effect. Investigators have shown that larger stones tend to cause more intense inflammatory reactions leading to edema.[5] Corticosteroids stabilize neutrophil lysosomes, therefore, decreasing inflammation and edema related to mechanical irritation.[67] Here, we have administered 30 mg of deflazacort for 10 days. The majority of the authors recommended not to use for more than 10 days to prevent the side effects of prolonged use.[58910] In our clinical practice, we are not routinely using deflazacort for MET because of its high cost and also as it limit the duration of MET. In the present study, we observed that the inflamed ureteric orifice appears as prominent soft tissue swelling on CT scan [Figure 4]. Normally there is slight or absent soft tissue prominence at this region. As a result, a stone impacted at the UVJ might be expected to be displaced slightly anteriorly from the posterior bladder wall on axial CT images.[11] Mean operative time of patients in the study group was lower than controlled and it was found to be statistically significant (P - 0.031). We also noticed a high incidence (12.69%) of ureteric and trigonal false passage in the controlled group. False passage mostly developed, while entering through inflamed ureteric orifice and may necessitating termination of the procedure.[12] Al-Awadi et al.,[13] in their series of iatrogenic ureteric injury following URSL, documented 15 false passages (18.3%), making it one of the most common complications in their series. Statistically significant re-treatment rate in the control group was because of higher incidence of failed URS negotiation accompanied with severe procedure related pain and poor field visibility secondary to repeated trauma to the inflamed UVJ area. This was there as on why 20.63% of patients in the control group had gross hematuria for more than 24 h and it was found to be significant (P - 0.029) compared to study group. In our study, hospital stay was mostly due to severe procedure related pain and gross hematuria. One patient in the control group developed clot retention and was managed with clot evacuation and irrigation. No higher incidence of symptomatic bacteriruria was noticed in the controlled group. We found that pre-operative identification of prominent soft tissue swelling in the region of UVJ strongly correlate with the intra-operative findings. We also observed that stone size significantly correlate with the endoscopic appearance of inflamed and or obliterated ureteric orifice. A cut-off value of 10.24 mm showed sensitivity and specificity of 66.70% and 80.40%, respectively for prediction of inflamed and or obliterated ureteric orifice. The CONSORT diagram of the present study is depicted in Figure 5.


Role of steroidal anti-inflammatory agent prior to intracorporeal lithotripsy under local anesthesia for ureterovesical junction calculus: A prospective randomized controlled study.

Lodh B, Singh KA, Sinam RS - Urol Ann (2015 Apr-Jun)

Nonenhance computed tomography scans showing soft tissue eprominence in the region of left uretero vesical junction
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4374257&req=5

Figure 4: Nonenhance computed tomography scans showing soft tissue eprominence in the region of left uretero vesical junction
Mentions: The incidence of urolithiasis in Manipur (a north east state of India) is alarmingly high as observed by Singh et al.[2] and Marak et al.[3] Therefore, it is not uncommon for us to evident a ureteric and UVJ calculus undergoing ureterorenoscopic lithotripsy (URSL) under local anesthesia. However, occasionally we face difficulties, while dealing UVJ calculus and it is mostly due to inflamed and or obliterated ureteric orifice that resulted in an adverse outcome. In such situation, negotiation of URS through the ureteric orifice is the key predictor of outcome of URSL with respect to UVJ calculus. We prefer to use hydrophilic guidewire 0.035 inches during ureteroscopy. Guidewire access is of paramount importance during difficult cases because it enables the surgeon to negotiate a troublesome spot either to find back the ureter and continue with the ureteroscopy or to deploy a stent and return at a later date.[4] However not surprisingly due to intense inflammation at UVJ secondary to calculus, it is often impossible to access the ureter even with guide wire. Our study was aimed to identify effects of pharmacotherapy on forthcoming events related to URSL for UVJ calculus. In the present study, we have used tablet deflazacort (a glucocorticoid) because of its faster and potent anti-inflammatory effect that is achieved at a low dose compared to nonsteroidal anti-inflammatory drugs. We have avoided the pre-operative use of Diclofenac except for analgesia single shot half-an-hour prior to the procedure, to prevent potential bias that may arise due to its anti-inflammatory effect. Investigators have shown that larger stones tend to cause more intense inflammatory reactions leading to edema.[5] Corticosteroids stabilize neutrophil lysosomes, therefore, decreasing inflammation and edema related to mechanical irritation.[67] Here, we have administered 30 mg of deflazacort for 10 days. The majority of the authors recommended not to use for more than 10 days to prevent the side effects of prolonged use.[58910] In our clinical practice, we are not routinely using deflazacort for MET because of its high cost and also as it limit the duration of MET. In the present study, we observed that the inflamed ureteric orifice appears as prominent soft tissue swelling on CT scan [Figure 4]. Normally there is slight or absent soft tissue prominence at this region. As a result, a stone impacted at the UVJ might be expected to be displaced slightly anteriorly from the posterior bladder wall on axial CT images.[11] Mean operative time of patients in the study group was lower than controlled and it was found to be statistically significant (P - 0.031). We also noticed a high incidence (12.69%) of ureteric and trigonal false passage in the controlled group. False passage mostly developed, while entering through inflamed ureteric orifice and may necessitating termination of the procedure.[12] Al-Awadi et al.,[13] in their series of iatrogenic ureteric injury following URSL, documented 15 false passages (18.3%), making it one of the most common complications in their series. Statistically significant re-treatment rate in the control group was because of higher incidence of failed URS negotiation accompanied with severe procedure related pain and poor field visibility secondary to repeated trauma to the inflamed UVJ area. This was there as on why 20.63% of patients in the control group had gross hematuria for more than 24 h and it was found to be significant (P - 0.029) compared to study group. In our study, hospital stay was mostly due to severe procedure related pain and gross hematuria. One patient in the control group developed clot retention and was managed with clot evacuation and irrigation. No higher incidence of symptomatic bacteriruria was noticed in the controlled group. We found that pre-operative identification of prominent soft tissue swelling in the region of UVJ strongly correlate with the intra-operative findings. We also observed that stone size significantly correlate with the endoscopic appearance of inflamed and or obliterated ureteric orifice. A cut-off value of 10.24 mm showed sensitivity and specificity of 66.70% and 80.40%, respectively for prediction of inflamed and or obliterated ureteric orifice. The CONSORT diagram of the present study is depicted in Figure 5.

Bottom Line: Re-treatment rates in the study group were lower than the control group (4.76% vs. 17.46%) and found to be statistically significant (P - 0.044).It is found that computed tomography (CT) appearance (r - 0.399) and stone size (r - 0.410) strongly correlate with the endoscopic findings of the region of UVJ (P - 0.001).The present study showed the administration of tablet deflazacort (a steroidal anti-inflammatory agent) significantly improves the outcome of URSL under local anesthesia.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Regional Institute of Medical Sciences, Imphal, Manipur, India.

ABSTRACT

Objective: The objective of the following study is to assess the effect of steroidal anti-inflammatory agent on the outcome of ureterorenoscopic lithotripsy (URSL) for ureterovesical junction (UVJ) calculus.

Settings and design: This was a prospective randomized controlled study conducted at the Department of Urology, Regional Institute of Medical Sciences, Imphal.

Subjects and methods: One hundred and twenty-six patients requiring ureteroscopic lithotripsy for UVJ calculus were randomly assigned into two groups. The study group received tablet deflazacort 30 mg once a day for 10 days prior to the procedure, whereas the control group did not receive such treatment. Parameters with respect to the outcome of the procedure were recorded for all patients in both groups.

Statistical analysis used: Fisher's exact and independent t-test was used to compare the outcome between the groups where P < 0.05 was considered to be statistically significant.

Results: There was significant statistical difference (P - 0.016) on the endoscopic appearance of the region of ureteric orifice in patients receiving steroidal anti-inflammatory agent compared with control. Severe procedure related pain and mean operative time was less in the study group compared to control (P - 0.020 and 0.031, respectively). Re-treatment rates in the study group were lower than the control group (4.76% vs. 17.46%) and found to be statistically significant (P - 0.044). It is found that computed tomography (CT) appearance (r - 0.399) and stone size (r - 0.410) strongly correlate with the endoscopic findings of the region of UVJ (P - 0.001).

Conclusions: Inflamed and or obliterated ureteric orifice is the major constraints for stone clearance at ureterovesical junction. The present study showed the administration of tablet deflazacort (a steroidal anti-inflammatory agent) significantly improves the outcome of URSL under local anesthesia. We strongly recommend its use prior to URSL for UVJ calculus, especially for stone size ≥10.24 mm and on CT evidence of prominent soft tissue swelling at the UVJ.

No MeSH data available.


Related in: MedlinePlus