Purpose: To assess the cost-effectiveness of medical expulsive therapy (MET) versus observation for large distal ureteral stones in China and provide preliminary evidence for the determination of the course of MET by mathematical estimation.
Materials and Methods: With linear success rate assumptions, a decision tree was constructed by TreeAge Pro 2011 software. The stones passage rates after observation or receiving 0.4 mg daily tamsulosin were estimated according to a large randomized clinical trial (RCT). The costs of ureteroscopy, drugs and examinations were estimated according to related price from pharmacies or hospitals, or the guidance price published by the government. MET was also compared with observation by the sensitivity analysis. The effectiveness of MET or observation was presented by quality-adjusted life-day. Mathematical estimation of stone expulsion time was made by using a decision-analytic Markov model under the assumption that the daily stone expulsion probability is constant.
Results: In China, the MET was associated with a $295.1 cost advantage over observation. The cost of ureteroscopy has to decrease to $77.8 to reach cost equivalence between observation and MET. Observation is cost-effective only if ureteroscopy is very cheap or the difference of stone expulsion rates is insignificant. The estimated expulsion time was much longer than those reported in above mentioned RCT.
Conclusion: Due to the high cost of ureteroscopy, MET showed a cost advantage over observation in treating distal ureteral stones in China. The daily stone passage rate was inconstant. More studies are needed to find the appropriate duration of MET.
H. G. Tiselius. Epidemiology and medical management of stone disease. BJU Int. 2003;8(91):758-67.
CD Jr Scales, A. C. Smith, J. M. Hanley, C. S. Saigal. Prevalence of kidney stones in the United States. Eur Urol. 2012;1(62):160-5.
Z. Ye, G. Zeng, H. Yang, et al. Efficacy and Safety of Tamsulosin in Medical Expulsive Therapy for Distal Ureteral Stones with Renal Colic: A Multicenter, Randomized, Double-blind, Placebo-controlled Trial. Eur Urol. 2017;
B. Eryildirim, C. Sahin, M. Tuncer, et al. Effect of medical expulsive therapy on the health-related quality of life of patients with ureteral stones: a critical evaluation. Int Urol Nephrol. 2015;8(47):1271-5.
S. Gravas, V. Tzortzis, A. Karatzas, A. Oeconomou, M. D. Melekos. The use of tamsulozin as adjunctive treatment after ESWL in patients with distal ureteral stone: do we really need it? Results from a randomised study. Urol Res. 2007;5(35):231-5.
D. M. Coll, M. J. Varanelli, R. C. Smith. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR Am J Roentgenol. 2002;1(178):101-3.
W. A. Hubner, P. Irby, M. L. Stoller. Natural history and current concepts for the treatment of small ureteral calculi. Eur Urol. 1993;2(24):172-6.
C. Seitz, E. Liatsikos, F. Porpiglia, H. G. Tiselius, U. Zwergel. Medical therapy to facilitate the passage of stones: what is the evidence? Eur Urol. 2009;3(56):455-71.
J. F. Donaldson. Difference of opinion--In the era of flexible ureteroscopy is there still a place for Shock-wave lithotripsy? Opinion: YES. Int Braz J Urol. 2015;2(41):199-202.
R. Manikandan, Z. Gall, T. Gunendran, D. Neilson, A. Adeyoju. Do anatomic factors pose a significant risk in the formation of lower pole stones? Urology. 2007;4(69):620-4.
Y. Sumino, H. Mimata, Y. Tasaki, et al. Predictors of lower pole renal stone clearance after extracorporeal shock wave lithotripsy. J Urol. 2002;4 Pt 1(168):1344-7.
K. Madbouly, K. Z. Sheir, E. Elsobky. Impact of lower pole renal anatomy on stone clearance after shock wave lithotripsy: fact or fiction? J Urol. 2001;5(165):1415-8.
J. M. Hollingsworth, B. K. Canales, M. A. Rogers, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355):i6112.
S. Kumar, K. Jayant, M. M. Agrawal, S. K. Singh, S. Agrawal, K. M. Parmar. Role of tamsulosin, tadalafil, and silodosin as the medical expulsive therapy in lower ureteric stone: a randomized trial (a pilot study). Urology. 2015;1(85):59-63.
S. Puvvada, P. Mylarappa, K. Aggarwal, A. Patil, P. Joshi, R. Desigowda. Comparative efficacy of tadalafil versus tamsulosin as the medical expulsive therapy in lower ureteric stone: a prospective randomized trial. Cent European J Urol. 2016;2(69):178-82.
F. Porpiglia, D. Vaccino, M. Billia, et al. Corticosteroids and tamsulosin in the medical expulsive therapy for symptomatic distal ureter stones: single drug or association? Eur Urol. 2006;2(50):339-44.
M. Dellabella, G. Milanese, G. Muzzonigro. Randomized trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi. J Urol. 2005;1(174):167-72.
Knoll T. Petrik A. Turk C. Guidelines on urolithiasis. European Association of Urology. 2014;
Z. Ye, H. Yang, H. Li, et al. A multicentre, prospective, randomized trial: comparative efficacy of tamsulosin and nifedipine in medical expulsive therapy for distal ureteric stones with renal colic. BJU Int. 2011;2(108):276-9.
F. Porpiglia, G. Ghignone, C. Fiori, D. Fontana, R. M. Scarpa. Nifedipine versus tamsulosin for the management of lower ureteral stones. J Urol. 2004;2(172):568-71.
X. Sun, W. Guan, H. Liu, et al. Efficacy and safety of PDE5-Is and alpha-1 blockers for treating lower ureteric stones or LUTS: a meta-analysis of RCTs. BMC Urol. 2018;1(18):30.
M. De Sio, R. Autorino, G. Di Lorenzo, et al. Medical expulsive treatment of distal-ureteral stones using tamsulosin: a single-center experience. J Endourol. 2006;1(20):12-6.
J. M. Hollingsworth, M. A. Rogers, S. R. Kaufman, et al. Medical therapy to facilitate urinary stone passage: a meta-analysis. Lancet. 2006;9542(368):1171-9.
M. C. Michel, J. J. de la Rosette. alpha-blocker treatment of urolithiasis. Eur Urol. 2006;2(50):213-4.
J. K. Parsons, L. A. Hergan, K. Sakamoto, C. Lakin. Efficacy of alpha-blockers for the treatment of ureteral stones. J Urol. 2007;3(177):983-7; discussion 987.
E. Yilmaz, E. Batislam, M. M. Basar, D. Tuglu, M. Ferhat, H. Basar. The comparison and efficacy of 3 different alpha1-adrenergic blockers for distal ureteral stones. J Urol. 2005;6(173):2010-2.
S. Sasaki, Y. Tomiyama, S. Kobayashi, Y. Kojima, Y. Kubota, K. Kohri. Characterization of alpha1-adrenoceptor subtypes mediating contraction in human isolated ureters. Urology. 2011;3(77):762.e13-7.
Y. Itoh, Y. Kojima, T. Yasui, K. Tozawa, S. Sasaki, K. Kohri. Examination of alpha 1 adrenoceptor subtypes in the human ureter. Int J Urol. 2007;8(14):749-53.
S. Sigala, M. Dellabella, G. Milanese, et al. Evidence for the presence of alpha1 adrenoceptor subtypes in the human ureter. Neurourol Urodyn. 2005;2(24):142-8.
K. L. Penniston, S. Y. Nakada. Development of an instrument to assess the health related quality of life of kidney stone formers. J Urol. 2013;3(189):921-30.
K. L. Penniston, J. A. Antonelli, D. P. Viprakasit, et al. Validation and Reliability of the Wisconsin Stone Quality of Life Questionnaire. J Urol. 2017;5(197):1280-1288.
A. K. Ibrahim, I. H. Mahmood, N. S. Mahmood. Efficacy and safety of tamsulosin vs. alfuzosin as medical expulsive therapy for ureteric stones. Arab J Urol. 2013;2(11):142-7.