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Ureteric colic has been an age-old problem encountered in medical practice. Ureteric stones are a known cause of this problem. Many conservative medical therapies have been researched and studied. Tamsulosin, an Alpha 1A specific inhibitor which was initially used in the treatment of benign prostatic hyperplasia has recently been shown to increase the rate of spontaneous passage of distal ureteral stones. Alpha adrenergic blocker Tamsulosin reduces muscles spasm in the ureteric wall, decreases peristalsis below and raises pressure above the stone thus facilitating stone passage. Use of Tamsulosin 0.4 mg daily in patients with distal ureteric stones is clinically safe and cost effective.

Objective: To determine the diagnostic value of ultrasound signs of urinary stones less than or equal to 10 mm and to determine clinico-radiological variants of ureteric colic. Methods: A total of 455 ultrasound investigations were performed in patients referring to emergency department with urolithiasis and symptoms suspected of ureteric colic between January 2021 and May 2021. In addition to microscopic evaluation of urine sediment to detect different crystals and non-contrast spiral computed tomography to detect stones, B-mode and color Doppler sonography was performed to assess the presence of acoustic shadow (AS) and twinkle artifacts (TA) as possible signs of stone(s) in ureter. Results: While the sensitivity and specificity of AS and TA were higher than 90% in patients with stones greater than 5 mm; positive prognostic values of these parameters were found to be extremely low for stones with sizes of 1–3 mm with specificity and sensitivity values not exceeding 53%. The sensitivity and specificity of AS and TA in the upper and lower ureters were higher for stones greater than or equal to 5 than for compared to those less than 5 mm. At the same time, the diagnostic values of TA and AS for middle ureter stones were very limited. The most prevalent clinico-radiological variants of ureteric colic were types I, III, and V being observed in 39%, 28% and 21% cases, respectively. Conclusion: Our results demonstrate that TA and AS parameters seem to have a very low sensitivity and specificity in the diagnosis of urinary stones less than 5 mm. The diagnostic value of TA and AS increase significantly in stones greater than or equal to 5 mm. Therefore, clinicians need to be very careful for overestimating the diagnostic values of TA and AS for stones less than 5 mm and non-contrast spiral computed tomography must be the method of choice for patients presenting to emergency department with ureteric colic.

BACKGROUND Imaging plays a major role in the diagnosis and management of patients with urolithiasis. Non-Contrast Computed Tomography (NCCT) is generally accepted as the gold standard, but there are concerns over higher radiation exposure from NCCT to the patient population. Our prospective study compared the diagnostic accuracy of plain X-ray KUB (Kidney, Ureter, Bladder) and USG (Ultrasonography) with NCCT in the evaluation of patients with ureteric colic. METHODS This study conducted from December 2018 to January 2020 in the Department of Urology, Vijayanagar Institute of Medical Sciences, and attached Hospital. 230 patients with ureteric colic were evaluated for ureteric calculi with x-ray KUB, USG (Ultrasonography) abdomen and pelvis and NCCT (Non-Contrast Computed Tomography) KUB region. RESULTS Out of 230 patients, 168 (73 %) were males and 62 (26.9 %) were females. Ages of the study population ranged from 18 to 55 yrs. 198 of the 230 patients were confirmed to have ureteric calculus, with lower ureteric calculus 97 (48.9 %), upper ureteric 65 (32.8 %), middle ureteric 29 (14.6 %), and multiple 7 (3.5 %). X-ray and USG (Ultrasonography) group yielded a sensitivity of 86.3 %, a specificity of 87.5 %, positive predictive value 97 %, and negative predictive value 51 %. While On NCCT (Non-Contrast Computed Tomography), a total of 192 patients (96 %) demonstrated ureterolithiasis of the 198 patients confirmed to have ureteric calculi (Table 2). X-ray and USG group yielded a sensitivity of 96.9 %, specificity of 93.6 %, positive predictive value 98.9 %, and negative predictive value 83 %. CONCLUSIONS Combination of x-ray KUB and USG, and NCCT were found to be excellent imaging modalities for the detection of ureteric calculi. X-ray KUB and USG can be used as the first investigation of choice for patients with ureteric colic and for follow up of patients after treatment. KEYWORDS Ureteric Colic, Ureterolithiasis, Ultrasonography

ObjectiveThe WHO declared SARS-CoV-2 a pandemic on 11th March 2020 prompting a rapid change to surgical practice. This study focuses on how the management of ureteric colic has adapted in a major tertiary referral unit during the peak of the pandemic so that lessons be can be learned in case a second wave occurs. Materials and MethodsWe compared admission rates and treatment patterns against national and European guidelines in 20 weeks, divided into pre- and peri-pandemic. ResultsA total of 72 patients were admitted during the study period. 64% (46/72) were admitted pre-pandemic. 22% (10/46) of these were septic (5 stented, 5 nephrostomized) while 20% (9/46) were managed conservatively. 59% (27/46) of pre-pandemic admissions were suitable for active treatment, of which 48% (13/27) received definitive treatment (11 ureteroscopy (URS), 2 shockwave lithotripsy (SWL)) all within 48 hours of admis-sion. 52% (14/27) had temporising procedures (11 stented, 3 nephrostomized) and underwent definitive treatment within 63 days.Of the total patients, 36% (26/72) were admitted peri-pandemic. 23% (6/26) were septic (1 stent, 5 nephrostomized), while 31% (8/26) were managed conservatively. 46% (12/26) were suitable for active treatment. 75% (9/12) received definitive treatment (4 URS, 5 SWL) of which 33% (4/12) within 48 hours and the remaining treated and stone free within 12 days. 25% (3/12) had temporising procedures (2 stented, 1 nephrostomized), with the definitive treatment provided within 17 days. ConclusionUreteric colic admissions were reduced by almost half during the pandemic. There has been increased primary treatment with a reduction in temporising procedures and time to receiving definitive treatment. In the ‘new normal,’ lessons learned must be carried forward to maintain high rates of definitive treatments.

OBJECTIVE To determine the diagnostic accuracy of ultra-low-dose computed tomography (ULDCT) compared with standard-dose CT (SDCT) in the evaluation of patients with clinically suspected renal colic, in addition to secondary features (hydroureteronephrosis, perinephric stranding) and additional pathological entities (renal masses). PATIENTS AND METHODS A prospective, comparative cohort study was conducted amongst patients presenting to the emergency department with signs and symptoms suggestive of renal or ureteric colic. Patients underwent both SDCT and ULDCT. Single-blinded review of the image sets was performed independently by three board-certified radiologists. RESULTS Among 21 patients, the effective radiation dose was lower for ULDCT [mean (SD) 1.02 (0.16) mSv] than SDCT [mean (SD) 4.97 (2.02) mSv]. Renal and/or ureteric calculi were detected in 57.1% (12/21) of patients. There were no significant differences in calculus detection and size estimation between ULDCT and SDCT. A higher concordance was observed for ureteric calculi (75%) than renal calculi (38%), mostly due to greater detection of calculi of

Purpose There is a lack of data on the natural history of asymptomatic intra-renal calculi. In this study we investigate stone related events (SREs) in patients with untreated intra-renal calculi. We also investigate predictive factors for SREs. Materials and Methods All patients diagnosed with an asymptomatic intra-renal calculus on CT KUB managed conservatively with interval imaging for ≥6 months were included. Patients were evaluated for any stone related event. The rate of event according to calculus size, location and number of calculi was also analysed. Multivariate logistic regression analysis was performed to determine significant predictors for SREs. Results In total, 266 renal units from 177 patients met inclusion criteria. The mean stone size was 4.44mm (range of 1-25mm). Duration of follow-up was 43.78 ± 26.86 months (range 6-106 months). The overall rate of SRE's including intervention (n=80) and spontaneous stone passage following ureteric colic (n= 40) was 45.1% (n=120/266). Stones >5mm were more likely to lead to an event compared to stones ≤5mm (OR: 2.94; p=0.01). Inter-polar stones and stones located in multiple calyces were more likely to cause a SRE than lower pole stones (OR: 2.05; p=0.05 and OR:2.29; p=0.03 respectively). Conclusion In this large series of patients with asymptomatic intra-renal calculi, the incidence of a spontaneous SRE was 45.1% after 41 months. Stone size and stone location were significant predictors for stone related event. Information from this study will enable urologists to accurately risk stratify patients with asymptomatic renal stones.

Introduction The British Association of Urological Surgeons (BAUS) released guidance in 2018 regarding the optimum management of acute ureteric colic: a condition which can present as a surgical emergency. Our aim was to review the current practice at our hospital in diagnosing and managing acute ureteric colic and ultimately, implement sustainable change to address any areas of limitations. Method The following data was retrospectively collected for of all patients admitted with acute ureteric colic: investigations performed, medications administered, details of surgical intervention and follow-up. 1st Cycle: March 2017 to February 2018. Intervention: Teaching sessions delivered to staff (including doctors and nurses) in the A&E and urology department. 2nd Cycle: January 2019 to December 2019. Results 268 patients presented to A&E with ureteric colic – 18% increase from previous year. On admission: 60.4% of patients had serum calcium checked, 97.7% had a CT KUB performed within 24 hours and 67.2% were given NSAIDs; this is a 20.4%, 0.4% and 5.2% increase from the previous year, respectively. Only 31.3% of patients had an acute surgical intervention. The average wait time for clinic follow-up was reduced to 41 days following departmental education, but only 26.4% of patients were seen within the BAUS advised 4-week timeframe. Conclusions Re-audit showed distinct improvement in the management of acute ureteric colic. Thus, departmental education strategies have had a positive impact. It is recommended that the reservation of one daily elective theatre slot for an emergency operation and a computerised clinic booking system will further optimise our management in line with BAUS guidance.

Aim To assess how many patients had a non-contrast CT as first-line investigation for suspected renal colic, and how this was affected by the release of the 2019 NICE guidelines. A secondary aim was to assess the proportion of patients who had CT KUBs that demonstrated a ureteric calculus. Method CT KUB scans performed over two separate 3 month periods were identified. These reflected periods of time before and after the new NICE guidelines. Electronic records were used to assess if the patients had an ultrasound performed as the initial diagnostic investigation, instead of a CT scan. The results of the scans were reviewed to identify if a ureteric or renal calculus had been positively identified. Results In the period before the new guidelines, 61 patients were scanned. 4 had an ultrasound to assess for a stone prior to a CT. All of these patients were medical inpatients. None of the ultrasounds diagnosed a stone. 22/61 patients had CT-proven stones (36%) In the period after the new guidelines, 79 patients were scanned. 12 had an ultrasound to assess for a stone prior to a CT. 8 were medical patients, 3 were surgical and 1 was gynaecological. 1 ultrasound diagnosed a stone. 28/79 patients had CT-proven stones (35.4%) Conclusions The release of new guidelines did not improved compliance with suggested imaging pathways. This clearly demonstrates an area for improvement. It is also worth noting that only 1/3 of referrals with suspected renal colic did actually have a stone, which has implications for specialty referral pathways.

Objective: To assess the utility of trans-vaginal ultrasonography in evaluation of non-pregnant sexually active female patients with lower ureteric calculi. Methods: A prospective study was done from January 2015 to December 2017 including non-pregnant sexually active females with suspected ureteric calculus. Trans-abdominal ultrasound was initially done in all patients. In those patients in whom trans-abdominal ultrasound was inconclusive or there was indirect evidence of lower ureteric calculus in form of ureteral dilation but no calculus was evident, trans-vaginal ultrasound was done. The patients with ureteric calculi detected on trans-vaginal ultrasound and kept on conservative management were also followed up with trans-vaginal ultrasound. Non-contrast computed tomography was done in patients with inconclusive trans-vaginal ultrasound. Results: As per the study protocol, 156 out of the total 468 patients evaluated by trans-abdominal ultrasound were eligible for trans-vaginal ultrasound. Trans-vaginal ultrasound was done in 149 patients, as seven patients did not give consent. Seventy-nine patients were detected with a lower ureteric calculus on trans-vaginal ultrasound and 27 patients had gynecologic or other cause for their symptoms. Forty-three patients had an inconclusive trans-vaginal ultrasound of which 36 underwent non-contrast computed tomography, among them only one patient had a lower ureteric calculus. Stone free status could be easily demonstrated on follow-up trans-vaginal ultrasound. Conclusion: Trans-vaginal ultrasound in addition to trans-abdominal ultrasound is a very useful tool in evaluation of sexually active females with suspected lower ureteric calculus. Keywords: Trans-abdominal ultrasound, Trans-vaginal ultrasound, Lower ureteric calculus, Ureteric colic, Ureter

BACKGROUND ESWL is suitable for stones smaller than 2 cm situated in upper and middle calyx. The routine insertion of DJ stents during ESWL of renal calculi is controversial. Some studies support the role of DJ stents in facilitating stone passage and preventing renal colic whereas other reports claim that stent causes significant lower urinary tract symptoms, hematuria, urinary tract infection and can even lower the stone-free rate. METHODS This is a prospective study conducted among 81 patients each in stented and non stented group who underwent ESWL for renal calculus. The primary outcome measured was stone fragmentation .The secondary outcomes measured were renal colic, urinary tract infection, steinstrasse and stent related LUTS. RESULTS Stone fragmentation rates in stented and non-stented groups were 91.4% and 86.4% respectively (p-value > 0.05). Ureteric colic in the stented group was only 14.8% but 45.7% in the non-stented group had ureteric colic (p-value

This chapter summarizes the results of the SUSPEND trial, a methodologically rigorous three-armed randomized controlled trial of medical expulsive therapy in the form of the alpha-blocker tamsulosin or the calcium channel blocker nifedipine versus placebo. The mean stone size in all three groups was comparable and three-quarters of the stones were 5 mm or less. It was a “negative trial” that failed to demonstrate a substantial benefit from the widely established practice of treating patients with small ureteral stones with medical expulsive therapy. Serious adverse events were very infrequent.

Dr. Yunqiao Qiu from Guangzhou University of TCM has discovered a certain point located near costalspinal angle, which can relieve acute ureteric colic effectively and named it as “Qiu’s point”. This paper conducted a meta-analysis of the clinical efficacy of Qiu’s acupuncture point in the treatment of acute ureteric colic caused by ureteral calculus, in order to comprehensively analyze the role of Qiu’s acupuncture point in the relieve of acute ureteric colic. All randomized controlled trials (RCTs) from relevant articles in Chinese and English by October 31, 2019 have been selected, excluding cohort studies and case reports. Statistical analyses are performed using the Review Manager V.5.3 and R packages Metafor. We use the Cochrane risk of bias tool for randomized trials to assess the risk of bias of included studies. Meta-analysis results demonstrated that Qiu’s acupuncture point have some positive effects for acute ureteric colic caused by ureteral calculus.

Objective To assess the effectiveness of a telemedicine service for ureteric colic patients in reducing the number of unnecessary face-to-face consultations and shortening waiting time for appointments. Methods A telemedicine workflow was implemented as a quality improvement study using the Plan-Do-Study-Act method. All patients presenting with ureteric colic without high-risk features of fever, severe pain, and hydronephrosis, were recruited, and face-to-face appointments to review scan results were replaced with phone consultations. Data were prospectively collected over 3 years (January 2017 to December 2019). Patient outcomes including the reduction in face-to-face review visits, time to review, reattendance and intervention rates, were tracked in an interrupted time-series analysis, and qualitative feedback was obtained from patients and clinicians. Results Around 53.2% of patients presenting with ureteric colic were recruited into the telemedicine workflow. A total of 465 patients (46.2%) had normal scan results and 250 patients (24.9%) did not attend their scan appointments, hence reducing the number of face-to-face consultations by 71.1%. A total of 230 patients (22.9%) required subsequent follow-up with urology, while 61 patients (6.1%) were referred to other specialties. Mean (SD) time to review was 30.0 (6.2) days, 6-month intervention rate was 3.4% (n = 34) and unplanned reattendance rate was 3.2% (n = 32). Around 93.1% of patients reported satisfaction with the service. Conclusion The ureteric colic telemedicine service successfully and sustainably reduced the number of face-to-face consultations and time to review without compromising on patient safety. The availability of this telemedicine service has become even more important in helping us provide care to patients with ureteric colic in the current COVID-19 pandemic.

OBJECTIVE: To perform a systematic review to identify the clinical, fiscal and environmental evidence on the use of urological telehealth and/or virtual clinic strategies. Our secondary aim was to highlight research gaps in this rapidly evolving field. METHODS: Our PROSPERO registered (CRD42019151946) systematic search of Embase, Medline and Cochrane Review Database was performed for original research articles pertaining to adult urology telehealth or virtual clinic strategies. Risk of bias (RoB) assessment performed according to Cochrane 2.0 RoB or Joanna Briggs Institute Checklist for non-randomised studies. RESULTS: 5,813 participants met inclusion from 18 original articles (2 randomised controlled trials; 10 prospective; 6 retrospective). Urology sub-specialities: Uro-oncology (n=6), General urology (n=8), Endo-urology (n=2), and Lower urinary tract symptoms and/or incontinence (n=2). Across all sub-specialties, prospective studies utilising VC reported: primary median VC discharge rate of 16.6% (IQR 14.7%-29.8%) and primary median face-to-face (FTF) clinic referral rate of 32.4% (IQR 15.5%-53.3%). Further, direct cost analysis demonstrated a median annual cost-savings of £56,232 (IQR £46,260-£61,116). Grade II and IIIb complications were reported in two acute ureteric colic studies, with a rate of 0.20% (3/1,534) and 0.13% (2/1,534), respectively. Annual carbon footprint avoided ranged from 0.7 to 4.35 metric tonnes of CO2 emissions, depending on mode of transport utilised. Patient satisfaction was inconsistently reported, and assessments lacked prospective evaluation using validated questionnaires. CONCLUSION: Virtual urology clinics are a promising new platform which can offer clinical, financial and environmental benefits to support an increasing urological referral burden. Further prospective evidence is required across urological subspecialties to confirm equivalency and safety against traditional face-to-face assessment.

INTRODUCTION AND OBJECTIVE:Renal colic is a common urological problem with a lifetime incidence of approximately 8-19% in males and 3-5% in females. The MIMIC Study was a 4171 patient cohort study ...

These guidelines have been developed by the British Association of Urological Surgeons to give a framework to clinicians, based primarily in the UK, for the management of patients presenting acutely with ureteric colic. They have been developed by consensus with reference to the American Urological Association/Endourological Society guidelines on the surgical management of stones and the European Association of Urology guidelines on urolithiasis, and adapted to the logistics of those practicing within the National Health Service. Grades of recommendation and levels of evidence are based upon the system adopted by the European Association of Urology.

In this special COVID-19 edition of JELEU, we start with three articles that discuss aspects of urological management that have been affected by the coronavirus pandemic: the impact of living with cystinuria, the challenges of delivering a urodynamic service, and the consequences of adding a CT chest to a CTKUB for patients with pain suggestive of ureteric colic.

Patients with ureteric calculi usually present with ipsilateral “loin to groin” pain. Rarely ureteric colic may present with contralateral pain, which is referred to as “mirror pain”. We report the case notes of a rare presentation of contralateral ureteric colic or “mirror pain” secondary to a ureteric calculus. A comprehensive literature review was also conducted. “Mirror pain” or contralateral ureteric colic is rare. Urologists should be aware of this unusual clinical presentation and appreciate that upper urinary tract calculi can cause pain on the contralateral side.

INTRODUCTION AND OBJECTIVES:Ureteric colic is a common condition that causes severe pain and generates substantial health system utilization. Traditional management includes analgesia and a trial o...

Objectives: The objective was to determine accuracy of ultrasound in thediagnosis of ureteric calculi confirmed on non-contrast Computed Tomography amongpatients with acute ureteric colic. Study Design: Cross-sectional study. Setting: EmergencyDepartment of Nishtar Hospital, Multan. Period: 11-07-2012 to 10-01-2013. Materials andMethods: 100 consecutive patients presenting with acute severe ureteric colic and fulfillingthe inclusion and exclusion criteria were enrolled for the study from the emergency departmentof Nishtar Hospital Multan. Ultrasonography was done in all patients and USG findings wererecorded for the presence or absence of hyperechoic shadows in the ureteric. All the patientsunderwent CT scan to confirm or refute the findings of Ultrasonography. Result: Mean age ofthe patients was 37.85 + 12.60 years. Males were 53 (53%) while females were 47 (47%). Meanduration of pain before presentation was 14.81 + 6.20 hours. Mean severity of pain on visualanalogue scale was 9.40 + 0.8. Overall 79 patients were diagnosed as having ureteric calculi.Ultrasonography detected the ureteric stone in 75 patients and was all found to have stoneon CT scan and represented true positives. Among 25 patients in whom ultrasound did notdemonstrate any stone, 4 were found to have ureteric stone on CT scan thus representing falsenegative whereas 21 (84%) were confirmed on CT scan not to have any stone, thus representingTrue negatives. The sensitivity of USG for detection of ureteric stone was found to be 94.9%,the specificity was 100%, and positive predictive value was 100% while negative predictivevalue was 84% .There was no significant effect of age or gender on the accuracy of ultrasound.Conclusion: Ultrasonography is a readily available, non-invasive and reliable investigation inpatients presenting with acute flank pain to diagnose ureteric stones with a specificity of 100%and a sensitivity approaching 95%. Thus it is recommended that it should be used routinely forthe evaluation of patients presenting with acute flank pain.

The purpose of this study was to assess the efficacy of model-based iterative reconstruction (MBIR), statistical iterative reconstruction (SIR), and filtered back projection (FBP) image reconstruction algorithms in the delineation of ureters and overall image quality on non-enhanced computed tomography of the renal tracts (NECT-KUB). This was a prospective study of 40 adult patients who underwent NECT-KUB for investigation of ureteric colic. Images were reconstructed using FBP, SIR, and MBIR techniques and individually and randomly assessed by two blinded radiologists. Parameters measured were overall image quality, presence of ureteric calculus, presence of hydronephrosis or hydroureters, image quality of each ureteric segment, total length of ureters unable to be visualized, attenuation values of image noise, and retroperitoneal fat content for each patient. There were no diagnostic discrepancies between image reconstruction modalities for urolithiasis. Overall image qualities and for each ureteric segment were superior using MBIR (67.5 % rated as 'Good to Excellent' vs. 25 % in SIR and 2.5 % in FBP). The lengths of non-visualized ureteric segments were shortest using MBIR (55.0 % measured 'less than 5 cm' vs. ASIR 33.8 % and FBP 10 %). MBIR was able to reduce overall image noise by up to 49.36 % over SIR and 71.02 % over FBP. MBIR technique improves overall image quality and visualization of ureters over FBP and SIR.

Acute flank pain is a common presentation to the emergency department (ED), and imaging studies play an important role in establishing an accurate diagnosis. Computed Tomography of Kidneys, Ureters, Bladder (CT KUB) has surpassed all other imaging modalities to become the gold standard in detection of ureteric calculi. The purpose of this study is to identify the range and management of alternative diagnoses established by CT KUB in patients with suspected ureteric colic. Two hundred and fifteen consecutive CT KUB examinations ordered in the ED of a tertiary-care centre for suspected ureteric colic were retrospectively reviewed. This comprised of 134 male (62.3%) and 81 female (37.7%) patients with a mean age of 53 years old. The positive detection rate for ureteric calculi in males was 43.3% compared to a lower rate for females of 29.6% (p < 0.05). Almost two-thirds of patients were discharged following CT KUB imaging, and admission rates were significantly higher in those with alternative radiological findings (p < 0.04) Alternative radiological findings occurred in 72 patients (33.5%), including 15 patients (7.0%) who had clinically important alternative pathology. The rate of clinically important alternative findings was significantly higher in males than females, 9.7% versus 2.5% respectively (p = 0.04). Surgical intervention was more common in patients with alternative radiological findings classified as gastrointestinal (18.2%) compared to non-gastrointestinal (3.6%), however this did not reach statistical significance (p = 0.07). In conclusion, significant alternative pathology was identified using CT KUB in 7% of patients with suspected ureteric colic. The low rates of detection of ureteric calculi and significant alternative pathology in female patients suggests a more thorough clinical assessment is warranted to improve their management, prior to ordering investigations with exposure to radiation.