1. Sunaryo Hardjowijoto Department Urology Airlangga School of Medicine-Soetomo Hospital Surabaya UroFiesta Surabaya 20151

2. ESTIMATED PREVALENCE OF USD IN USA (NHANES data) 1994 : 5.2% in overall 2010 : 8.8% Lifetime risk : 5 – 10% Recurrence rate : - 1 year : 10% - 5 year : 35% - 10 year : 50% UroFiesta Surabaya 20152

3. Modalities of Treatment Medical therapy Ureteroscopy - Rigid - Flexible – Laser – RIRS ESWL PCNL Combination UroFiesta Surabaya 20153 Medical Symptomatic Theraphy Medical Expulsive Theraphy

4. The Choice of Treatment Depends on : Patient factors Anatomical consideration Stone size and location Characteristics Surgeon / urologist preference Patient preference after informed consent UroFiesta Surabaya 20154

5. DEFINITION OF MET : Any effort to enhance stone expultion medicaly without manipulative treatment. UroFiesta Surabaya 20155

6. MEDICAL EXPULSIVE THERAPY ( MET ) : Not indicated if : -Recurrent disabling pain -Significant / persistent urinary obstruction -Sign of infection -Electrolyte abnormality -Renal insufficiency -Solitary kidney -History of open / endoscopic surgery UroFiesta Surabaya 20156

7. Aim and benefit of MET : -Enhance stone spontaneous passage -Faster stone expulsion -Decrease colic events -Decrease analgetic / narcotic use -Decrease hospital visits -Reduce medical costs But  MET remains underutilized WHY?? UroFiesta Surabaya 20157

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12. METHODS OF MET Prior to α adrenergic blocker and Ca channel blockers -Increased fluid intake -Royale diuresis -Use of diuretic -Use of analgetics -Use of anti emetic -Jumping UroFiesta Surabaya 201512

13. URETERIC STONES : 22% of all urinary calculi 70% seen in distal ureter Usually present with colicky pain Most of them will pass spontaneously –  of stones – Location of stones UroFiesta Surabaya 201513

14. Spontaneous Passage of Ureteral Stones Diameter : < 5mm: 75% 5-7mm: 60% 7-9mm: 48% > 9mm: 25% (Coll AJR : 2002) Location on ureter : -Prox : 48% -mid ureter : 60% -Distal : 75% -UVJ : 79% Time of expulsion up to 1 month in small stones < 5mm in size ( Miller & Kane Jurol 1999) UroFiesta Surabaya 201514

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17. TARGETED MET the drug and rationally use in MET Drugs -α1A/1D blockers (Tamsulosin) -Ca channel blocking agents (Nifedipine) -PDE inhibitor -Corticosteroids (Prednisone) Rationally basic : -Relaxation of ureteral muscle -Relaxation of smooth ureteral muscle -Relaxation via No-cGMP pathway -Antiinflammatory  reducing submucosal edema UroFiesta Surabaya 201517

18. Scientific Basic of PDE5 inhibitors PDE 5 inhibitor can reverse the tension of isolated human ureteral smooth muscle via cGMP mediated pathways. The efficacy in reducing tension : SNP > Var > Sil > Tad > BSC SNP: Sodium Nitroprusside BSC: Butil Scopolamine UroFiesta Surabaya 201518

19. Duration of Treatment 1 week : Corticosteroid 6 weeks : 12 weeks : UroFiesta Surabaya 201519

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24. MET after ESWL UroFiesta Surabaya 201524

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28. SUMMARY 1.The incidence of USD still increasing. 2.The armamanterim of USD treatment consist of medical therapy, URS, RIRS, ESWL, PCNL and Combination. 3.MET is an excellent alternative treatment in selective cases of USD. UroFiesta Surabaya 201528

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