THE USE OF MEDICAL EXPULSIVE

THERAPY DURING PREGNANCY:

A WORLDWIDE PERSPECTIVE AMONG
EXPERTS

Granville L. Lloyd, MD,1 Amy Lim, MD, PhD,1 Nabeel Hamoui, MD,2
Stephen Y. Nakada, MD,1 and Stephanie J. Kielb, MD2

Agung Adhitya Indra

INTRODUCTION
 Medical expulsive therapy (MET)  assist
the spontaneous passage  ureteral calculi
 international acceptance benefit from alpha
blockers, CCB, glucocorticoid steroids, and
PDE-5 inhibitors  relaxation smooth muscle
and reduction inflammation
 nonobstetric hospital admission 
pregnancy is nephrolithiasis occurs in 0.1%
of deliveries
INTRODUCTION
 PMET drugs presumed ureteral calculi during
pregnancy  has not been studied  safety
and utility are unknown
 Selective alpha 1a blocker
 FDA- not approved  pregnancy
 FDA-approved  symptomatic BPH

 This study characterize worldwide  MET in

pregnancy with presumed ureteral calculus (P-
MET)  factors associated physician decision
to use or not use
MATERIAL AND METOD

 9 question survey  worldwide membership

Endourology Society & AUA
 survey delivered  society administered e-mail lists
to registered active members.
 instrument administered  University of Wisconsin-
licensed Qualtrics survey system (Provo, UT).
 No individual data gathered configured to prevent
answer revision  one survey per electronic device
to prevent readministration.
 survey went live (May 4, 2015 - June 6, 2015) 
Qualtrics data analysis
MATERIAL AND METOD

 Questions assessed
 worldwide geographic location and size
 type of practice
 degree of training
 specialization in stone disease care, and
 interval since training completion
 use or nonuse of MET and P-MET,
 preferred pharmacologic MET/ P-MET agents,
 reasoning for nonuse
 physicianreported perception of malpractice risk
environment.
RESULT
RESULT
RESULT
 564 worldwide survey  mean survey
completion time 2 minutes & dropout rate 3%.
 289 (52%) completed Endourology fellowship
training or specifically focusing their practices
on urologic stone disease
 90% using MET convenient or routinely
adult patient.
 MET in nonpregnant adults  high and not
influenced by region, training, time in practice,
specialization, or practice type.
RESULT
 Expert practitioners less to utilize P-MET than
nonexperts this difference failed statistical
significance ( p = 0.06).
 P-MET in AUA
 prescribe 27.3%
 dispensing 71.8%.

 worldwide  the time from training, degree of

specialization in stone care, and practice type 
not to significantly interact with adoption of P-
MET.
RESULT
RESULT
 P-MET
 1st tamsulosin 89.3% (Category B)
 2nd Calcium channel blockers 7.3% (Category C)
 3rd alfuzosin 6.9%(Category B)
 reasons for rejecting PMET
 adverse outcome 76.7%
 legal risk 52.8%
 safety 23.9%
 influenced by local obstetrician 15.6%
 felt P-MET ineffective 7.6% slightly higher 2.4% not
using MET in nonpregnant adults.
RESULT
 perception medicolegal risk on ‘‘average risk’’
55.4%  not associated with a decreased
usage P-MET ( p = 0.21)
 American urologists (65%)high risk US
medicolegally
 US urologists ‘‘rarely or never’’ using P-MET
154 of 323 (47.7%)  those regions US,
avoidance P-MET  perception of high legal
risk.
DISCUSSION

 effectiveness P-MET is unknown

progesterone-mediated physiologic
relaxation  ureter occurs in pregnancy.
 alpha blockade and calcium blocker not
significant benefit  smooth muscle
deactivation.
 Risks are unknown & safety poorly studied in
pregnancy.
DISCUSSION
 super-selective alpha blockers tamsulosin and
alfuzosin  Pregnancy Category B
 nonselective alpha blockers terazosin and
doxazosin, calcium channel blockers, and
glucocorticoid Pregnancy Category C
 uterus contain receptors for alphaadrenergic
agonists impact of blockers active  gravid
state is unknown.
 Calcium channel blockers  delay the initiation
of labor in animal and in vitro human models, as
does alpha blockade.
DISCUSSION
 Prescriber pregnancy category as a guide  difficult
to assess in this study.
 tamsulosin and alfuzosin are Pregnancy Category B
 all others are Pregnancy Category C
 worldwide MET practice types, intervals from
training, and involvement with stone care and region.
 MET usage not been previously assessedon this
sample of urologists high and uniform.
 P-MET  fewer practitioners tamsulosin, not
appear modulated by those factors.
DISCUSSION

 variation P-MET no associated factors

were able to be identified.
 experts in stone care less to utilize P-MET
than nonexperts difference failed to reach
statistical significance ( p = 0.06).
 high legal risk areas are the US  where
adoption was reported to be lower.
DISCUSSION
 majority (59.6%) of endourology-trained or
stone-focused practitioners do not dispense
P-MET.
 Bias choosing to respond to surveys
practitioners with different practice patterns
than nonresponders.
 influenced by fear of negative outcomes in P-
MET utility of this therapy in facilitating
stone passageare unclear
CONCLUSIONS

 MET internationally  ureteralcalculi.

 expert concern about safety & effectiveness.

 44.3% worldwide practitioners utilize MET

in pregnant patients.
 because limitation of drug evaluation in the
pregnant  retrospective assessmentbest
evaluating use of MET in this population