Evaluation of Preoperative Tamsulosin Use in Ureteroscopic Holmium Laser Lithotripsy for Elderly Patients with Ureteral Stones

Summary

This study evaluated preoperative tamsulosin in elderly patients undergoing ureteroscopic holmium:YAG laser lithotripsy. Tamsulosin was associated with shorter operative time, fewer complications, reduced hospital stay, and higher stone-free rates. These findings suggest that short-course preoperative tamsulosin may serve as a safe, low-cost adjunct to optimize outcomes in geriatric ureteral stone management.

Abstract

The objective of this protocol was to evaluate perioperative clinical outcomes associated with short-course preoperative tamsulosin administration in elderly patients undergoing ureteroscopic holmium:YAG laser lithotripsy for ureteral stones. Medical records of patients aged ≥ 60 years were retrospectively reviewed. Patients were categorized into a preoperative tamsulosin group and a control group based on documented medication exposure prior to surgery. Baseline demographic and stone characteristics were comparable between groups. Comparative analysis showed that operative duration was shorter, the need for ureteral dilation was lower, postoperative inflammatory response was reduced, hospitalization was shorter, and stone-free rates at short-term follow-up were higher in the tamsulosin group. These differences were observed when comparing patients who received preoperative tamsulosin with those who did not receive α-blocker therapy. Postoperative complications occurred less frequently in the tamsulosin group, although several differences did not reach statistical significance, and no treatment-related serious adverse effects were observed. These observations indicate a potential association between preoperative tamsulosin use and improved procedural efficiency. This approach may provide a simple pharmacologic strategy to facilitate ureteroscopic access and perioperative recovery in appropriately selected elderly patients. However, due to the retrospective design, single-center setting, limited sample size, and short follow-up duration, causal relationships and long-term safety cannot be established. Prospective multicenter randomized studies are required to confirm these findings and further define the role of routine preoperative tamsulosin in geriatric ureteroscopic management.

Introduction

Urolithiasis remains one of the most common urological conditions worldwide, with a growing incidence among older adults due to increased life expectancy and evolving metabolic risk factors. In elderly patients, ureteral stones often present unique clinical challenges, including reduced physiological reserve, higher comorbidity burden, and age-related anatomical changes of the ureter¹. These factors may increase procedural complexity and the risk of perioperative complications. Therefore, optimizing minimally invasive management strategies in this population is of particular clinical importance^2,3. Ureteroscopy combined with holmium:YAG laser lithotripsy represents a standard treatment for ureteral calculi. In this context, perioperative pharmacologic strategies that improve ureteral access may enhance the efficiency and safety of ureteroscopic lithotripsy. Despite technological advances such as improved endoscopes and laser systems, initial ureteral access remains a critical and sometimes challenging step, especially in elderly patients with decreased ureteral compliance⁴. Resistance at the ureteral orifice, ureteral spasm, and mucosal injury may prolong operative time and increase the need for adjunctive maneuvers such as balloon dilation or pre-stenting⁵. These challenges have prompted investigation into pharmacologic strategies aimed at facilitating ureteral access and minimizing instrumentation-related trauma⁶. Alpha-adrenergic antagonists, particularly selective α1-blockers such as tamsulosin, reduce ureteral smooth muscle tone through inhibition of α1-adrenergic receptors in the distal ureter and ureterovesical junction. This pharmacologic relaxation may facilitate easier ureteroscope insertion and reduce resistance during endoscopic access⁷. While tamsulosin is widely used as medical expulsive therapy for distal ureteral stones, recent studies have explored its potential role as a short-course preoperative adjunct prior to ureteroscopy⁸⁹. Several investigations suggest that preoperative tamsulosin may enhance ureteral compliance, reduce insertion force during ureteroscope or access sheath placement, and decrease the need for mechanical dilation^10,11. However, reported results remain heterogeneous, and high-quality evidence specifically focusing on elderly patients is limited. Therefore, further evaluation of the perioperative role of tamsulosin in geriatric ureteroscopic procedures is warranted¹².

The elderly population may derive particular benefit from pharmacologic ureteral relaxation. Shorter operative time and reduced ureteral manipulation are associated with improved perioperative stability and potentially lower rates of complications such as infection, bleeding, and postoperative discomfort^13,14,15. Pharmacologic ureteral relaxation may therefore represent a practical strategy to facilitate safer ureteroscopic procedures in elderly patients^16,17. Moreover, complete stone clearance during the primary procedure is especially important in older patients, who are at increased risk from repeat interventions due to comorbid conditions and diminished physiological reserve^18,19,20,21. Although some studies have reported improved intraoperative efficiency and stone-free rates with preoperative α1-blockade, data in geriatric cohorts remain sparse^22,23,24,25.

Concerns persist regarding potential systemic adverse effects of tamsulosin, including hypotension and dizziness, particularly in patients with cardiovascular comorbidities or polypharmacy. Therefore, evaluating both the efficacy and safety of short-course preoperative tamsulosin in elderly patients undergoing ureteroscopy is clinically relevant^26,27.

In this context, the present study retrospectively evaluates the association between short-course preoperative tamsulosin use and perioperative outcomes in patients aged ≥ 60 years undergoing ureteroscopic holmium:YAG laser lithotripsy for ureteral stones. Specifically, we compare operative parameters, need for ureteral dilation, postoperative complications, stone-free rates, and early functional recovery between patients who received preoperative tamsulosin and those who did not. By focusing on an elderly cohort, this study aims to clarify the potential role of pharmacologic ureteral relaxation in optimizing ureteroscopic outcomes in geriatric stone management.

Protocol

1. Study design and ethical approval

1. Obtain approval from the Institutional Ethics Committee before initiating the study.
   The study protocol was conducted in accordance with the ethical standards of the Institutional Ethics Committee of Jinyun County Second People’s Hospital and the principles of the Declaration of Helsinki and was approved by the Institutional Ethics Committee of Jinyun County Second People’s Hospital (IRB approval no. JYEY20260515). The requirement for written informed consent for study participation was waived due to the retrospective nature of the study.
2. Conduct a retrospective, comparative, single-center study in the Department of Urology at a tertiary care teaching hospital.
3. Identify eligible participants by reviewing hospital electronic medical records, urology department surgical logbooks, and operative records of elderly patients (aged ≥ 60 years) who underwent ureteroscopic holmium:YAG laser lithotripsy for unilateral ureteral stones during the predefined study period.
4. Screen medical records of elderly patients (aged ≥ 60 years) who underwent ureteroscopic holmium:YAG laser lithotripsy for unilateral ureteral stones during the predefined study period and include all patients who meet the predefined eligibility criteria.
   NOTE: Written informed consent for the surgical procedure was obtained from all patients at the time of treatment in accordance with institutional policy because of the retrospective nature of the study.

2. Patient selection and study grouping

1. Define inclusion criteria as given below:
   1. Include patients aged ≥ 60 years.
   2. Confirm the presence of a single unilateral ureteral stone (5–15 mm) using Non-Contrast Computed Tomography (NCCT) or ultrasonography.
   3. Include patients scheduled for elective ureteroscopic holmium:YAG laser lithotripsy.
   4. Ensure patients meet American Society of Anesthesiologists (ASA) physical status I–III.
2. Apply exclusion criteria as given below:
   1. Exclude patients with multiple or bilateral ureteral stones.
   2. Exclude patients with a history of ureteral stricture, urological malignancy, or prior ureteral surgery.
   3. Exclude patients with active urinary tract infection at the time of surgery.
   4. Exclude patients with known hypersensitivity to tamsulosin or other α-blockers.
   5. Exclude patients who used α-blockers or anticholinergic medications within one month prior to surgery.
   6. Exclude patients with significant cardiovascular instability or contraindications to anesthesia.
3. Assign study groups
   1. Categorize patients based on documentation of preoperative medication exposure recorded in hospital electronic medical records and prescription charts. Review medication history to determine whether patients received oral tamsulosin (0.4 mg once daily) for 5 consecutive days prior to ureteroscopy.
   2. Classify patients who received tamsulosin as the tamsulosin group and classify patients who did not receive any preoperative α-blocker therapy as the control group.
   3. Assign patients receiving oral tamsulosin (0.4 mg once daily for 5 consecutive days before ureteroscopy) to Group A (Tamsulosin group, n = 52). Administer the final dose of tamsulosin on the day prior to the ureteroscopic procedure.
   4. Assign patients who did not receive preoperative α-blocker therapy to Group B (Control group, n = 53).
      NOTE: Group allocation is determined by routine clinical practice and surgeon preference rather than randomization.
4. Record baseline patient characteristics
   1. Record baseline demographic variables including age, sex, and relevant comorbid conditions such as hypertension, Diabetes mellitus, cardiovascular disease, and benign prostatic hyperplasia.
   2. Document stone-related variables, including stone location, size, and laterality. Determine stone size and location using preoperative radiological imaging such as NCCT or ultrasonography.

3. Preoperative evaluation

1. Perform clinical assessment
   1. Obtain a detailed medical history and conduct a physical examination.
   2. Document comorbid conditions including hypertension, Diabetes mellitus, cardiovascular disease, and benign prostatic hyperplasia.
2. Conduct laboratory investigations
   1. Perform complete blood count (CBC), as part of the preoperative evaluation.
   2. Measure serum creatinine and blood urea levels to assess renal function.
   3. Measure serum electrolyte levels.
   4. Perform liver function tests.
   5. Assess coagulation profile including prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (APTT).
   6. Measure fasting and postprandial blood glucose levels.
3. Perform additional clinical investigations
   1. Perform electrocardiography (ECG) and chest radiography when clinically indicated, particularly in patients older than 65 years.
   2. Perform urinalysis and urine microscopy.
   3. Obtain urine culture and sensitivity testing to exclude urinary tract infection.
   4. Administer culture-directed antibiotics for at least 3 days before surgery in patients with positive urine cultures. Proceed with surgery only after completion of antibiotic therapy and confirmation of infection control.
4. Conduct radiological assessment
   1. Perform ultrasonography of the kidney, ureter, and bladder (KUB) to assess hydronephrosis, evaluate renal morphology, and identify the preliminary location of ureteral stones.
   2. Perform X-ray KUB for radiopaque stones to confirm stone visibility, determine stone location along the ureteral tract, and assist in preoperative planning.
   3. Perform non-contrast CT of the kidney, ureter, and bladder (NCCT KUB) using axial slices of 3–5 mm thickness. Measure the maximum stone diameter (mm) on axial images and record stone density in Hounsfield units (HU) using a standardized region-of-interest tool on the CT workstation.
   4. Evaluate the presence of hydronephrosis and identify any anatomical variations.
5. Perform anesthetic evaluation
   1. Refer patients for preoperative anesthesiology evaluation as part of the routine preoperative assessment.
   2. Confirm suitability for spinal or general anesthesia based on the patient’s clinical condition and anesthesiologist evaluation. Administer spinal anesthesia using 0.5% hyperbaric bupivacaine (2.5–3.0 mL) via the intrathecal route at the L3–L4 or L4–L5 interspace when spinal anesthesia is selected. Alternatively, administer general anesthesia with intravenous induction using propofol (1.5–2 mg·kg^-1) and fentanyl (1–2 µg·kg^-1), followed by airway management and maintenance with inhalational anesthetic agents such as sevoflurane, according to institutional anesthesia protocols.

4. Prepare the patient for ureteroscopic lithotripsy

1. Position the patient in the lithotomy position on the operating table under strict aseptic conditions.
   Administer spinal anesthesia using 0.5% hyperbaric bupivacaine (2.5–3.0 mL) at the L3–L4 or L4–L5 interspace. In selected patients, general anesthesia was induced with intravenous propofol (1.5–2 mg·kg⁻¹) and fentanyl (1–2 µg·kg⁻¹), followed by maintenance with sevoflurane (1–2%).
2. Administer intravenous ceftriaxone (1 g) approximately 30 min prior to surgical incision as prophylactic’s antibiotic therapy.

5. Ureteroscopic access

1. Perform cystoscopy using a 21 Fr or 23 Fr rigid cystoscope sheath connected to a standard 30° lens and video camera system to visualize the bladder and identify the ureteric orifice. Maintain continuous bladder irrigation using sterile normal saline to ensure adequate visualization during the procedure.
2. Advance a 0.035-inch hydrophilic or PTFE-coated guidewire into the ureter under fluoroscopic guidance.
3. Advance a 6/7.5 Fr semi-rigid ureteroscope over the guidewire to visualize the stone.
4. Insert a ureteral access sheath (9.5/11.5 Fr or 10/12 Fr) when necessary to facilitate repeated access and reduce intrarenal pressure.
5. Perform ureteral balloon dilation if resistance is encountered during ureteroscope advancement by inserting a ureteral balloon dilator (10–12 Fr) over the guidewire and inflating the balloon under fluoroscopic guidance to a pressure of 10–15 atm for approximately 30–60 seconds to achieve adequate ureteral dilation.

6. Stone fragmentation

1. Fragment stones using a holmium:YAG laser with energy settings of 0.6–1.2 J and frequency of 8–15 Hz.
2. Select the laser lithotripsy technique based on stone size and consistency. Use the dusting technique for smaller or softer stones by applying low-energy, high-frequency laser settings (0.6–0.8 J, 10–15 Hz) to produce fine particles that can pass spontaneously. Use the fragmentation technique for larger or harder stones by applying higher energy and lower frequency settings (1.0–1.2 J, 8–10 Hz) to create fragments that can be retrieved using a stone basket when necessary.
3. Allow fragments ≤ 2 mm to pass spontaneously.
4. Retrieve larger stone fragments using a stone retrieval basket when fragments are larger than approximately 2–3 mm, when spontaneous passage is unlikely, or when fragments obstruct the ureteral lumen and may impede adequate stone clearance.
5. Document intraoperative ureteral injuries and classify them using the Traxer and Thomas ureteral injury grading system.

7. Stent placement

1. Insert a double-J ureteral stent (DJ Stent) (4.8 Fr or 6 Fr; length 24–26 cm) at the end of the procedure in cases of ureteral edema, mucosal trauma, residual stone fragments larger than 2 mm, prolonged operative time (> 45 min, significant intraoperative bleeding, or when there is concern for postoperative ureteral obstruction.
2. Place the ureteral stent under the following conditions:
   1. Place the stent if ureteral edema is observed during the procedure.
   2. Place the stent if mucosal trauma occurs during ureteroscopic manipulation.
   3. Place the stent if residual stone fragments larger than 2 mm remain.
   4. Place the stent if the operative time exceeds 45 min.
   5. Place the stent if significant intraoperative bleeding occurs.
3. Maintain the stent for 1–3 weeks based on intraoperative findings and clinical judgment.
   NOTE: The duration of ureteral stent placement was determined according to intraoperative findings and procedural complexity. A shorter duration of approximately 1 week was considered in patients with minimal ureteral mucosal trauma, complete stone clearance, and shorter operative time without significant ureteral edema. An intermediate duration of around 2 weeks was used in cases with moderate ureteral edema, mild mucosal irritation, or the presence of small residual fragments ≤ 2 mm, as well as in procedures of moderate duration. A longer duration of up to 3 weeks was recommended in patients with significant ureteral trauma, requirement for ureteral dilation, prolonged operative time (> 45 min), intraoperative complications such as bleeding or ureteral perforation, or when residual fragments > 2 mm were present and further intervention was anticipated. Stent removal was performed during follow-up using cystoscopic guidance or according to institutional practice.

8. Record the following intraoperative data

1. Record stone size in mm.
2. Record stone location (upper ureter, middle ureter, or lower ureter).
3. Record total operative time, defined as the duration from ureteroscope insertion to removal.
4. Record the requirement for ureteral dilation.
5. Record intraoperative complications including mucosal abrasion, ureteral perforation, or bleeding.
6. Record any procedure termination or conversion to an alternative surgical procedure.

9. Perform postoperative care and follow-up

1. Monitor patients for haematuria, fever, flank pain, and urinary retention.
2. Administer analgesics (paracetamol or diclofenac) as required.
3. Perform CBC, serum creatinine, and urine microscopy on postoperative day 1.
4. Document postoperative complications including the following:
   1. Fever ≥ 38 °C.
   2. Persistent hematuria lasting more than 24 h.
   3. Urinary retention.
   4. Suspected ureteral structure.
5. Review patients 1 week after surgery for clinical evaluation and DJ stent removal when applicable.
6. Perform a second follow-up at 4 weeks postoperatively using imaging to assess residual stones.
7. Perform ultrasonography of the KUB as routine follow-up imaging to evaluate hydronephrosis and detect residual stone fragments.
8. Perform X-ray KUB selectively in patients with radiopaque stones or when residual stones are suspected on ultrasonography.
9. Conduct ultrasonography using a 3.5–5 MHz abdominal probe and obtain X-ray KUB images with the patient in the supine position to assess residual radiopaque stones.
10. Define stone-free status as complete clearance or residual fragments ≤ 2 mm on imaging.
11. Perform repeat NCCT KUB if imaging findings are uncertain.
12. Consider repeat intervention in patients with significant residual stone burden, defined as residual stone fragments larger than 2 mm on follow-up imaging or the presence of symptomatic obstruction. Evaluate residual fragments using ultrasonography and/or X-ray KUB during the 4-week follow-up visit.
13. Consider repeat ureteroscopy or extracorporeal shockwave lithotripsy (ESWL) when residual fragments exceed 2 mm, when persistent flank pain occurs, when hydronephrosis is detected, or when imaging demonstrates ureteral obstruction caused by retained fragments.

10. Statistical analysis

1. Perform statistical analysis using SPSS software version 26.0.
2. Assess continuous variables for normal distribution using appropriate statistical tests (e.g., Shapiro–Wilk test) prior to analysis. Express normally distributed continuous variables as mean ± standard deviation.
3. Compare continuous variables using the independent Student’s t-test.
4. Present categorical variables as frequencies and percentages.
5. Analyze categorical variables using the Chi-square test or Fisher’s exact test.
6. Consider a p-value < 0.05 as statistically significant.

Results

Baseline demographic and clinical characteristics

Baseline demographic and clinical characteristics were comparable between the two groups (Table 1). The mean age was 66.30 ± 4.20 years in Group A (tamsulosin group) and 65.90 ± 4.80 years in Group B (control group) (p = 0.620). Sex distribution was similar between groups, with male-to-female ratios of 32:20 in Group A and 34:19 in Group B (p = 0.840).

There were no...

Discussion

The present study demonstrated comparable baseline demographic and clinical characteristics between the two groups, ensuring internal validity of outcome comparisons. Age distribution, sex ratio, comorbidity profile, and ASA physical status were similar, minimizing confounding effects. These findings align with the population-based observations of previous authors²⁸, who emphasized the importance of demographic equivalence in upper urinary tract stone management studies. Similarly, Juliebø-Jo...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Analgesics (Paracetamol/Diclofenac)	Multiple	ANL-POSTOP-24B	NSAID use per renal function and bleeding risk
Anesthesia Workstation & Drugs	Dräger / GE; hospital formulary	ANES-SET-24	ASA I–III patients only per protocol
Ceftriaxone 1 g IV	Any WHO-GMP manufacturer	CEF-1G-2409	Adjusted per culture sensitivity when needed
Double-J Ureteral Stents 4.8–6 Fr, 24–26 cm	Coloplast / Boston Scientific	DJ-26CM-24Q3	Dwell time 1–3 weeks as per protocol
Flexible Ureteroscope	Boston Scientific (LithoVue) / Olympus (URF series)	FX-URS-25-LOT01	Choice per surgeon preference and anatomy
Fluoroscopy C-Arm	Siemens / GE OEC	FL-ARM-2022	ALARA protocols followed
Holmium:YAG Laser System	Lumenis / Dornier / Quanta System	HOYAG-2024-UNIT	Settings typically 0.6–1.2 J, 8–15 Hz per protocol
Hydrophilic Guidewire 0.035"	Terumo (Glidewire) / Boston Scientific (Jagwire)	GW-HY-035-24A	Backup PTFE guidewire available
Laser Fibers 200–365 µm	Boston Scientific / Cook Medical / Quanta Fibers	LF-272-2409	Fiber tip regularly stripped and cleaved to maintain efficiency
NCCT KUB Imaging	Siemens / GE Healthcare	CT-NCCT-24	Radiation minimization per protocol
Personal Protective Equipment (PPE)	3M / Ansell	PPE-OR-24	Standard precautions
Postoperative α-blocker (optional)	Astellas / generic	TAM-POST-24	Use at clinician discretion
Semi-Rigid Ureteroscope 6/7.5 Fr	Karl Storz or Olympus	UR-2024-001	High-level disinfection/sterilization between cases per IFU
Stone Retrieval Basket 1.5–2.2 Fr	Cook N-Circle / Boston Zero Tip	RB-UR-2409	Use per fragment size and location
Tamsulosin Capsules 0.4 mg	Astellas Pharma / Any GMP-compliant manufacturer	HYP-TAM-2407A	Administered under prescription; monitor for orthostatic hypotension
Ultrasound System	Philips / GE	US-RENAL-2023	Operator-dependent; standardized protocol used
Ureteral Access Sheath 9.5/11.5 Fr and 10/12 Fr	Cook Flexor / Boston Navigator HD	UAS-1012-2408	Selected based on anatomy and need
Ureteral Balloon Dilator 12–15 Fr	Boston Scientific / Cook Medical	BAL-UR-2410	Used less frequently in tamsulosin group
Urinalysis Strips & Culture Media	Siemens Multistix / Oxoid	UA-CLT-24	Processed by hospital laboratory
Urinary Catheters (Foley) 14–16 Fr	BD / Teleflex	FOL-UR-2410	Removed when voiding adequate