Efficacy of expulsive therapy using nifedipine or tamsulosin, both associated with ketoprofene, after shock wave lithotripsy of ureteral stones

Alpha-blockers after shock wave lithotripsy for renal or ureteral stones in adults

BACKGROUND

Shock wave lithotripsy (SWL) is a widely used method to treat renal and ureteral stone. It fragments stones into smaller pieces that are then able to pass spontaneously down the ureter and into the bladder. Alpha-blockers may assist in promoting the passage of stone fragments, but their effectiveness remains uncertain.  OBJECTIVES: To assess the effects of alpha-blockers as adjuvant medical expulsive therapy plus usual care compared to placebo and usual care or usual care alone in adults undergoing shock wave lithotripsy for renal or ureteral stones.

SEARCH METHODS

We performed a comprehensive literature search of the Cochrane Library, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, several clinical trial registries and grey literature for published and unpublished studies irrespective of language. The date of the most recent search was 27 February 2020.

SELECTION CRITERIA

We included randomized controlled trials of adults undergoing SWL. Participants in the intervention group had to have received an alpha-blocker as adjuvant medical expulsive therapy plus usual care. For the comparator group, we considered studies in which participants received placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion/exclusion, and performed data abstraction and risk of bias assessment. We conducted meta-analysis for the identified dichotomous and continuous outcomes using RevManWeb according to Cochrane methods using a random-effects model. We judged the certainty of evidence on a per outcome basis using GRADE.

MAIN RESULTS

We included 40 studies with 4793 participants randomized to usual care and an alpha-blocker versus usual care alone. Only four studies were placebo controlled. The mean age of participants was 28.6 to 56.8 years and the mean stone size prior to SWL was 7.1 mm to 13.2 mm. The most widely used alpha-blocker was tamsulosin; others were silodosin, doxazosin, terazosin and alfuzosin.  Alpha-blockers may improve clearance of stone fragments after SWL (risk ratio (RR) 1.16, 95% confidence interval (CI) 1.09 to 1.23; I² = 78%; studies = 36; participants = 4084; low certainty evidence). Based on the stone clearance rate of 69.3% observed in the control arm, an alpha-blocker may increase stone clearance to 80.4%. This corresponds to 111 more (62 more to 159 more) participants per 1000 clearing their stone fragments. Alpha-blockers may reduce the need for auxiliary treatments after SWL (RR 0.67, 95% CI 0.45 to 1.00; I² = 16%; studies = 12; participants = 1251; low certainty evidence), but also includes the possibility of no effect. Based on a rate of auxiliary treatments in the usual care arm of 9.7%, alpha-blockers may reduce the rate to 6.5%. This corresponds 32 fewer (53 fewer to 0 fewer) participants per 1000 undergoing auxiliary treatments. Alpha-blockers may reduce major adverse events (RR 0.60, 95% CI 0.46 to 0.80; I² = 0%; studies = 7; participants = 747; low certainty evidence). Major adverse events occurred in 25.8% of participants in the usual care group; alpha-blockers would reduce this to 15.5%. This corresponds to 103 fewer (139 fewer to 52 fewer) major adverse events per 1000 with alpha-blocker treatment. None of the reported major adverse events appeared drug-related; most were emergency room visits or rehospitalizations. Alpha-blockers may reduce stone clearance time in days (mean difference (MD) -3.74, 95% CI -5.25 to -2.23; I² = 86%; studies = 14; participants = 1790; low certainty evidence). We found no evidence for the outcome of quality of life. For those outcomes for which we were able to perform subgroup analyses, we found no evidence of interaction with stone location, stone size or type of alpha-blocker. We were unable to conduct an analysis by lithotripter type. The results were also largely unchanged when the analyses were limited to placebo controlled studies and those in which participants explicitly only received a single SWL session.

AUTHORS' CONCLUSIONS

Based on low certainty evidence, adjuvant alpha-blocker therapy following SWL in addition to usual care may result in improved stone clearance, less need for auxiliary treatments, fewer major adverse events and a reduced stone clearance time compared to usual care alone. We did not find evidence for quality of life. The low certainty of evidence means that our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.

Role of Tamsulosin Therapy after Extracorporeal Shockwave Lithotripsy for Renal Stones: Randomized Controlled Trial

INTRODUCTION

To evaluate the efficacy of adjunctive tamsulosin therapy after extracorporeal shockwave lithotripsy (SWL) for renal stones.

MATERIALS AND METHODS

This prospective study was conducted on patients who underwent single-session SWL for solitary renal stone less than 20 mm. Post-SWL, patients were randomly divided into 2 groups; the tamsulosin group (TG), received a daily dose of tamsulosin 0.4 mg, for a maximum of 12 weeks, with post-SWL traditional analgesia and control group (CG), received the traditional analgesia alone.

RESULTS

The study enrolled 271 patients and eventually only 249 (123 in TG and 126 in CG) completed the study. The overall stone free rate was 73.5%: 78.0% in TG and 69.0% in CG (p = 0.108). In TG, 8.1% of patients experienced at least one episode of acute renal/ureteral colic compared with 19.8% of controls (p = 0.008). The mean cumulative analgesia dosage per subject was 313 mg in TG and 346 mg in CG (p < 0.001). Overall, 14 patients developed steinstrasse and 6 of them (all in CG) needed urgent intervention (p = 0.031).

CONCLUSIONS

Daily tamsulosin therapy does not enhance the clearance of stone fragments but decreases the pain episodes, analgesia dosage and need for adjuvant intervention after SWL for renal stones.

CUA Guideline: Management of ureteral calculi

The focus of this guideline is the management of ureteral stones. Specifically, the topics covered include: conservative management, medical expulsive therapy, active intervention with either shockwave lithotripsy (SWL) or ureteroscopy (URS), factors affecting SWL treatment success, optimizing success, and special considerations (e.g., pregnancy, urinary diversion). By performing extensive literature reviews for each topic evaluated, we have generated an evidence-based consensus on the management of ureteral stones. The objective of this guideline is to help standardize the treatment of ureteral stones to optimize treatment outcomes.

The Efficacy and Safety of Tamsulosin Combined with Extracorporeal Shockwave Lithotripsy for Urolithiasis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND PURPOSE

Many studies have been conducted to investigate adjunctive tamsulosin therapy after extracorporeal shockwave lithotripsy (SWL) for urolithiasis. The results from those studies, however, are still inconsistent. Therefore, we performed a meta-analysis to provide an update on the clinical efficacy and safety of tamsulosin combined with SWL for urolithiasis.

METHODS

A systematic search was performed in PubMed, Cochrane Library, and Embase to identify all relevant randomized controlled trials until January 2015. Two reviewers independently assessed trial quality and extracted data. Meta-analysis was conducted with Review Manager (RevMan), version 5.1.

RESULTS

Twenty-one studies (2093 subjects in total) were identified in the current meta-analysis. Compared with a control group, the experimental group (tamsulosin combined with SWL) showed an increased overall benefit for stone expulsion, with pooled risk ratio (RR) of 1.20 (95% confidence interval [CI], 1.15-1.26). With respect to the different geographic regions, European and American had a high possibility of improvement in stone expulsion (RR: 1.33, 95% CI, 1.19-1.49). According to the stone locations (renal, upper and lower ureteral) and sizes (4-10 mm and 11-24 mm), tamsulosin is more useful for lower ureteral stone (RR: 1.28; 95% CI, 1.14-1.43) and larger sized stones (RR: 1.49; 95% CI, 1.28-1.75). The effect estimates did not vary markedly when stratified by follow-up durations but varied by dose of tamsulosin. Furthermore, a shorter expulsion time, reduced occurrence of steinstrasse, fewer incidences of colic, and lower analgesic requirements were observed within the experimental group. In addition, tamsulosin is well tolerated, and its adverse events rarely led to dropouts of patients.

CONCLUSIONS

Overall, evidence suggests that tamsulosin combined with SWL is safe and effective in enhancing stone expulsion for patients with urolithiasis. Furthermore, high-quality, randomized and placebo-controlled trials evaluating the efficacy and safety of tamsulosin should be performed.

Adjunctive medical therapy with α-blocker after extracorporeal shock wave lithotripsy of renal and ureteral stones: a meta-analysis

BACKGROUND

Although some trials assessed the efficacy and safety of the α-blocker in facilitating renal and ureteral stones expulsion after extracorporeal shock wave lithotripsy (ESWL), the role of the α-blocker in facilitating upper urinary calculi expulsion after ESWL remain controversial.

AIMS

To determine the efficacy and safety of the α-blocker in facilitating renal and ureteral stones expulsion after ESWL.

METHODS

A literature search was carried out using the PubMed database, EMBASE and the Cochrane Library database to identify relevant studies. Two reviewers independently extracted data and assessed methodological quality. Pooled effect estimates were obtained using a fixed- and random-effects meta-analysis.

RESULTS

The meta-analysis included 23 RCTs, α-blocker significantly enhanced expulsion rate of upper urinary tract calculi after ESWL (P<0.00001; RR 1.21; 95% CI 1.12-1.31), significantly promoted steinstrasse expulsion (P=0.03; RR 1.25; 95% CI 1.03-1.53), significantly shortened the discharge time of upper urinary tract calculi (P=0.0001; MD -2.12; 95% CI -3.20--1.04), significantly reduced the patient's pain VAS score (P=0.001; RR -1.0; 95% CI -1.61--0.39). Compared with the control group, dizziness (P=0.002; RR 5.48; 95% CI 1.91-15.77), anejaculation (P=0.02; RR 12.17; 95% CI 1.61-91.99) and headache (P=0.04; RR 4.03; 95% CI 1.04-15.72) in the α-blocker group was associated with a higher incidence.

CONCLUSIONS

Treatment with α-blocker after ESWL appears to be effective in enhancing expulsion rate of upper urinary tract calculi, shortening the discharge time of upper urinary tract calculi, reducing the patient's pain. The side effects of α-blocker were light and few.

A comparison of nifedipine and tamsulosin as medical expulsive therapy for the management of lower ureteral stones without ESWL

Administration of nifedipine or tamsulosin has been suggested to augment stone expulsion rates. We aimed to compare the stone expulsion rates and adverse effects associated with the use of nifedipine or tamsulosin as medical expulsive therapy (MET) for the management of lower ureteral stones (LUS) without extracorporeal shock wave lithotripsy (ESWL) via a literature review and meta-analysis. Relevant randomized controlled trials (RCTs) were identified from the Medline, EMBASE, Cochrane CENTRAL, and Google Scholar databases. Finally, a total of 7 RCTs with 3897 patients were included. Our meta-analysis showed that tamsulosin could significantly increase the stone expulsion rate relative to nifedipine in patients with LUS (random-effects model; risk ratio [RR] = 0.81; 95% confidence interval [CI] = 0.75–0.88; P < 0.00001). The subgroup analysis indicated no statistically significant difference between the drugs with regard to minor or major adverse effects (fixed-effect model; RR = 1.19, 95% CI = 0.91–1.54, P = 0.20; and RR = 1.63, 95% CI = 0.22–11.82, P = 0.63, respectively). This meta-analysis demonstrated that tamsulosin was more effective than nifedipine in patients with LUS, as evidenced by the higher stone expulsion rate. Tamsulosin treatment should therefore be considered for patients with LUS.

A prospective evaluation of pain associated with stone passage, stents, and stent removal using a visual analog scale

OBJECTIVE

To investigate the perception of colicky pain due to ureteral stones and double-J (DJ)-associated discomfort and to evaluate the role of clinical parameters that might influence the perception of pain.

MATERIALS AND METHODS

From November 2011 to May 2012, 124 consecutive patients with colicky pain due to ureteral stones and ureteroscopic stone extraction underwent DJ stent placement. A visual analog scale (VAS) was used to assess the pain at ureteral colic, during indwelling DJ stent, and at DJ stent removal. The association of clinical data with pain scores was also analyzed.

RESULTS

Pain perception at the time of colic did not vary according to sex (P = .804), age (P = .674), or DJ stent length (P = .389). Stone size (<4 mm) was a predictor of a high VAS score (P = .001). Patients with recurrent stone formation had significantly less pain at the time of colic (P = .004), and DJ stent removal (P = .004) than those with the first instance of stone formation. The clinical experience at cystoscopic DJ stent removal influenced pain perception (P <.001).

CONCLUSION

Using a VAS for the evaluation of pain perception is a valid method for the objectification of subjective discomfort. The VAS is an easy to administer scale and provides accurate information on the patients' status. Additional studies with larger cohorts focusing on pain perception using the VAS and other validated questionnaires are recommended to produce more consistent data.

Recent finding and new technologies in nephrolitiasis: a review of the recent literature

This review summarizes recent literature on advances regarding renal and ureteral calculi, with particular focus in areas of recent advances in the overall field of urolithiasis. Clinical management in everyday practice requires a complete understanding of the issues regarding metabolic evaluation and subgrouping of stone-forming patients, diagnostic procedures, effective treatment regime in acute stone colic, medical expulsive therapy, and active stone removal. In this review we focus on new perspectives in managing nephrolitihiasis and discuss recentadvances, including medical expulsive therapy, new technologies, and refinements of classical therapy such as shock wave lithotripsy, give a fundamental modification of nephrolithiasis management. Overall, this field appears to be the most promising, capable of new developments in ureterorenoscopy and percutaneous approaches. Further improvements are expected from robotic-assisted procedures, such as flexible robotics in ureterorenoscopy.

Efficacy of tamsulosin oral controlled absorption system after extracorporeal shock wave lithotripsy to treat urolithiasis

OBJECTIVE

To determine the efficacy of the tamsulosin oral controlled absorption system as an adjuvant therapy to extracorporeal shock wave lithotripsy (ESWL) for the expulsion of ureteral and renal stones.

METHODS

A consecutive sample of 248 patients with ureteral or renal stones who underwent ESWL in an academic hospital was included in a 12-week, prospective, open-label, randomized clinical trial. Of the 248 patients, 186, including 77 with ureteral stones (mean size 9 mm) and 109 with renal stones (mean size 13 mm) completed the study. After successful ESWL, the patients were randomized to standard medical care (corticosteroids and analgesics) or standard care plus the tamsulosin oral controlled absorption system 0.4 mg/d for 1 month. The stone clearance rate, interval to the elimination of stone fragments, incidence of renal colic, and the need for rehospitalization were assessed at 4, 8, and 12 weeks.

RESULTS

The stone clearance rate was significantly greater for the patients treated with tamsulosin than for those in the standard care group at 4 (73.4% vs 55.9%, respectively; P < .001) and 12 (91.3% vs 74.6%, respectively; P < .05) weeks. Tamsulosin treatment was also associated with a significantly lower interval to the elimination of stone fragments (P < .001), a significantly lower rehospitalization rate (P < .001), and a significantly lower proportion of patients with acute renal colic (P < .05) than standard care alone. No severe adverse events leading to treatment discontinuation were observed.

CONCLUSION

Adjuvant treatment with tamsulosin, in addition to standard treatment with steroids and analgesics, improved the outcome of ESWL.

Meta-analysis showing the beneficial effect of α-blockers on ureteric stent discomfort

What's known on the subject? and What does the study add? Ureteric stents cause significant discomfort and this is probably related to ureteric smooth muscle spasm and trigonal irritation. Alpha-adrenoceptor antagonists reduce smooth muscle activity and are already widely used in medical expulsive therapy to aid passage of ureteric calculi. This meta-analysis incorporating five randomized controlled trials provides evidence that alpha-adrenoceptor antagonists reduce stent-related pain and storage symptoms as assessed by the Ureteric Stent Symptoms Questionnaire (USSQ).

OBJECTIVES

• To evaluate the efficacy of α-blockers with respect to improving stent-related symptoms. • Ureteric stents remain a source of marked discomfort and their placement is often required after certain ureteroscopic procedures or in the acute setting. This analysis identifies and reviews the several studies that have investigated the role of α-blockers after stent placement.

MATERIALS AND METHODS

• Pubmed/Medline, EMBASE, CINAHL and Cochrane Library databases were scrutinized using standard MeSH headings. • Randomized or controlled trials comparing α-blockers with control or standard therapy were included. • In all studies, patients completed the Ureteral Stent Symptom Questionnaire (USSQ). • The study data were independently reviewed by two assessors.

RESULTS

• In total, five studies of varying quality were identified, including 461 patients receiving either tamsulosin or alfuzosin, or control. • On meta-analysis, all five studies showed a reduction in USSQ urinary symptom score and body pain scores. There was mean reduction of 8.4 (95% CI, 5.6-11.1) in the urinary symptom score and 7.2 (95% CI, 2.5-11.8) in the body pain score. • In three studies, the numbers of patients experiencing stent related pain were stated: 45% (51/114) of patients receiving an α-blocker experienced painful episodes within the follow-up period defined for that study compared to 76% (88/116) in the control groups, which is equivalent to a relative risk of pain of 0.59 (95% confidence interval, 0.47-0.71). • There were also reductions in other aspects of the USSQ, such as the general health score and sexual matters score, although these were not statistically significant or uniformly reported.

CONCLUSION

• There is evidence that α-blockers provide an improvement in discomfort after placement of a ureteric stent.

Tamsulosin as an expulsive therapy for steinstrasse after extracorporeal shock wave lithotripsy: a randomized controlled study

OBJECTIVE

Steinstrasse is a well-known complication following extracorporeal shockwave lithotripsy (ESWL). The objective of this study was to evaluate the efficacy of tamsulosin as a management of steinstrasse.

MATERIAL AND METHODS

88 patients with unilateral steinstrasse were treated between January 2005 and December 2008. The patients were randomly allocated into two equal groups. There were no significant differences between groups for age, gender, stone location, stone length or stone fragment size (p > 0.05). Patients in group 1 (study group) received a single daily morning dose of tamsulosin (0.4 mg) for a maximum of 4 weeks, in addition to pain-relieving therapy. Patients in group 2 (control group) received only the pain-relieving therapy. All patients were checked weekly with a plain X-ray of the urinary tract, urinary ultrasonography, urine analysis and serum creatinine. Pain episodes, day of spontaneous stone expulsion, total analgesic dosage and drug side-effects were recorded.

RESULTS

Stone expulsion occurred in 32 of the 44 patients (72.7%) receiving tamsulosin and in 25 of the 44 patients (56.8%) in the control group. Patients receiving tamsulosin had a significantly higher stone expulsion rate (p = 0.017). There were no significant differences between groups for mean stone expulsion time or number of analgesics used. Twelve patients (27.3%) in the group receiving tamsulosin and 19 patients (43.3%) in the control group needed hospitalization; the group difference was statistically significant (p = 0.017).

CONCLUSIONS

When compared with no treatment, tamsulosin can significantly facilitate expulsion of retained ureteral stone fragments following ESWL.

Medical therapy to facilitate the passage of stones: what is the evidence?

CONTEXT

Medical expulsive therapy (MET) for urolithiasis has gained increasing attention in the last years. It has been suggested that the administration of alpha-adrenoreceptor antagonists (alpha-blockers) or calcium channel blockers augments stone expulsion rates and reduces colic events.

OBJECTIVE

To evaluate the efficacy and safety of MET with alpha-blockers and calcium channel blockers for upper urinary tract stones with and without prior extracorporeal shock wave lithotripsy (ESWL).

EVIDENCE ACQUISITION

A systematic review of the literature was performed in Medline, Embase, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews searched through 31 December 2008 without time limit. Efficacy and safety end points were evaluated in 47 randomised, controlled trials assessing the role of MET. Meta-analysis was conducted using Review Manager (RevMan) v.5.0 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).

EVIDENCE SYNTHESIS

Pooling of alpha-blocker and calcium channel blocker studies demonstrated a higher and faster expulsion rate compared to a control group (risk ratio [RR]: 1.45 vs 1.49; 95% confidence interval [CI]: 1.34-1.57 vs 1.33-1.66). Similar results have been obtained after ESWL (RR: 1.29 vs 1.57; 95% CI: 1.16-1.43 vs 1.21-2.04). Additionally, lower analgesic requirements, fewer colic episodes, and fewer hospitalisations were observed within treatment groups.

CONCLUSIONS

Pooled analyses suggest that MET with alpha-blockers or calcium channel blockers augments stone expulsion rates, reduces the time to stone expulsion, and lowers analgesia requirements for ureteral stones with and without ESWL for stones < or = 10 mm. There is some evidence that a combination of alpha-blockers and corticosteroids might be more effective than treatment with alpha-blockers alone. Renal stones after ESWL also seem to profit from MET. The vast majority of randomised studies incorporated into the present systematic review are small, single-centre studies, limiting the strength of our conclusions. Therefore, multicentre, randomised, placebo-controlled trials are needed.

Adjuvant therapy after surgical stone management

The aim of this article was to review the most widely researched adjuvant medical therapies for the surgical management of urolithiasis. Articles were identified and reviewed from PubMed and Medline databases with MeSH headings focusing on the various surgical treatments of urolithiasis and adjuvant therapy. Additional articles were retrieved from references and conference proceedings. Surgical treatments reviewed included shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. Adjuvant therapy was considered medical or complementary therapy as an adjunct to these surgical interventions. Adjuvant therapy for the surgical management of urolithiasis has been documented to increase stone-free rates, reduce stone remission rates, prevent renal damage, and decrease postoperative morbidity. A variety of agents have been studied, ranging from antioxidants to alpha-blockers and to alkalinizing agents. Additionally, there is increasing interest in complementary adjuvant therapy (ie, acupuncture). Adjuvant therapy is a fertile area for research in the surgical management of urolithiasis. The optimal agents have yet to be determined and therefore further investigation is warranted and necessary.

[Ureter drugs]

Many improvements have been made recently in the field of the ureteral smooth muscle pharmacology. After a brief summary on physiological basis, we review what is known about effects on ureter of different drugs class. In a second part, we review clinical applications for renal colic analgesia, calculi expulsive medical therapy, ESWL adjuvant treatment and preoperative treatment before retrograde access. There are now sufficient data on NSAID and alpha-blockers. beta-agonists, especially for beta3 selective ones, and topical drugs before retrograde access are interesting and should be further evaluated.

Efficacy of Tamsulosin with Extracorporeal Shock Wave Lithotripsy for Passage of Renal and Ureteral Calculi

Objective:

To review the evidence for the safety and efficacy of adjunctive tamsulosin in enhancing the efficacy of renal and ureteral stone clearance when used with extracorporeal shock wave lithotripsy (ESWL).

Data Sources:

A search of MEDLINE (1950-January 2008), PubMed (1950-January 2008), and the Iowa Drug Information System (1966-January 2008) was performed using the search terms tamsulosin and extracorporeal shock wave lithotripsy. MeSH headings included lithotripsy and adrenergic α-antagonists. Additional references were found by searching bibliographic references of resulting citations.

Study Selection and Data Extraction:

All studies utilizing tamsulosin therapy after a single session of ESWL or after the development of steinstrasse, an accumulation of stone fragments that obstructs the ureter, were included.

Data Synthesis:

To date, 5 prospective studies have evaluated the efficacy of tamsulosin combined with ESWL in enhancing the passage of renal and ureteral stones. in one trial, 12-week renal stone clearance was 60% in the control group compared with 78.5% in the tamsulosin group (p = 0.037). Among trials that evaluated overall ureteral stone clearance, efficacy rates were 33.3-79.3% in the control groups compared with 66.6-96.6% in the tamsulosin groups. Reports of pain and supplemental analgesic dosing were consistently lower with tamsulosin, but data on the incidence of subsequent retreatment with ESWL or ureteroscopy was rarely reported. Adjunctive tamsulosin particularly enhanced the passage of renal stones 10-24 millimeters in diameter. Overall, tamsulosin was well tolerated.

Conclusions:

Overall, evidence suggests that adjunctive tamsulosin therapy combined with ESWL is safe and effective in enhancing stone clearance in patients with renal stones 10-24 millimeters in diameter. Evidence regarding ureteral stone clearance is inconclusive, although adjunctive tamsulosin has been reported to reduce painful episodes. Larger prospective trials evaluating different dosages and stone locations, as well as the ability of tamsulosin to reduce repeat ESWL or more invasive methods such as ureteroscopy should be performed.