Tamsulosin for Ureteral Stones in the Emergency Department: A Randomized, Controlled Trial

Alpha-blockers: the magic pill for endourology-The great delusion

PURPOSE

The present paper takes a different and more critical look at the role of alpha-blockers, sometimes nicknamed as "magical pills", in particular for stone disease and medical expulsive therapy (MET).

METHODS

A non-systematic narrative review was performed, synthesizing pertinent information from selected articles, and critically evaluating their conclusions. Sometimes different views on alpha-blockers were laid bare, including curiosities or other entertaining nuances suitable to the present topic, but always maintaining sharp objectivity and the foremost scientific rigor.

RESULTS AND CONCLUSIONS

Alpha-blockers seem to be a panacea, being used to treat a wide variety of non-urological diseases and conditions. Urological applications include erectile dysfunction to benign prostatic hyperplasia, from incontinence to urinary retention, or even to facilitate urinary stone passage along the urinary tract. Due to its versatility, alpha-blockers appear to be the Swiss army knife of urological medications. However, the efficacy of alpha-blockers for MET, pain management, or facilitating upper tract access is very disappointing, bringing no, or in some instances, only marginal benefits. Their treatment results are far from being significant or impressive let alone magical. Regular sexual intercourse is an effective alternative to alpha-blockers, providing faster ureteral stone expulsion rates and reducing the need for pain medication. Most of the research supporting alpha-blockers has been based on single-center, underpowered, low-quality studies. These low-quality studies biased several subsequent meta-analyses, contaminating them with their low-quality data, enhancing and prolonging this delusion. These results emphasize the need for large, multi-centric, unbiased, randomized, double-blinded, placebo-controlled trials to prevent future year-long delusions that may afflict any medical field.

Effect of alpha-adrenoceptor antagonists on sexual function. A systematic review and meta-analysis

BACKGROUND

Alpha-adrenoreceptor antagonists or alpha-blockers are used in the treatment of hypertension, in the therapy of benign prostatic hyperplasia and in medical expulsive treatment of ureteral stones. These agents may affect the sexual function, with differences between drugs within the same class, depending on their selectivity for receptor subtypes. The aim of this review was to analyze the effects of alpha-blockers on sexual function.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis by searching PubMed, EMBASE and other databases for randomized controlled trials (RCTs) reporting sexual adverse effects in patients treated with alpha-blockers. Odds ratios for sexual dysfunction were calculated using random effects Mantel-Haenszel statistics.

RESULTS

Out of 608 records retrieved, 75 eligible RCTs were included in the meta-analysis. Compared with placebo, alphablockers were associated with increased odds of ejaculatory disorders both in patients with lower urinary tract symptoms (LUTS) associated to benign prostatic hyperplasia (BPH) (OR: 7.53, 95% CI: 3.77-15.02, Z = 5.73, p < 0.00001, I2 = 55%) and in patients with ureteral stones (OR: 2.88, 95% CI: 1.50-5.44, Z = 3.19, p < 0.001, I2 = 31%). Uroselective alpha-blockers showed higher odds of ejaculatory disorders. Conversely, nonselective alpha-blockers were not associated with higher odds of ejaculatory dysfunction. Silodosin was associated with increased odds of ejaculatory dysfunction compared with tamsulosin (OR: 3.52, 95% CI: 2.18-5.68, 15 series, 1512 participants, Z = 5.15, p < 0.00001, I2 = 0%). Naftopidil and alfuzosin showed lower odds of ejaculatory dysfunction compared to uroselective alpha-blockers.No statistically significant differences in the odds of erectile dysfunction were observed when alpha-blockers were compared to placebo.

Is tamsulosin effective for the passage of symptomatic ureteral stones: A systematic review and meta-analysis

BACKGROUND

Some trials have stated that there is no benefit to tamsulosin administration for clearing ureteral stones, which is contrary to previous studies. To confirm the efficacy of tamsulosin for treating symptomatic ureteral stones, we performed this review.

METHODS

We searched the PubMed, Embase, and Cochrane Library databases to identify all studied variables, including tamsulosin, urinary stones, expulsion, and side effects. In addition, for all patients and different stone sizes, the treatment efficacy, expulsion rate, and expulsion time were also recorded for this treatment.

RESULTS

Forty-nine studies involving 6436 patients met the inclusion criteria. The data synthesized from these studies indicated that tamsulosin improved the renal stone clearance rate (80.5% vs 70.5%; mean difference (MD), 1.16; 95% confidence interval (CI), 1.13-1.19; P <.00001) and reduced the expulsion time (MD, -3.61; 95% CI, -3.77 to -3.46; P ≤.00001). Regarding complications, no significant difference was found between the 2 groups in terms of the total side effects (MD, 1.15; 95% CI, 0.97-1.35; P = .10) or divided complications, including retrograde ejaculation (P = .01), hypotension (P = .52), dizziness (P = .07), diarrhea (P = .58), vomiting (P = .88), headache (P = .84), nausea (P = .91), and fatigue (P = .10).

CONCLUSIONS

Tamsulosin should be strongly recommended for patients with ureteral stones to increase treatment efficacy. The side effects were not significantly different between the tamsulosin and control treatments.

Alpha-blockers as medical expulsive therapy for ureteral stones

BACKGROUND

Ureteral colic is a common reason for patients to seek medical care. Alpha-blockers are commonly used to improve stone passage through so-called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant.

OBJECTIVES

To assess effects of alpha-blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease.

SEARCH METHODS

On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies.

SELECTION CRITERIA

We included RCTs of ureteral stone passage in adult patients that compared alpha-blockers versus standard therapy.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta-analysis using a random-effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per-outcome basis using the GRADE approach.

MAIN RESULTS

We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo.Stone clearance: Based on the overall analysis, treatment with an alpha-blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low-quality evidence). A subset of higher-quality, placebo-controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate-quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants.Major adverse events: Based on the overall analysis, treatment with an alpha-blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low-quality evidence). A subset of higher-quality, placebo-controlled trials suggest that alpha-blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants.Patients treated with alpha-blockers may experience shorter stone expulsion times (mean difference (MD) -3.40 days, 95% CI -4.17 to -2.63; low-quality evidence), may use less diclofenac (MD -82.41, 95% CI -122.51 to -42.31; low-quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate-quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low-quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants.A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha-blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha-blocker type.

AUTHORS' CONCLUSIONS

For patients with ureteral stones, alpha-blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha-blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm).

Efficacy and Safety of Tamsulosin in Medical Expulsive Therapy for Distal Ureteral Stones with Renal Colic: A Multicenter, Randomized, Double-blind, Placebo-controlled Trial

BACKGROUND

Recent large high-quality trials have questioned the clinical effectiveness of medical expulsive therapy using tamsulosin for ureteral stones.

OBJECTIVE

To evaluate the efficacy and safety of tamsulosin for distal ureteral stones compared with placebo.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a double-blind, placebo-controlled study of 3296 patients with distal ureteral stones, across 30 centers, to evaluate the efficacy and safety of tamsulosin.

INTERVENTION

Participants were randomly assigned (1:1) into tamsulosin (0.4mg) or placebo groups for 4 wk.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary end point of analysis was the overall stone expulsion rate, defined as stone expulsion, confirmed by negative findings on computed tomography, over a 28-d surveillance period. Secondary end points included time to stone expulsion, use of analgesics, and incidence of adverse events.

RESULTS AND LIMITATIONS

Among 3450 patients randomized between September 1, 2011, and August 31, 2013, 3296 (96%) were included in the primary analysis. Tamsulosin benefits from a higher stone expulsion rate than the placebo (86% vs 79%; p<0.001) for distal ureteral stones. Subgroup analysis identified a specific benefit of tamsulosin for the treatment of large distal ureteral stones (>5mm). Considering the secondary end points, tamsulosin-treated patients reported a shorter time to expulsion (p<0.001), required lower use of analgesics compared with placebo (p<0.001), and significantly relieved renal colic (p<0.001). No differences in the incidence of adverse events were identified between the two groups.

CONCLUSIONS

Our data suggest that tamsulosin use benefits distal ureteral stones in facilitating stone passage and relieving renal colic. Subgroup analyses find that tamsulosin provides a superior expulsion rate for stones >5mm, but no effect for stones ≤5mm.

PATIENT SUMMARY

In this report, we looked at the efficacy and safety of tamsulosin for the treatment of distal ureteral stones. We find that tamsulosin significantly facilitates the passage of distal ureteral stones and relieves renal colic.

Alpha blockers in the management of ureteric lithiasis: A meta-analysis

INTRODUCTION

Effective medical expulsion for ureteric stones with α-blockers offers numerous advantages over surgical alternatives. However, its effectiveness remains uncertain and with the publication of new trial data, the available evidence requires reappraisal.

OBJECTIVE

The aim of this study was to assess the efficacy of α-blockers the management of ureteric lithiasis.

METHODS

A systematic review of the literature, with predefined search criteria, was conducted using PubMed and Embase. All randomised trials comparing α-blocker monotherapy to placebo or standard therapy were included. Stone expulsion rate was the primary outcome measure. Secondary outcome measures were time to stone expulsion, analgesic usage and pain scores. Subgroup analyses assessed individual adrenergic antagonists and variations in standard therapy. Sensitivity analysis was based on stone location, stone size, Cochrane Risk of Bias score and study protocol. Summary effects were calculated using a random-effect model and presented as Relative risks (RR) and mean differences (MD) for dichotomous and continuous outcome measures, respectively.

RESULTS

Sixty-seven studies randomising 6654 patients were included in the meta-analysis. Stone expulsion rates improved with α-blockers (RR, 1.49; 95% CI 1.38-1.61). Contrast enhanced funnel showed evidence of publication bias. Stone expulsion time was 3.99 days (CI -4.75 to -3.23) shorter with α-blockers. Similarly, patients required 106.53 mg [CI -148.20 to -64.86] less diclofenac compared with control/placebo, and had 0.80 [CI -1.07 to -0.54] fewer pain episodes. Visual Analogue Scores were also reduced, -2.43 [CI -3.87 to -0.99]. All formulations of α-antagonists all demonstrated beneficial effects over conservative treatment/placebo. Sensitivity analysis demonstrated significant effects of stone location, stone size and study design.

CONCLUSIONS AND RELEVANCE

Despite the opposing results of recently published trial, current evidence continues to demonstrate a potential benefit of α-blocker treatment particularly for distal stones over 5 mm.

Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis

OBJECTIVE

 To investigate the efficacy and safety of alpha blockers in the treatment of patients with ureteric stones.

DESIGN

 Systematic review and meta-analysis.

DATA SOURCES

 Cochrane Central Register of Controlled Trials, Web of Science, Embase, LILACS, and Medline databases and scientific meeting abstracts to July 2016.

REVIEW METHODS

 Randomized controlled trials of alpha blockers compared with placebo or control for treatment of ureteric stones were eligible. : Two team members independently extracted data from each included study. The primary outcome was the proportion of patients who passed their stone. Secondary outcomes were the time to passage; the number of pain episodes; and the proportions of patients who underwent surgery, required admission to hospital, and experienced an adverse event. Pooled risk ratios and 95% confidence intervals were calculated for the primary outcome with profile likelihood random effects models. Cochrane Collaboration's tool for assessing risk of bias and the GRADE approach were used to evaluate the quality of evidence and summarize conclusions.

RESULTS

 55 randomized controlled trials were included. There was moderate quality evidence that alpha blockers facilitate passage of ureteric stones (risk ratio 1.49, 95% confidence interval 1.39 to 1.61). Based on a priori subgroup analysis, there seemed to be no benefit to treatment with alpha blocker among patients with smaller ureteric stones (1.19, 1.00 to 1.48). Patients with larger stones treated with an alpha blocker, however, had a 57% higher risk of stone passage compared with controls (1.57, 1.17 to 2.27). The effect of alpha blockers was independent of stone location (1.48 (1.05 to 2.10) for upper or middle stones; 1.49 (1.38 to 1.63) for lower stones). Compared with controls, patients who received alpha blockers had significantly shorter times to stone passage (mean difference -3.79 days, -4.45 to -3.14; moderate quality evidence), fewer episodes of pain (-0.74 episodes, -1.28 to -0.21; low quality evidence), lower risks of surgical intervention (risk ratio 0.44, 0.37 to 0.52; moderate quality evidence), and lower risks of admission to hospital (0.37, 0.22 to 0.64; moderate quality evidence). The risk of a serious adverse event was similar between treatment and control groups (1.49, 0.24 to 9.35; low quality evidence).

CONCLUSIONS

 Alpha blockers seem efficacious in the treatment of patients with ureteric stones who are amenable to conservative management. The greatest benefit might be among those with larger stones. These results support current guideline recommendations advocating a role for alpha blockers in patients with ureteric stones.

SYSTEMATIC REVIEW REGISTRATION

 PROSPERO registration No CRD42015024169.

Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones

Introduction

Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasound is a sign of a ureteral stone, and has a reported sensitivity of 72–83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number.

Methods

This was a structured, explicit, retrospective chart review. Two blinded investigators used reviewed charts of all adult patients over a 6-month period with a final diagnosis of renal colic. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasound performed by an emergency physician. We included only those patient encounters with both CT-proven renal calculi and documented bedside ultrasound results.

Results

125 patients met inclusion criteria. The overall sensitivity of ultrasound for detection of hydronephrosis was 78.4% [95% confidence interval (CI)=70.2–85.3%]. The overall sensitivity of a positive ultrasound finding of either hydronephrosis or visualized stones was 82.4% [95%CI: 75.6%, 89.2%]. Based on a prior assumption that ultrasound would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p=0.016) difference in detecting hydronephrosis in patients with a stone ≥6 mm (sensitivity=90% [95% CI=82–98%]) compared to a stone <6 mm (sensitivity=75% [95% CI=65–86%]). For those with 3 or more stones, sensitivity was 100% [95% CI=63–100%]. There were no patients with stones ≥6 mm that had both a negative ultrasound and lack of hematuria.

Conclusion

In a population with CT-proven urolithiasis, ED bedside ultrasonography had similar overall sensitivity to previous reports but showed better sensitivity with increasing stone size and number. We identified 100% of patients with stones ≥6 mm that would benefit from medical expulsive therapy by either the presence of hematuria or abnormal ultrasound findings.

Naftopidil versus flopropione as medical expulsive therapy for distal ureteral stones: results of a randomized, multicenter, double-blind, controlled trial

PURPOSE

A multicenter, double-blind, randomized, controlled trial was conducted to determine the efficacy of naftopidil as medical expulsive therapy (MET) for patients with distal ureteral stones.

METHODS

Ninety-two patients presenting with a single distal ureteral stone ≤10 mm were randomly assigned to receive either naftopidil (75 mg of naftopidil once in the morning and placebo twice a day) or flopropione (80 mg three times a day). The primary end point was time to stone expulsion calculated by the Kaplan-Meier method. Secondary end points were the percentages of patients who required analgesics, hospital admission, and surgery, the number of working days lost to the disease, and treatment safety.

RESULTS

Overall, three patients were excluded from the final analysis. No significant differences were noted in age, stone size, and stone side between the treatment arms. The median time to stone expulsion was 8 days [95 % confidence interval (CI), 3-16] for the naftopidil group, and this was significantly less than the 18 days (95 % CI, 11 to not reached) for the flopropione group (p = 0.03). On multivariate Cox regression analysis, the hazard of expulsion was 1.8-fold higher for the naftopidil group than for the flopropione group after adjustment for age, sex, stone side, and stone size. No significant differences were noted in the secondary end points.

CONCLUSIONS

The administration of naftopidil significantly improved time to stone expulsion in patients with distal ureteral stones ≤10 mm. We believe that this is the first multicenter, double-blind, randomized, controlled trial demonstrating the efficacy of naftopidil for MET.

Tamsulosin for treatment of unilateral distal ureterolithiasis: a systematic review and meta-analysis

OBJECTIVES

The lifetime prevalence of ureterolithiasis is approximately 13% for men and 7% for women in the United States. Tamsulosin, an α-antagonist, has been used as therapy to facilitate the expulsion of lithiasis. Whether it is a good treatment for distal lithiasis remains controversial. We conducted a systematic review and meta-analysis to evaluate the effect of tamsulosin on the passage of distal ureterolithiasis.

METHODS

A systematic search was conducted using MEDLINE, EMBASE, and Cochrane Central. Trial eligibility was evaluated by two investigators. All randomized controlled trials (RCTs) comparing tamsulosin to standard therapy or placebo for the treatment of a single distal ureterolithiasis ≤ 10 mm in adult patients with renal colic confirmed by radiographic imaging were included. Data extraction was conducted in duplicate. Primary outcome was the expulsion rate, and secondary outcomes were the mean time for ureterolithiasis expulsion, analgesic requirements, and side effects. Mantel-Haenszel random effect models were used, and heterogeneity was assessed using I² statistics. Data were presented with relative risks (RRs).

RESULTS

The search strategy identified 685 articles, of which 22 studies were included. Combined results suggested a benefit for the expulsion of ureterolithiasis (≤ 10 mm) when tamsulosin was used compared to a standard treatment (RR 1.50 [95% CI 1.31-1.71], I²  =  70%). A decrease in the average time of expulsion of the ureterolithiasis of 3.33 days in favour of tamsulosin was observed (95% CI -4.23, -2.44], I²  =  67%).

CONCLUSION

Tamsulosin increases the rate of spontaneous passage of distal ureterolithiasis (≤ 10 mm).

Alpha-blockers as medical expulsive therapy for ureteral stones

BACKGROUND

Urinary stone disease is one of the most common reasons for patients visiting a urology practice, affecting about 5% to 10% of the population. Annual costs for stone disease have rapidly increased over the years and most patients with ureteral colic or other symptoms seek medical care. Stone size and location are important predictors of stone passage. In most cases medical expulsive therapy is an appropriate treatment modality and most studies have been performed with alpha-blockers. Alpha-blockers tend to decrease intra-ureteral pressure and increase fluid passage which might increase stone passage. Faster stone expulsion will decrease the rate of complications, the need for invasive interventions and eventually decrease healthcare costs. A study on the effect of alpha-blockers as medical expulsive therapy in ureteral stones is therefore warranted.

OBJECTIVES

This review aimed to answer the following question: does medical treatment with alpha-blockers compared to other pharmacotherapy or placebo impact on stone clearance rate, in adult patients presenting with symptoms of ureteral stones less than 10 mm confirmed by imaging? Other clinically relevant outcomes such as stone expulsion time, hospitalisation, pain scores, analgesic use and adverse effects have also been explored.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register to 9 July 2012 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, handsearching conference proceedings, and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs), comparing alpha-blockers with other pharmacotherapy or placebo on ureteral stone passage in adult patients were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Reporting bias was investigated using funnel plots. Subgroup analysis was used to explore possible sources of heterogeneity. Sensitivity analysis was performed removing studies of poor methodological quality.

MAIN RESULTS

Thirty-two studies (5864 participants) were included. The stone-free rates were significantly higher in the alpha-blocker group (RR 1.48, 95% CI 1.33 to 1.64) when compared to standard therapy. Stone expulsion time was 2.91 days shorter with the use of alpha-blockers (MD -2.91, 95% CI -4.00 to -1.81). Use of alpha-blockers reduced the number of pain episodes (MD -0.48, 95% CI -0.94 to -0.01), the need for analgesic medication (diclofenac) (MD -38.17 mg, 95% CI -74.93 to -1.41) and hospitalisation (RR 0.35, 95% CI 0.13 to 0.97). Patients using alpha-blockers were more likely to experience adverse effects when compared to standard therapy (RR 2.74, 95% CI 1.38 to 5.45) or placebo (RR 2.73, 95% CI 1.50 to 4.96). Most adverse effects were mild of origin and did not lead to cessation of therapy, and several studies reported no adverse events in either the treatment or control group.In 7/32 studies patients and doctors were both blinded. In the other studies blinding was not described in the methods or no blinding had taken place. Two studies described incomplete data and only one study showed a relatively high number of patients who withdrew from the study. These factors limited the methodological strength of the evidence found.

AUTHORS' CONCLUSIONS

The use of alpha-blockers in patients with ureteral stones results in a higher stone-free rate and a shorter time to stone expulsion. Alpha-blockers should therefore be offered as part of medical expulsive therapy as one of the primary treatment modalities.

Tamsulosin and spontaneous passage of ureteral stones in children: a multi-institutional cohort study

PURPOSE

Tamsulosin is associated with increased passage of ureteral stones in adults but its effectiveness in children is uncertain. We determined the association between tamsulosin and the spontaneous passage of ureteral stones in children.

MATERIALS AND METHODS

We performed a multi-institutional retrospective cohort study of patients 18 years or younger who presented between 2007 and 2012 with ureteral stones up to 10 mm and who were treated with tamsulosin or oral analgesics alone. The outcome was spontaneous stone passage, defined as radiographic clearance and/or patient report of passage. Subjects prescribed tamsulosin were matched with subjects prescribed analgesics alone, using nearest neighbor propensity score matching to adjust for treatment selection. Conditional logistic regression models were used to estimate the association between tamsulosin and spontaneous passage of ureteral stones, adjusting for stone size and location.

RESULTS

Of 449 children with ureteral stones 334 were eligible for inclusion, and complete data were available for 274 patients from 4 institutions (99 receiving tamsulosin, 175 receiving analgesics alone). Following case matching, there were no differences in age, gender, weight, height, stone size or stone location between the 99 subjects prescribed tamsulosin and the 99 propensity score matched subjects prescribed analgesics alone. In the tamsulosin cohort 55% of ureteral stones passed, compared to 44% in the analgesics alone cohort (p=0.03). In multivariate analysis adjusting for stone size and location tamsulosin was associated with spontaneous passage of ureteral stones (OR 3.31, 95% CI 1.49-7.34).

CONCLUSIONS

The odds of spontaneous passage of ureteral stones were greater in children prescribed tamsulosin vs analgesics alone.

Can tamsulosin facilitate expulsion of ureteral stones? A meta-analysis of randomized controlled trials

OBJECTIVES

To determine the efficacy and safety of the adrenergic alpha-antagonist tamsulosin in facilitating ureteral stones expulsion.

METHODS

A literature search was carried out using the PubMed database, Medline via Ovid, Embase and the Cochrane Library database to identify randomized controlled trials evaluating the efficiency of tamsulosin in the treatment of ureteral stones. Meta-analysis and forest plots were carried out by use of Review Manager version 5.1 software (Cochrane Collaboration).

RESULTS

Compared with the control group, the tamsulosin group had an increase in expulsion rate of 51% and a decrease in expulsion time of 2.63 days. Furthermore, tamsulosin was found to reduce the risk of ureteral colic during treatment by 40% and also the risk of requirement of auxiliary procedures during follow up by 60%. In terms of safety, the tamsulosin group had a 117% increase in the incidence of side-effects compared with the control group, especially for incidence of dizziness.

CONCLUSION

Tamsulosin facilitates the expulsion of ureteral calculi by providing a higher expulsion rate, a shorter expulsion time, a lower incidence of ureteral colic during treatment and a lower requirement of auxiliary procedures. However, the incidence of dizziness occurring during tamsulosin treatment is significantly higher in this setting.

Tamsulosin for ureteral stones: a systematic review and meta-analysis of a randomized controlled trial

BACKGROUND/AIMS

To evaluate the efficacy of tamsulosin as a medical expulsive therapy of ureteral stones.

METHODS

We searched PubMed, EMBASE, the Cochrane Library, and ISI-Science Citation Index up to December 2011. All randomized controlled trials were identified in which patients were randomized to receive either tamsulosin or standard therapy with/without placebo for ureteral stones. Outcome measures assessed were overall stone expulsion rate (primary) and expulsion time, and the number of pain episodes (secondary). Three authors independently assessed study quality and extracted data. All data were analyzed using RevMan 5.0.

RESULTS

Twenty-nine trials with a total of 2,763 patients met the inclusion criteria. The pooled analysis showed a 19% improvement in stone clearance with tamsulosin. According to the doses of tamsulosin, the pooling effects of tamsulosin were analyzed, with a higher expulsion rate obtained than in controls. Compared with calcium channel blockers, there was a higher stone expulsion rate in tamsulosin. In addition, a shorter expulsion time, fewer colic episodes and adverse effects were observed.

CONCLUSIONS

Tamsulosin is a safe and effective medical expulsive therapy choice for ureteral stones. It should be recommended for most patients with distal ureteral stones before stones are 10 mm in size. In future, high-quality multicenter, randomized and placebo-controlled trials are needed to evaluate the outcome.

Urolithiasis in the emergency department

Urolithiasis commonly presents to the emergency department with acute, severe, unilateral flank pain. Patients with a suspected first-time stone or atypical presentation should be evaluated with a noncontrast computed tomography scan to confirm the diagnosis and rule out alternative diagnoses. Narcotics remain the mainstay of pain management but in select patients, nonsteroidal anti-inflammatories alone or in combination with narcotics provide safe and effective analgesia in the emergency department. Whereas most kidney stones can be managed with pain control and expectant management, obstructing kidney stones with a suspected proximal urinary tract infection are urological emergencies requiring emergent decompression, antibiotics, and resuscitation.

Management of ureteral calculi and medical expulsive therapy in emergency departments

Introduction:

Ureteral stones are a common problem in daily emergency department practice. Patients may be offered medical expulsive therapy (MET1) to facilitate stone expulsion and this should be offered as a treatment for patients with distal ureteral calculi, who are amenable to waiting management. Emergency department clinicians and family practitioners are often in the front line regarding the diagnosis and treatment of symptomatic nephrolithiasis and this commentary is dedicated to them because their decisions directly influence the outcome of the acute stone episode and appropriate referral patterns.

Materials and Methods:

The aim of this systematic review and meta-analysis was to understand the role of MET in the treatment of obstructing ureteral calculi. A bibliographic search covering the period from January 1980 to March 2010 was conducted in PubMed, MEDLINE and EMBASE. The searches were restricted to publications in English. This analysis is based on the 21 studies that fulfilled the predefined inclusion criteria.

Results:

A metaregression analysis of expulsion time showed a statistically significant advantage in the experimental group, in which the mean expulsion time was 6.2 days compared to 10.3 days in controls. The treatment effect on expulsion rate (P = 0.53) was partially lost as the size of the stones decreased because of the high spontaneous expulsion rate of small stones and the expulsion time was not influenced by pharmacological treatment (P = 0.76) if the stone size was smaller than 5 mm. Analysis of the tamsulosin database. A total of 1283 participants were included in the 17 studies. These studies showed that compared to standard therapy or placebo, tamsulosin had significant benefits, being associated with both a higher stone expulsion rate (P < 0.001) and reduction of the expulsion time (P = 0.02). Reductions in the need for analgesic therapy, hospitalization and surgery are also shown. Analysis of the nifedipine database. The number of participants in each trial ranged from 25 to 70. Compared to standard therapy, the use of nifedipine significantly improved the spontaneous stone expulsion rate (P < 0.001). The mean expulsion time was slightly, but not statistically significantly, different (P = 0.19) between the treatment and control groups. A possible benefit of nifedipine, in terms of significantly reducing the doses of analgesics required, was reported in three studies. There was no difference between the tamsulosin- and nifedipine-treated groups with regard to expulsion time (P = 0.17) or expulsion rate (P = 0.79).

Conclusions:

Despite all its advantages, MET is rarely used, representing a failure of the translation of medical science into practice. These data raise concerns not only about the quality of care of patients who could benefit from resolution of stones without anaesthetic and surgical risks but also with regard to potential cost savings. MET should be offered as a treatment for patients with distal ureteral calculi who are amenable to a waiting management.