Efficacy and safety of silodosin in the medical expulsion therapy for distal ureteral calculi: a systematic review and meta-analysis

Deciding on a novel predictive value to gauge how well patients with lower ureteric stones respond to medical expulsive therapy

This study, conducted over 4 years in Baghdad, Iraq, aimed to determine the importance of ureteric jet assessment in medical expulsive therapy (MET) for distal ureteral stones. A total of 156 patients with distal ureteral stones (≤ 10 mm) participated, and their ureteric jets were observed using a color Doppler scanner before and after 2 weeks of MET. The main focus was the success rate of stone expulsion. Our results showed that 50% of patients had detectable ureteric jets after 2 weeks of MET, and 21.8% experienced successful stone expulsion. After 4 weeks, 23.7% achieved stone expulsion, while 54.5% still had remaining stones. Patients who had a positive baseline ureteric jet were significantly more likely to successfully expel their stones. This study highlights the importance of monitoring ureteric jet movement in MET for distal ureteral stones.

Efficacy of mirabegron for ureteral stones: a systematic review with meta-analysis of randomized controlled trials

Background: Medical expulsive therapy demonstrates efficacy in managing ureteral stones in patients amenable to conservative interventions. This meta-analysis aims to evaluate the effectiveness of mirabegron in the treatment of ureteral stones. Methods: From conception to November 2023, we examined PubMed databases, the Cochrane Library, Embase, Ovid, Scopus, and trial registries for this systematic review and meta-analysis. We chose relevant randomized controlled trials (RCTs) evaluating the efficacy of mirabegron as an expulsive treatment for ureteral stones. The Cochrane risk of bias method was used to assess the quality of the evidence. Outcome measures, which included the stone expulsion rate (SER), expulsion time, and pain episodes, were analyzed using RevMan 5.4 and Stata 17. Results: Seven RCTs (N = 701) had enough information and were ultimately included. In patients with ureteral stones, mirabegron-treated patients had a substantially higher SER [odds ratio (OR) = 2.57, 95% confidence interval (CI) = 1.41-4.68, p = 0.002] than placebo-treated patients. Subgroup analysis revealed that mirabegron was superior to placebo in patients with small ureteral stones (OR = 2.26, 95% CI = 1.05-4.87, p = 0.04), with no heterogeneity between studies (p = 0.54; I2 = 0%). Mirabegron patients had a higher SER than the control group for distal ureteral stones (DUSs) (OR = 2.48, 95% CI = 1.31-4.68, p = 0.005). However, there was no difference in stone ejection time or pain episodes between groups. Conclusion: Mirabegron considerably improves SER in patients with ureteral stones, and the effect appears to be more pronounced for small and DUSs. Nevertheless, mirabegron treatment was not associated with improved stone expulsion time or pain management.

A Comparison Between Silodosin and Tamsulosin for Medical Expulsive Therapy of Distal Ureteric Calculus

INTRODUCTION

Medical expulsive therapy (MET) is an established treatment option for distal ureteric stones. Tamsulosin, a selective alpha-1 blocker, has been used for MET with good results, while silodosin, a more selective alpha-1a blocker, is more effective than tamsulosin for MET. Thus, this study aimed to compare the efficacy of silodosin with tamsulosin.

METHODS

This prospective randomized study was conducted at the Department of Urology, Government Chengalpattu Medical College Hospital, Tamil Nadu, India. Eighty patients who presented with ureteric colic and were radiologically diagnosed with distal ureteric calculus of size <10mm were included. Participants in the silodosin group received tablet silodosin 8mg OD until the passage of the stone, not more than two weeks, and analgesics as per demand. And participants in the tamsulosin group received tablet tamsulosin 0.4mg OD until the passage of the stone, not more than two weeks, and analgesics as per demand.

RESULTS

A total of 80 patients were included in the study. Forty patients in the silodosin group and forty patients in the tamsulosin group were included. In the silodosin group, out of 40 patients, 38 expelled the calculus. In the tamsulosin group, out of 40 patients, 28 expelled the calculus. The silodosin group had a significantly higher rate of expulsion, with a p-value of 0.003. Stone expulsion time was shorter in the silodosin group when compared with the tamsulosin group (10.15 vs. 13.4 days). Analgesic usage during medical expulsive therapy was lower in the silodosin group (5.68 vs. 8.4). We observed significant differences in comparing the outcome, stone expulsion time, and analgesic requirement between the silodosin and tamsulosin groups. We observed no significant difference between the groups for age-wise and gender-wise comparisons. Furthermore, non-expulsion of calculus in four patients and pain in eight patients were the reasons for intervention in the tamsulosin group. The reason for intervention in the silodosin group was the non-expulsion of calculus in two patients.

CONCLUSION

Using silodosin for MET of distal ureteric calculus, we found to have a better stone expulsion rate, early expulsion time, and reduced analgesic requirement.

Efficacy of pre-operative silodosin on flexible ureteroscopy procedure: A randomized controlled study

Objectives

To evaluate the impact of silodosin on stages of flexible ureteroscopy (F-URS) procedures, complications, and stone-free rate (SFR).

Patients and Methods

A prospective, randomized, controlled comparison research was conducted on 106 patients who were randomly allocated into two groups: the study group (52 patients) received F-URS with preoperative daily uptake of 8 mg silodosin for 10 days, and the control group (54 patients) received F- URS without silodosin uptake. Two patients were lost during the follow up in the study group and four patients were also lost in the controls.

Results

Operative time, application access sheath time (AAST), entrance to ureteric orifice time (ETUOT), and entrance to bladder time (ETBT) were significantly lower in the study group compared to controls. Meanwhile, F-URS time & laser time was higher in the study group compared to controls but without statistically significant difference. Complications were insignificalty different between both studied goups with no impact on SFR.

Conclusion

Before ureteroscopy, silodosin, an adjunctive alpha-blocker therapy, was successful in treating stones resulting in shortening the procedural time, with no impact on SFR or complication rate.

Meta-Analysis of the Safety and Efficacy of α-Adrenergic Blockers for Pediatric Urolithiasis in the Distal Ureter

OBJECTIVE

Pediatric urolithiasis is a common condition, and medical expulsive therapy has grown to be accepted by many parents. We carried out a meta-analysis to identify the efficacy and safety of α-adrenergic blockers for the treatment of pediatric urolithiasis.

METHODS

We identified related articles from the PubMed, Embase, and Cochrane Library databases. All published randomized controlled trials (RCTs) describing the use of α-adrenergic blockers and placebo treatment for pediatric distal urolithiasis were involved. The outcomes included stone expulsion rate, stone expulsion time, pain episodes, need for analgesia, adverse events, and related subgroup analyses.

RESULTS

A total of nine RCTs were involved in our study, including 586 patients. We found that α-adrenergic blockers could significantly increase the rate of stone expulsion [odds ratio (OR), 3.49; 95% confidence interval (CI), 2.38-5.12; p < 0.00001], reduce the stone expulsion time [mean difference (MD), -5.15; 95% CI, -8.51 to -1.80; p = 0.003], and decrease pain episodes (MD, -1.02; 95% CI, -1.33 to -0.72; p < 0.00001) and analgesia demand (MD, -0.92; 95% CI, -1.32 to -0.53; p < 0.00001) but had a higher incidence of side effects (MD, 2.83; 95% CI, 1.55 to 5.15; p = 0.0007). During subgroup analyses, different medications (tamsulosin, doxazosin, and silodosin) also exhibited better efficiencies than placebo, except for doxazosin, which showed no difference in expulsion time (MD, -1.23; 95% CI, -2.98 to 0.51; p = 0.17). The three kinds of α-adrenergic blockers also appeared to be better tolerated, except for tamsulosin with its greater number of adverse events (MD, 2.85; 95% CI, 1.34 to 6.03; p = 0.006). Silodosin led to a better expulsion rate than tamsulosin (OR, 0.42; 95% CI, 0.20 to 0.92; p = 0.03). In addition, α-adrenergic blockers increased the stone expulsion rate regardless of stone size and decreased the expulsion time of stones measuring <5 mm (MD, -1.71; 95% CI, -2.91 to -0.52; p = 0.005), which was not the case for stones measuring >5 mm in expulsion time (MD, -3.61; 95% CI, -10.17 to 2.96; p = 0.28).

CONCLUSION

Our review suggests that α-adrenergic blockers are well-tolerated and efficient for treating pediatric distal urolithiasis. We also conclude that silodosin is the best choice of drug, offering a better expulsion rate, but it remains to be evaluated further by future studies.

Comparison of the efficacy of silodosin and a terpene combination in the medical expulsive therapy of distal ureteral stones

OBJECTIVE

We aimed to compare the efficacy of silodosin and a terpene combination in the treatment of distal ureteral stones.

METHODOLOGY

The data of the patients admitted to the urology policlinic with renal colic, diagnosed with distal ureteral stones, and followed up with medical expulsive therapy between December 2017 and June 2018 were retrospectively reviewed. The patients were divided into two groups: Group 1 comprised 72 patients that received 8 mg/day silodosin and Group 2 consisted of 51 patients that were given three capsules of a terpene combination daily. The groups were compared in terms of the patients' demographic characteristics, medical history, localisation of the present stone, renal collecting system status, daily fluid intake, number of emergency service visits, number of additional analgesic applications needed, number of pain attacks, number of days off work, stone expulsion rate and time to stone expulsion.

RESULTS

Of the total 123 patients, 98 (79.7%) were stone-free. The stone-free rate was 75.0% in Group 1 and 86.3% in Group 2, with no statistical difference between the two groups. However, the number of visits to the emergency service because of pain, number of additional analgesic applications required, number of days off work, and time to stone expulsion were statistically significantly lower in Group 2 than in Group 1.

CONCLUSIONS

The treatment of distal ureteral stones with silodosin is as effective as the terpene combination. However, the terpene combination is more effective than silodosin in managing pain and accelerating stone expulsion.

Comparison of efficacy of three commonly used alpha-blockers as medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis

Introduction:

The efficacy of alpha-blockers as medical expulsive therapy (MET) is well established. However, it is not known which of the three most commonly used alpha-blockers (tamsulosin, alfuzosin and silodosin) is the most efficacious. With this study we aimed to assess the efficacy of the three commonly used alpha-blockers as MET for distal ureter stones.

Materials and Methods:

For this review, we searched multiple databases such as PubMed/Medline, Scopus, Embase, OviD SP, CINAHL, and web of science to identify all the relevant randomized studies comparing the efficacy of tamsulosin, alfuzosin, and silodosin. Preferred reporting items for systematic reviews for network meta-analysis (PRISMA-NMA) were followed while conducting this review and the study protocol was registered with PROSPERO (CRD42020175706).

Results:

In this review, 31 studies with 7077 patients were included. Compared to placebo all the treatment groups were more effective for both stone expulsion rate (SER) and stone expulsion time (SET). For both SER and SET, silodosin had the highest SUCRA (94.8 and 90.4) values followed by alfuzosin (58.8 and 64.9) and tamsulosin (46.2 and 44.5). The incidence of postural hypotension was similar with all the drugs, whereas, the incidence of retrograde ejaculation was significantly higher for silodosin. Overall confidence for each comparison group in this review ranged from “very low” to “moderate” according to the CINeMA approach.

Conclusion:

Among the three commonly used alpha-blockers silodosin is the most efficacious drug as MET for lower ureter stones followed by alfuzosin and tamsulosin.

Silodosin versus Tamsulosin as Medical Expulsive Therapy for Children with Lower-Third Ureteric Stones: Prospective Randomized Placebo-Controlled Study

AIM

To compare the efficacy and safety of silodosin versus tamsulosin as medical expulsive therapy for stones of lower-third ureter in children.

PATIENTS AND METHODS

This prospective single-blind placebo-controlled randomized study included 167 pediatric patients who presented with distal ureteric stone (DUS) less than 1 cm. Patients were randomized into 3 groups; group I received silodosin 4 mg once daily, and group II received tamsulosin 0.4 mg while those in group III had placebo. The side effects of the used drugs, both rate and time of stone expulsion, and number of pain episodes were compared among the study groups for a maximum of 4 weeks.

RESULTS

Follow-up data of our patients after treatment revealed that the stone expulsion rate was significantly higher and the time to stone expulsion was significantly shorter in group I (89.3%, 12.4 ± 2.3 days) and group II (74.5%, 16.2 ± 4.2 days) compared to group III (51.8%, 21.2 ± 5.6). However, a statistically significant difference between silodosin and tamsulosin groups in favor of the former one was reported regarding the 2 studied items. Meanwhile, pain episodes requiring analgesia were statistically fewer in group I and II in contrast to placebo group. Adverse events were comparable among all groups.

CONCLUSION

Silodosin provides significantly better stone expulsion rate and shorter expulsion time than tamsulosin for treatment of DUS. Both medications showed good safety profiles in children. However, further studies are required on a larger scale to confirm our results. Assessment of drug safety on younger age-group is still needed.

Evaluation of the efficacy of sexual intercourse on distal ureteral stones in women: a prospective, randomized, controlled study

AIM

To evaluate the efficacy of sexual intercourse in the expulsion of distal ureteric stones in women.

MATERIALS AND METHODS

A total of seventy woman patients with distal ureteral or intramural stone were randomly divided into two groups. Group 1 included 35 patients who were advised to do sexual intercourse 3-4 times/week with the administration of symptomatic treatment, and group 2 (control group) included 35 patients receiving symptomatic treatment only and were instructed not to do sexual intercourse or masturbation during the study. After 4 weeks follow up; the expulsion rate, need for analgesic and ureterorenoscopic lithotripsy were compared for each group.

RESULTS

The mean ages of the patients in groups 1 and 2 were 36.4 ± 10.8, 37.1 ± 12.4, respectively. The mean stone size was 7.01 ± 1.6 in group 1, 6.67 ± 1.4 mm in group 2 (p: 0.3). Stone expulsion rate, in the first 2 weeks for group 1 was 80% (28/35), while 51.4% (18/35) in group 2 (p < 0.001). In the 4th week, the expulsion rate for group 1 was 85.7%, but 60% in group 2 (p < 0.001). The mean expulsion time was shorter in group 1 (12 ± 4.2 days) than group 2 (16.1 ± 6.4 days) (p < 0.01). The analgesic needs in groups 1 and 2 were found to be 1.9 ± 0.7, 2.6 ± 0.8 times/a day respectively, and were significantly lower in group 1 (p < 0.001).

CONCLUSION

At least three or four sexual intercourses per week seem to increase the spontaneous passage for distal or intramural ureteral stones in women. Furthermore, sexual intercourse reduces the need for analgesics.

Pooled analysis of the efficacy and safety of adjunctive alpha-blocker therapy before ureteroscopy in the management of ureteral stones

Objective

To evaluate the efficacy and safety of adjunctive alpha-blocker therapy before ureteroscopy in the management of ureteral stones.

Methods

The databases MEDLINE^®, EMBASE and The Cochrane Controlled Trail Register of Controlled Trials were searched between January 1980 and June 2019 to identify randomized controlled trials (RCTs) that referred to the use of alpha-blockers as adjunctive therapy before ureteroscopy for the treatment of ureteral stones. Odds ratios (ORs) with 95% confidence intervals (CIs) were used for dichotomous outcomes; and mean difference (MD) with 95% CIs were used to report continuous outcomes.

Results

The analysis included five RCTs with a total of 557 patients. Compared with placebo, patients that received adjunctive alpha-blockers had significantly higher successful access to the stone (OR 5.44; 95% CI 2.99, 9.88), a significantly higher stone-free rate at the end of week 4 (OR 3.75; 95% CI 2.20, 6.39), significantly less requirement for balloon dilatation (OR 0.26; 95% CI 0.15, 0.44) and a significantly lower risk of complications (OR 0.25; 95% CI 0.15, 0.42). There was no significant difference in the operation time between the two groups (MD –3.33; 95% CI –7.03, 0.37).

Conclusions

Adjunctive alpha-blocker therapy administered before ureteroscopy was effective in the management of ureteral stones with a lower risk of complications than placebo treatment.

The evaluation of the effectiveness of Gilaburu (Viburnum opulus L.) extract in the medical expulsive treatment of distal ureteral stones

OBJECTIVE

Medical expulsive therapy is an important non-invasive treatment modality that facilitates the passage of ureteral stones. The aim of the present study was to evaluate the efficacy of Gilaburu (Viburnum opulus) extract in the treatment of distal ureteral stones <10 mm.

MATERIAL AND METHODS

Data of 103 patients were retrospectively analyzed. Patients were divided into two groups: those given V. opulus 1000 mg peroral 3×2 and diclofenac 50 mg peroral on-demand (n=53) and those given only diclofenac sodium 50 mg peroral on-demand (n=50). Comparisons of stone expulsion rates and the elapsed time until the expulsion between the groups were determined as primary outcome measures. The comparison of the need for additional treatment [ureteroscopy (URS) or extracorporeal shock wave lithotripsy (ESWL)], the need for emergency admission, analgesic requirement, and the complication rates in additional treatment were determined as secondary outcome measures.

RESULTS

The mean age of the patients was 45.8±14.5 years. The rate of stone expulsion was significantly higher (82% vs. 66%, p=0.026), and elapsed time to stone expulsion was significantly shorter (9±1.8 vs. 14±2.3 day, p=0.018) in the V. opulus group. The need for additional treatment (URS and ESWL) and analgesic requirement was less in the V. opulus group (9.4% vs. 20%, p=0.038 and 24.5% vs. 44%, p=0.042, respectively).

CONCLUSION

V. opulus is an herbal treatment alternative that facilitates the passage of ureteral stones <10 mm. Prospective, randomized studies are needed to support these results.

Meta-analysis of the efficacy of sexual intercourse for distal ureteric stones

OBJECTIVE

This meta-analysis was performed to evaluate the efficacy of sexual intercourse for treatment of distal ureteral stones.

METHODS

Randomized controlled trials (RCTs) of sexual intercourse for treatment of distal ureteral stones were searched using PubMed, EMBASE, and the Cochrane Controlled Trials Register.

RESULTS

Three RCTs comprising 240 patients were included in the meta-analysis, which showed that sexual intercourse was effective in treating distal ureteral stones. The expulsion rate of distal ureteral stones at the second week (odds ratio [OR] = 6.61, 95% confidence interval [CI]: 3.66 to 11.94), expulsion rate of distal ureteral stones at the fourth week (OR = 4.00, 95% CI: 2.09 to 7.64), and number of analgesic injections (mean difference [MD] = -0.79, 95% CI: -1.51 to -0.08) indicated that sexual intercourse was more effective than placebo. However, the mean expulsion time of distal ureteral stones (MD = -3.98, 95% CI: -8.77 to 0.81) showed no difference between sexual intercourse and placebo.

CONCLUSIONS

Compared with placebo, sexual intercourse exhibited greater efficacy for the treatment of distal ureteral stones, whilst potentially alleviating pain.

Efficacy of silodosin on the outcome of semi-rigid ureteroscopy for the management of large distal ureteric stones: blinded randomised trial

Objective

To evaluate the efficacy of silodosin therapy, as a new α-adrenergic receptor (α-AR) blocker, on the success rate of semi-rigid ureteroscopy (URS) for the management of large distal ureteric stones.

Patients and methods

This prospective study recruited 127 adult patients with single distal ureteric stone of ≥1 cm. The patients were randomly allocated to two groups: the first group included 62 patients who received silodosin (8 mg) for 10 days before URS (Silodosin group), whilst the second group included 65 patients who received placebo, in the form of multivitamins, for 10 days before URS (Placebo group). All patients underwent URS and a pneumatic lithoclast was used for stone fragmentation.

Results

The mean (SD) operative time was shorter in the Silodosin group compared with the Placebo group, at 41.61 (4.67) vs 46.85 (4.6) min, respectively. Furthermore, advancing the ureteroscope to access the stone failed in a statistically significant number of patients in the Placebo group compared with the Silodosin group (13 vs two, respectively). The complication rate was significantly higher in the Placebo group compared with the Silodosin group (20% vs 6.4%, P = 0.036). Additionally, the need for postoperative analgesia was significantly lower in the Silodosin group compared with the Placebo group (8.1% vs 26.2%, P = 0.009).

Conclusion

Silodosin therapy prior to URS management of large distal ureteric stones seems to be associated with better advancing of the ureteroscope to access the stone, shorter procedure time, higher stone-free rate, lower incidence of complications, and lesser need for postoperative analgesia.

Silodosin versus tamsulosin for medical expulsive treatment of ureteral stones: A systematic review and meta-analysis

Silodosin, a recently introduced selective α-blocker, has a much higher selectivity for the α-1A receptor. The efficacy and safety of silodosin compared to tamsulosin in medical expulsive therapy (MET) are controversial. The objective of this study was to assess the efficacy and safety of silodosin compared to tamsulosin for treating ureteral stones <10 mm in diameter. We systematically searched the PubMed, EMBASE, Cochrane library, and Scopus databases from their inception to May 2018. We included randomized controlled studies (RCTs) and observational studies, which investigated stone expulsion rates using silodosin compared to tamsulosin. Data were synthesized using a random-effects model. Sixteen studies with 1824 patients were eligible for inclusion. Silodosin achieved significantly higher expulsion rates than tamsulosin (pooled risk difference (RD): 0.13, 95% confidence interval (CI): 0.09 to 0.18, GRADE: high). A subgroup analyses showed that silodosin has a significantly higher expulsion rate on stone sizes of 5-10 mm than tamsulosin (pooled RD: 0.14, 95% CI: 0.06 to 0.22, I2 = 0%). The superior effect was not observed on stone sizes <5 mm. A multivariate regression showed that the RD was negatively associated with the control expulsion rate after adjusting for age and gender (coefficient -0.658, p = 0.01). A sensitivity analysis showed that our findings were robust. Patients receiving silodosin also probably had a significantly shorter expulsion time (pooled mean difference (MD): -2.55 days, 95% CI: -4.06 to -1.04, I2 = 85%, GRADE: moderate) and may have fewer pain episodes (pooled MD: -0.3, 95% CI: -0.51 to -0.09, GRADE: low) but a higher incidence of retrograde ejaculation by 5% compared to those receiving tamsulosin. In conclusion, compared to tamsulosin, silodosin provided significantly better stone passage for patients with ureteral stones (particularly for sizes of 5~10 mm), shorter expulsion times, and fewer pain episodes but caused a higher incidence of retrograde ejaculation.

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).

Medical expulsive therapy for ureteric stones: Analysing the evidence from systematic reviews and meta-analysis of powered double-blinded randomised controlled trials

Objective

To conduct a systematic review and meta-analysis investigating the efficacy and safety of medical expulsive therapy (MET) in low risk of bias (RoB) randomised controlled trials (RCTs).

Methods

A Cochrane style systematic review was conducted on published literature from 1990 to 2016, to include low RoB and a power calculation. A pooled meta-analysis was conducted.

Results

The MET group included 1387 vs 1381 patients in the control group. The analysis reveals α-blockers increased stone expulsion rates (78% vs 74%) (P < 0.001), whilst calcium channel blockers (CCBs) had no effect compared to controls (79% vs 75%) (P = 0.38). In the subgroup analysis, α-blockers had a shorter time to stone expulsion vs the control group (P < 0.001). There were no significant differences in expulsion rates between the treatment groups and control group for stones <5 mm in size (P = 0.48), proximal or mid-ureteric stones (P = 0.63 and P = 0.22, respectively). However, α-blockers increased stone expulsion in stones >5 mm (P = 0.02), as well as distal ureteric stones (P < 0.001). The α-blocker group developed more side-effects (6.6% of patients; P < 0.001). The numbers needed to treat for α-blockers was one in 14, for stones >5 mm one in eight, and for distal stones one in 10.

Conclusion

The primary findings show a small overall benefit for α-blockers as MET for ureteric stones but no benefit with CCBs. α-blockers show a greater benefit for large (>5 mm) ureteric stones and those located in the distal ureter, but no benefit for smaller or more proximal stones. α-blockers are associated with a greater risk of side-effects compared to placebo or CCBs.

Role of silodosin as medical expulsive therapy in ureteral calculi: a meta-analysis of randomized controlled trials

The objective of this study is to investigate the efficacy of silodosin in medical expulsive therapy (MET) for ureteral stones. We conducted a systematic review and meta-analysis to determine the efficacy and safety of silodosin in MET for ureteral calculi. We searched PubMed, Embase, Medline, Central (the Cochrane Library, Issue 1,2013), Google Scholar from the inception to March 2015 for randomized controlled trials (RCTs), comparing silodosin with tamsulosin or control on ureteral stone passage. Eight RCTs with a total of 1145 ureteral stone patients (300 patients in the control group, 287 patients in the tamsulosin group, 558 patients in the silodosin group) were included in this meta-analysis. When compared with control, silodosin significantly improved expulsion rate of distal ureteral stones (RR: 1.42; 95% CI, 1.21-1.67; P < 0.0001), while there was no significant difference between silodosin and the control in expulsion rate of proximal (RR: 0.99; 95% CI, 0.69-1.43; P < 0.97) or mid (RR: 1.13; 95% CI, 0.60-2.16; P < 0.0001) ureteral stones. There was no significant difference between silodosin and tamsulosin in terms of expulsion time (WMD: -2.47; 95% CI, -5.32 to 0.39; P = 0.09), analgesic use (WMD: -0.39; 95% CI, -0.91 to 0.13; P  = 0.14) and retrograde ejaculation rate (RR: 1.85; 95% CI, 0.95-3.59; P = 0.07) in MET for distal ureteral stones. However, silodosin provided a significantly higher expulsion rate (RR: 1.25; 95% CI, 1.13-1.37; P < 0.0001) than tamsulosin for distal ureteral stones. Silodosin significantly improved expulsion rate of distal ureteral stones and was clinically superior to tamsulosin. Silodosin was ineffective in MET for proximal and mid ureteral stones. More RCT studies are needed to compare the efficacy of silodosin versus tamsulosin in MET for distal ureteral stones.

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.

Tamsulosin or Silodosin Adjuvant Treatment Is Ineffective in Improving Shockwave Lithotripsy Outcome: A Short-Term Follow-Up Randomized, Placebo-Controlled Study

INTRODUCTION

The role of α-blockers after shockwave lithotripsy (SWL) is controversial. The aim of our study was to evaluate the effect of tamsulosin and silodosin after SWL for kidney stones.

METHODS

From 2012 onward, a consecutive series of patients undergoing SWL were prospectively enrolled and randomized by closed envelopes in three groups receiving tamsulosin 0.4 mg (A), silodosin 8 mg (B), and placebo (C) daily for 21 days after SWL. Anthropometrics, stone size, and location were recorded before SWL. Visual analogue scale (VAS) score was collected at 6, 12, and 24 hours after treatment to evaluate patients' discomfort. Stone-free rate was assessed 1 and 3 weeks postoperatively. Complications and medical treatment-related adverse events (AEs) were recorded. Differences in VAS score, stone-free rate, and complications were compared among the groups.

RESULTS

Overall, 60 patients were enrolled. Mean stone sizes were 10.28 ± 2.46 mm, 10.45 ± 1.73 mm, and 9.23 ± 2.04 mm in groups A, B, and C, respectively (p = 0.474). There was no significant difference between the three groups with regard to stone location. Comparable energy was used to treat patients from the three groups. The overall 3-week stone-free rate was 53%: 58% in the tamsulosin group, 47% in the silodosin group, and 55% in the placebo group (p = 0.399). No significant differences were observed in the VAS scores reported by the groups at 6 hours (p = 1.254), 12 hours (p = 0.075), and 24 hours (p = 0.490). Overall, 12 complications were reported: 11 patients (7 in group C and 4 in group B) needed analgesics for colic, and 1 patient (group B) was surgically treated for Steinstrasse. Tamsulosin was superior to placebo (p = 0.008) and silodosin (p = 0.021) in preventing complications; no difference between silodosin and placebo (p = 0.629) was noted.

CONCLUSIONS

Tamsulosin and silodosin are ineffective in increasing stone-free rate as well as early patients' discomfort after extracorporeal lithotripsy.

Comparison of silodosin to tamsulosin for medical expulsive treatment of ureteral stones: a systematic review and meta-analysis

This study aimed at comparing the success rates of silodosin to the most commonly used for medical expulsive therapy (MET) tamsulosin for the management of ureteral stones. A systematic review using the search string: "silodosin AND (ston* OR calcu* OR expul*)" was conducted on Pubmed, SCOPUS, Web of Science, Cochrane Central Register. The Primary endpoint was the stone expulsion rate. Secondary endpoint was the time to stone expulsion. Two authors independently screened the studies depending on inclusion and exclusion criteria. Meta-analysis and forest-plot figures were calculated with the software Review Manager (RevMan 5.3.5). Variations were evaluated with the χ ² statistical method and heterogeneity with I ² index. After screening of 39 publications obtained by the initial search, three randomized controlled trials were eligible to be included in the meta-analysis. 407 patients were pooled. Favorable results were observed for silodosin in terms of stone expulsion rates with a risk ratio of 1.33 (95 % CI 1.17-1.50) (I ² = 0 %). Similarly, faster stone expulsion times were observed with silodosin when compared with tamsulosin. Mean difference -2.49 (95 % CI -3.40 to 1.58) (I ² = 89 %). This meta-analysis showed significantly higher stone expulsion rates and faster expulsion times in favor of silodosin when compared to tamsulosin.

Sildenafil citrate as a medical expulsive therapy for distal ureteric stones: A randomised double-blind placebo-controlled study

Objective

To study the effect of sildenafil citrate on spontaneous passage of distal ureteric stones (DUS).

Patients and methods

This was a randomised double-blinded placebo-controlled study of 100 patients with DUS. Inclusion criteria were: male, age 18–65 years, normal renal function, and a single radiopaque unilateral DUS of 5–10 mm. Patients were randomly allocated into two equal groups, one that received placebo and the other that received 50 mg sildenafil citrate once daily. Both investigators and patients were masked to the type of treatment. Patients self-administered the medication until spontaneous passage of the DUS. In patients where there was uncontrolled pain, fever, an increase in serum creatinine of >1.8 mg/dL, progressive hydronephrosis or no further progress after 4 weeks, a decision was taken for further treatment.

Results

In all, 47 and 49 patients were available for analysis in both the placebo and sildenafil citrate groups; respectively. Both groups were comparable for age and stone characteristics. Spontaneous expulsion occurred in 19 of 47 patients (40.4%) in the placebo group and in 33 of 49 (67.3%) in the sildenafil citrate group (P = 0.014). The mean time to stone expulsion was significantly shorter in the sildenafil citrate group (P < 0.001). A multivariable Cox proportional hazards model showed that receiving sildenafil citrate was the only independent factor that had a significant impact on stone passage with a hazard ratio of 2.7 (95% confidence interval 1.5–4.8; P < 0.001).

Conclusion

Sildenafil citrate enhances spontaneous passage of 5–10 mm DUS.

Efficacy and safety of silodosin in the medical expulsion therapy for distal ureteral calculi: a systematic review and meta-analysis

AIMS

Using a selective α-adrenoceptor blocker for medical expulsive therapy (MET) is an effective treatment approach widely used for ureteral stones. The aim of the review was to assess the efficacy and safety of silodosin in medical expulstion therapy compared with placebo and tamsulosin.

METHODS

A systematic search was performed in PubMed, Cochrane Library and Embase to identify randomized controlled trials that compared silodosin with a placebo or tamsulosin for ureteral calculi.

RESULTS

Eight publications involving a total of 1048 patients were used in the analysis, which compared silodosin with placebo and tamsulosin. We found that silodosin was effective in treating ureteral calculi in our meta-analysis and was superior to tamsulosin in its efficacy. The expulsion rate of all ureteral stones (OR 1.59, 95% CI 1.08, 2.36, P = 0.02), the expulsion rate of distal ureteral stones (OR 2.82, 95% CI 1.70, 4.67, P < 0.0001) and the expulsion time (days) of distal ureteral stones (standard mean difference (SMD) -4.71, 95% CI -6.60, -2.83, P < 0.00001) indicated that silodosin was more effective than the placebo. Moreover, expulsion rate (OR 2.54, 95% CI 1.70, 3.78, P < 0.00001), expulsion time (days) (SMD -2.64, 95% CI -3.64, -1.64, P < 0.00001) and pain episodes (P < 0.00001) indicated that silodosin was more effective than the tamsulosin. Even though silodosin had a significant increase in abnormal ejaculation compared with tamsulosin, no significant differences were observed for complications (OR 1.00, 95% CI 0.58, 1.74, P = 1.00).

CONCLUSIONS

This meta-analysis indicated that silodosin was superior to placebo or tamsulosin in the efficacy for distal ureteral calculi with better control of pain. The safety profile of silodosin was similar to tamsulosin though retrograde ejaculation was worse for silodosin use. We conclude that silodosin might have potential as a MET for ureteral stones.