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

Pooled-analysis of tadalafil and tamsulosin for ureteral calculi

Objective

Urolithiasis is a common urological diseases and affects the daily life of patients. Medical expulsive therapy has become acceptable for many parents. We conducted a meta-analysis to determine the efficacy and safety of tadalafil compared with tamsulosin for treating distal ureteral stones less than 10 mm in length.

Methods

Related studies were identified via searches of the PubMed, Embase, and Cochrane Library databases. All the articles that described the use of tadalafil and tamsulosin for treating distal ureteral stones were collected.

Results

A total of 14 studies were included in our meta-analysis. Our results revealed that tadalafil enhanced expulsion rate [odds ratio (OR) = 0.68, 95% confidence interval (CI): 0.47 to 0.98, p = 0.04]; reduced expulsion time [mean difference (MD) = 1.22, 95% CI (0.13, 2.30), p = 0.03]; lowered analgesia use [MD = 38.66, 95% CI (7.56, 69.77), p = 0.01] and hospital visits [MD = 0.14, 95% CI (0.06, 0.22), p = 0.0006]. According to our subgroup analysis, either tadalafil 5 mg or 10 mg did not promote expulsion rate and accelerate expulsion time compared with tamsulosin. But patients receiving 5 mg tadalafil decreased analgesia usage [MD = 101.04, 95% CI (67.56, 134.01), p < 0.00001].

Conclusion

Compared with tamsulosin, tadalafil demonstrates a higher expulsion rate and less expulsion time for patients with distal ureteral stones less than 10 mm with a favorable safety profile.

Renal Colic Pain Management by Tamsulosin with Morphine Versus Morphine in Adults: A Randomized Clinical Trial

Background

Acute renal colic is one of the most painful situations in patients' life. The best management modality for pain alleviation is of paramount importance.

Objectives

This study aimed to evaluate the effect of intravenously administered morphine and oral tamsulosin compared to the independent use of morphine in patients with renal colic.

Methods

This double-blind clinical trial was conducted on 200 patients aged 18 to 55 years with renal colic referred to the tertiary level referral hospital. The patients were randomly assigned to two groups, A and B. The subjects in group A were treated with intravenously administered morphine and oral tamsulosin hydrochloride capsules, while group B received morphine and control. The patients' pain intensity was evaluated using a visual analog scale.

Results

The mean age of the patients was 35.34 ± 8.32, and 72% were males. Before the study, the mean pain intensity was higher in the tamsulosin group (8.67 ± 1.53) than in the control group (7.85 ± 2.05; P = 0.003). After four and six hours, the mean pain intensity was significantly lower in the tamsulosin group (P = 0.028 and P = 0.008, respectively). According to the results, the pain intensity was significantly reduced six hours after the treatment compared to the pre-therapy phase (P < 0.001).

Conclusions

Given the significant effect of tamsulosin on pain alleviation in patients with renal colic, this medicine can be used as a complementary treatment to manage the pain in these patients and reduce the administration of narcotics.

The effect of tamsulosin in postoperative urinary retention: a meta-analysis of randomized controlled trials

Tamsulosin is a therapeutic drug of alpha-adrenergic antagonists. Previous randomized controlled trials and retrospective analyses have proved the efficacy of tamsulosin on many urinary system diseases. However, there is still a conflict about whether tamsulosin could prevent postoperative urinary retention (POUR). This meta-analysis aims to probe into the efficacy of tamsulosin for preventing POUR versus placebo. We searched MEDLINE, EMBASE, and Cochrane Library from December 31, 1999 to April 30, 2022, for randomized controlled trials (RCTs). Studies that were not RCTs or without negative controls were excluded. Cochrane Collaboration harmonized criteria were used to assess the risk of bias in included studies. Revman (version 5.3) software was invited to synthesize the results. We performed subgroup analyses to explore the factors that could influence tamsulosin's efficacy in POUR prevention. Our meta-analysis pooled 13 RCTs with 2163 patients. We concluded that tamsulosin brought about a significant reduction in the risk of POUR versus placebo (13.54% vs 20.88% for tamsulosin vs placebo, RR = 0.63, 95% CI 0.47 to 0.84, P = 0.002). Tamsulosin could significantly reduce the risk of POUR in abdominal (11.52% vs 20.25% for tamsulosin vs placebo, RR = 0.52, 95% CI 0.31 to 0.88, P = 0.02) and female pelvic surgery (15.57% vs 31.50% for tamsulosin vs placebo, RR = 0.51, 95% CI 0.31 to 0.82, P = 0.006) but not in spinal surgery (13.45% vs 12.75% for tamsulosin vs placebo, RR = 1.07, 95% CI 0.72 to 1.60, P = 0.73) and lower limb surgery (21.43% vs 33.33% for tamsulosin vs placebo, RR = 0.64, 95% CI 0.35 to 1.14, P = 0.13). The preventive effect of postoperative (17.70% vs 33.93% for tamsulosin vs placebo, RR = 0.53, 95% CI 0.33 to 0.85, P = 0.008) and postoperative with preoperative tamsulosin (13.96% vs 23.44% for tamsulosin vs placebo, RR = 0.64, 95% CI 0.43 to 0.93, P = 0.02) on POUR were significantly better than preoperative management (11.95% vs 14.63% for tamsulosin vs placebo, RR = 0.62, 95% CI 0.23 to 1.65, P = 0.34). Postoperative catheter placement appears to have a negative impact on the POUR-preventive effect of tamsulosin. (9.37% vs 16.46% for tamsulosin vs placebo, RR = 0.51, 95% CI 0.31 to 0.83, P = 0.007) Tamsulosin showed significantly effect on POUR prevention in patients during spinal (15.07% vs 26.51% for tamsulosin vs placebo, RR = 0.52, 95% CI 0.31 to 0.90, P = 0.02) and epidural anesthesia (12.50% vs 29.79% for tamsulosin vs placebo, RR = 0.42, 95% CI 0.18 to 1.00, P = 0.05) but not in general anesthesia (12.40% vs 18.52% for tamsulosin vs placebo, RR = 0.68, 95% CI 0.45 to 1.03, P = 0.07). Tamsulosin shows better outcomes for preventing POUR than placebo. Besides, tamsulosin showed a different effect on POUR prevention in the various surgical sites, anesthesia, medication management, and catheter use. However, our conclusions still have some limitations due to the lack of evidence.

Are adrenergic α1- antagonists beneficial for the access of retrograde ureteral access sheath or semi-rigid ureteroscope access? A systematic review and meta-analysis

Introduction

To evaluate the clinical benefit of preoperative adrenergic α1-antagonist therapy in the management of upper urinary calculi.

Materials and methods

Publications were searched for The Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE until 1 March 2022 that related to the adrenergic α1- antagonist intake as adjunctive therapy before retrograde surgery. Dichotomous data were reported with risk ratios (RR) with 95% confidence intervals (CIs) and the continuous data were reported with mean difference (MD) with 95% CIs.

Results

There were nine studies with 867 patients included in this meta-analysis. Preoperative adrenergic α1- antagonists could significantly elevate the compared with the placebo. Higher successful access rate to the stone was found in patients who received preoperative adrenergic α1- antagonists than those who received the placebo (RR 1.24; 95% CI 1.17-1.33). Besides, the application of preoperative adrenergic α1- antagonists can also elevate 4th-week stone-free rate (RR 1.20; 95% CI 1.12-1.28), decrease postoperative analgesia (RR 0.30;95% CI 0.20-0.46) and result in a lower risk of overall complications (RR 0.38; 95% CI 0.24-0.61).

Conclusion

Preoperative adjunctive adrenergic α1- antagonist therapy is effective and safe in the management of retrograde surgery with a higher successful access rate and lower risk of severe complications.

The effect of preoperative tamsulosin on ureteroscopic access in school-aged children

INTRODUCTION

Flexible ureteroscopes are not tailored for pediatric ureteral size and may not pass at first attempt into the pediatric ureter. Administration of tamsulosin preoperatively in adults has been shown to facilitate ureteral access sheath placement. Several studies have shown tamsulosin to be safe and effective when utilized for medical expulsive therapy in pediatric patients, but its utility for preoperative ureteral dilation has not been studied to date.

OBJECTIVE

We hypothesized that preoperative tamsulosin reduces failed ureteroscopic access in children.

MATERIALS AND METHODS

We conducted a retrospective review of patients aged 0-18 years undergoing flexible ureteroscopy (URS) from 2014 to 2019 at a single institution. Patients were divided into those taking 0.4 mg of tamsulosin daily for at least 1 week prior to surgery and those not taking tamsulosin. The primary outcome was failure to pass a 7.95 Fr flexible ureteroscope on initial attempt, requiring stent placement and staged management. Patients undergoing URS or stent placement within the prior year, requiring semi-rigid URS, or with genitourinary anomalies were excluded.

RESULTS AND DISCUSSION

A total of 49 patients met inclusion criteria. The tamsulosin group (n = 13) and non-tamsulosin group (n = 36) were similar with respect to demographic data. The percentage of prepubertal patients was 53% vs 33% (p = 0.19). The tamsulosin group had lower failed URS (38% vs 61%, p = 0.20). When stratified by age, both prepubertal and postpubertal patients in the tamsulosin group had lower failed URS (43% vs 67%, p = 0.67 and 33% vs 58%, p = 0.38). These clinically significant results suggest initial passage of a flexible ureteroscope is more successful in pediatric patients on preoperative tamsulosin. This study was largely limited by its low power and flaws inherent to its retrospective design.

CONCLUSION

Our results have implications for prescribing tamsulosin preoperatively to reduce multiple procedures and anesthetics in children. Adequately powered prospective trials are warranted to confirm preoperative tamsulosin reduces failed first-attempt flexible URS in children.

Ultrasound Diagnosis and Active Ureteroscopy for Obstructive Ureteral Calculi during Pregnancy: Multicenter Experience

Objectives: To evaluate the safety and efficacy of ultrasound (US) and primary ureteroscopy (URS) in the management of symptomatic obstructive ureteric stones during pregnancy. Patients and Methods: A prospective multicenter study was performed between June 2013 and December 2019, including all consecutive pregnant patients admitted to three urology centers with intractable renal colic with obstructed ureter secondary to obstructive ureteral calculi. Color Doppler ultrasound was used to evaluate renal Resistive Index (RI) and ureter jet. Primary URS was performed to remove the blocking stones. The safety and effectiveness of the procedures were assessed, as well as the stone-free rate (SFR) and the condition of the upper tract after delivery. Results: A total of 111 pregnant patients were included with a mean age of 27.4 ± 4.4 years and a mean renal RI of 0.78 ± 0.02. US diagnosed stones in 46.8% of patients, while 100 (90%) patients had altered lower ureter urinary jet, including 86.5% who had URS-confirmed ureteric stones; SFR was 95.8% with no serious urologic, fetal, or obstetric complications. Nine percent of patients had premature delivery, which was significantly correlated with postoperative urinary tract infection and premature uterine contraction (p ˂ 0.0001). In the third-month follow-up of US, all patients showed no residual hydronephrosis. Postoperative follow-up procedures were required in 15.3% of patients. Conclusion: Obstructive ureteral stones during pregnancy can be detected safely and appropriately with a combined elevated renal RI and absent ureteral jet detected by Doppler US. Definitive URS is an efficient and safe alternative option for those who fail in conservative management.

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.

Is Medical Therapy for Distal Ureteral Stones Efficient? Tamsulosin versus Deflazacort: A Prospective Randomised Trial

INTRODUCTION

 To evaluate the efficacy of tamsulosin and deflazacort in the spontaneous expulsion of distal ureteral stones when applied in an independent or combined manner.

METHODS

 134 patients with distal ureteral stones (4 - 10 mm) were included in tothe study. All patients were randomized into four groups: group 1 (n = 37) patients receiving tamsulosin (0.4 mg/day); group 2 (n = 26) patients receiving deflazacort (30 mg/day); group 3 (n = 37) patients receiving combined treatment (tamsulosin and deflazacort) with the same dosages; and group 4, control group cases (n = 34), receiving paracetamol on demand. Although deflazacort treatment was limited to 10 days due to the possible associated side effects, α-blocker and paracetamol lasted up to four weeks. Patients were followed up on a weekly basis and at the end of four weeks all groups were compared primarily with respect to the stone expulsion rates.

RESULTS

 No statistically significant difference was noted between all groups regarding the age, sex, or stone burden (p > 0.05). Spontaneous stone expulsion rates after 4 weeks were 64.8 %, 69.2 %, 75.7 %, and 26.4 % in group 1, 2, 3, and 4 respectively. Spontaneous passage rates were statistically higher in all treatment groups when compared with the control group. Despite the highest spontaneous stone expulsion rate noted in group 3; this difference was not statistically significant when compared with the group 1 and 2. No major side effect related to the medications was observed.

CONCLUSIONS

 Tamsulosin facilitated the spontaneous passage of distal ureteral stones < 10 mm in size in an effective manner particularly when applied in combination with an oral corticosteroid.

Efficacy and Safety of Alpha-Blockers for Kidney Stones in Adults

Objective: To review the literature for α-blocker treatment of kidney stones. Data Sources: PubMed search performed November 15, 2017, using the following search terms: alpha-blocker, alfuzosin, silodosin, or tamsulosin AND kidney or ureteral stones. Additional studies found through references of primary and tertiary literature. Inclusion criteria included English language, randomized controlled trials (not included in meta-analyses), and meta-analyses evaluating US available alpha-blockers as medical expulsive therapy with or without lithotripsy in adults with renal or ureteral stones, and no date limits. Study Selection and Data Extraction: Seven randomized controlled trials (RCTs), 1 case-control trial, and 6 meta-analyses were found and included in this review. Two RCTs and 4 meta-analyses evaluated alpha-blockers without lithotripsy. Five RCTs, 1 case-control trial, and 2 meta-analyses evaluated their use post-lithotripsy. The primary endpoint was stone clearance rate in most studies. Data Synthesis: For ureteral stones ≤10 mm treated without lithotripsy, alpha-blockers increased clearance in all meta-analyses and one RCT versus control. For ureteral or renal stones treated with lithotripsy, 4 RCTs and all meta-analyses found benefit with alpha-blockers compared with control. When results were stratified by stone size, alpha-blockers performed better for stones 10 to 20 mm, while there was no difference for stones <10 mm. Conclusion: Alpha-blockers are beneficial without lithotripsy for ureteral stones 5 to 10 mm. They are beneficial post-lithotripsy for renal or ureteral stones >10 mm. They can be considered post-lithotripsy for stones 5 to 10 mm, but little benefit may be seen. Although all uroselective alpha-blockers have been found to be effective, most data are with tamsulosin 0.4 mg daily.

Factors Affecting the Success Rate of Percutaneous Nephrolithotomy in Paediatric Patients

In this study, we aimed to determine factors affecting the success rate of percutaneous nephrolithotomy (PNL) in children. The series consisted of 41 consecutive children operated on by the same surgical team for renal calculi with PNL between June 2002 and May 2015 in our institution. A single calyx or pelvic stone was described as simple, while calculi located in more than one location (calyx and pelvis or more than one calices) or staghorn stones were described as complex. The procedure was deemed successful if the patient was completely stone-free (SF) or had residual fragments <4 mm. Thirty-four patients were found to be SF or had residual fragments <4 mm on the postoperative first day, thus the success rate was 82.9%. In complex stones, the success rate was significantly lower (45.5%) than simple stones (96.7%) (p < 0.001). The grade of hydronephrosis (Grade 0–1 vs. Grade 2–3) also had a negative impact on the success, with rates of 92.6% vs. 64.3%, respectively (p = 0.022). Previous urological procedure history on the same side yielded a success rate of 58.3%, whereas the success rate in the primary patients was 93.1% (p < 0.001). The localization of the stone (complex vs. simple), degree of hydronephrosis, and history of previous urological procedures were found to be the factors that affected the success of the paediatric PNL.

Do Preoperative Alpha Blockers Facilitate Ureteroscope Insertion at the Vesico-Ureteric Junction? An Answer from a Prospective Case-Controlled Study

Objective: To evaluate whether alpha blockers facilitate the navigation of the ureteroscope through the ureteric orifice, if administered preoperatively, based on the role of alpha blockers, mainly tamsulosin, in medical expulsive therapy of ureteric calculus. Methods: A prospective, case-control study of 174 patients who underwent ureteroscopic stone removal for lower or mid ureteral calculi between November 2014 and March 2016 was carried out. We included patients >14 years of age who were planned for ureteroscopic stone removal. We divided the patients into two groups, including those who were not prescribed alpha blockers prior to surgery (Group A: no alpha blocker) and those patients who were started on alpha blockers, tamsulosin 0.4 mg, 3 days prior to surgery (Group B: alpha blocker). We excluded patients with stone size >1 cm, spontaneous stone passage prior to surgery, unable to perform ureteroscopy (URS), and previous history of ureteroscopic intervention. Results: Our study included 124 patients, among whom 60 patients were prescribed alpha blockers preoperatively (Group B). The mean age of the study population was 37.62+9.74 (15–64 years) and the mean stone burden was 38.92+8.21 (15.94–58.12 mm2). The difference in rate of ureteroscope negotiation through the ureteric orifice between Groups A and B was not statistically significant (p=0.57). Conclusions: In URS, preoperative administration of alpha blockers failed to improve technical ease and lower complication rate. Further large group, multi-centre studies are required todiscover a definitive role of alpha blockers prior to URS.

The efficacy and safety of adrenergic alpha-antagonists in treatment of distal ureteral stones in pediatric patients: A systematic review and meta-analysis

OBJECTIVE

We carried out a systematic review and meta-analysis to evaluate the efficacy and safety of adrenergic alpha-antagonists as a medical expulsive therapy for ureteral stones in pediatric patients.

METHODS

The PubMed, EMBASE and Cochrane Controlled Trials Register databases were searched up to January 2016. All randomized controlled trials and all cohort studies in which patients were randomized to receive either adrenergic alpha-antagonists or placebo for ureteral stones were identified. The outcome measures assessed were overall stone expulsion rate (primary), expulsion time (secondary), and treatment-emergent adverse events.

RESULTS

Five trials with a total of 406 pediatric patients met the inclusion criteria. According to the doses of adrenergic alpha-antagonists, the pooling effects of adrenergic alpha-antagonists were analyzed, with a higher expulsion rate obtained than in controls, the stone expulsion rate (OR=2.70, 95% CI 1.49 to 4.91, P=0.001). Adrenergic alpha-antagonists statistically did not significantly decrease the number of the stone expulsion time with the placebo, the stone expulsion time (SMD=-4.65, 95% CI -9.76 to 0.45, P=0.07). Safety assessments included common treatment-emergent adverse events (TEAEs) (OR=2.01, 95% CI 0.74 to 5.48, P=0.17). Compared with placebos, there was a higher stone expulsion rate with the adrenergic alpha-antagonists; in addition, fewer adverse effects were observed.

CONCLUSIONS

This meta-analysis may suggest that adrenergic alpha-antagonists are a safe and effective medical expulsive therapy choice for ureteral stones in pediatric patients. As the level of classification of evidence-based medicine, the level of evidence of our article is Ia. But it remains to need a large-scale multicenter randomized controlled study to be further confirmed.

LEVEL OF EVIDENCE

The level of evidence of our study is V.

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.

Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo-controlled, randomised controlled trial and cost-effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin) (the SUSPEND trial)

BACKGROUND

Ureteric colic, the term used to describe the pain felt when a stone passes down the ureter from the kidney to the bladder, is a frequent reason for people to seek emergency health care. Treatment with the muscle-relaxant drugs tamsulosin hydrochloride (Petyme, TEVA UK Ltd) and nifedipine (Coracten(®), UCB Pharma Ltd) as medical expulsive therapy (MET) is increasingly being used to improve the likelihood of spontaneous stone passage and lessen the need for interventional procedures. However, there remains considerable uncertainty around the effectiveness of these drugs for routine use.

OBJECTIVES

To determine whether or not treatment with either tamsulosin 400 µg or nifedipine 30 mg for up to 4 weeks increases the rate of spontaneous stone passage for people with ureteric colic compared with placebo, and whether or not it is cost-effective for the UK NHS.

DESIGN

A pragmatic, randomised controlled trial comparing two active drugs, tamsulosin and nifedipine, against placebo. Participants, clinicians and trial staff were blinded to treatment allocation. A cost-utility analysis was performed using data gathered during trial participation.

SETTING

Urology departments in 24 UK NHS hospitals.

PARTICIPANTS

Adults aged between 18 and 65 years admitted as an emergency with a single ureteric stone measuring ≤ 10 mm, localised by computerised tomography, who were able to take trial medications and complete trial procedures.

INTERVENTIONS

Eligible participants were randomised 1 : 1 : 1 to take tamsulosin 400 µg, nifedipine 30 mg or placebo once daily for up to 4 weeks to make the following comparisons: tamsulosin or nifedipine (MET) versus placebo and tamsulosin versus nifedipine.

MAIN OUTCOME MEASURES

The primary effectiveness outcome was the proportion of participants who spontaneously passed their stone. This was defined as the lack of need for active intervention for ureteric stones at up to 4 weeks after randomisation. This was determined from 4- and 12-week case-report forms completed by research staff, and from the 4-week participant self-reported questionnaire. The primary economic outcome was the incremental cost per quality-adjusted life-year (QALY) gained over 12 weeks. We estimated costs from NHS sources and calculated QALYs from participant completion of the European Quality of Life-5 Dimensions health status questionnaire 3-level response (EQ-5D-3L™) at baseline, 4 weeks and 12 weeks.

RESULTS

Primary outcome analysis included 97% of the 1167 participants randomised (378/391 tamsulosin, 379/387 nifedipine and 379/399 placebo participants). The proportion of participants who spontaneously passed their stone did not differ between MET and placebo [odds ratio (OR) 1.04, 95% confidence interval (CI) 0.77 to 1.43; absolute difference 0.8%, 95% CI -4.1% to 5.7%] or between tamsulosin and nifedipine [OR 1.06, 95% CI 0.74 to 1.53; absolute difference 1%, 95% CI -4.6% to 6.6%]. There was no evidence of a difference in QALYs gained or in cost between the trial groups, which means that the use of MET would be very unlikely to be considered cost-effective. These findings were unchanged by extensive sensitivity analyses around predictors of stone passage, including sex, stone size and stone location.

CONCLUSIONS

Tamsulosin and nifedipine did not increase the likelihood of stone passage over 4 weeks for people with ureteric colic, and use of these drugs is very unlikely to be cost-effective for the NHS. Further work is required to investigate the phenomenon of large, high-quality trials showing smaller effect size than meta-analysis of several small, lower-quality studies.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN69423238. European Clinical Trials Database (EudraCT) number 2010-019469-26.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 63. See the NIHR Journals Library website for further project information.

The use of alpha-1 adrenergic blockers in children with distal ureterolithiasis: a systematic review and meta-analysis

INTRODUCTION

Urinary lithiasis is the main urologic cause of emergency treatment in adult patient. In the past years, the incidence in children population has increased. However, literature about the use of alpha-1 adrenergic blockers in pediatric population with distal ureterolithiasis is still scarce. The drug acts by decreasing ureter contractions, especially in the distal portion, facilitating calculus expulsion.

OBJECTIVE

This review has the objective to evaluate the use of alpha-1 adrenergic blockers as medical expulsive treatment in children with distal ureterolithiasis.

EVIDENCE ACQUISITION

An electronic literature search was performed using the MEDLINE, COCHRANE, and LILACS databases. We further searched manually the references of the primary studies. Searches were concluded on October 4th, 2014. Articles were selected, independently and in pairs, by the respective titles and summaries. Any divergence was resolved by consensus.

EVIDENCE SYNTHESIS

Alpha-1 adrenergic antagonists increased the probability of calculus expulsion by 27% (NNT=4). Calculi smaller than 5mm, increased by 33% (NNT=3). Larger than 5mm, increased by 34% (NNT=3).

CONCLUSION

Alpha-1 adrenergic blocker use is related with a greater incidence of expulsion of ureteral calculi, smaller or greater than 5mm, and fewer episodes of pain when compared to ibuprofen. However it is necessary larger samples to enhance the power analysis of the expulsion of ureteral calculi larger than 5mm and the episodes of pain.

PATIENT SUMMARY

This review analyzed the outcome of alpha adrenergic antagonist in children with ureteral calculi. We conclude that it is the best medicine for use, since it helps the expulsion of the stone.

Efficacy and Safety of Alfuzosin as Medical Expulsive Therapy for Ureteral Stones: A Systematic Review and Meta-Analysis

Background

Alfuzosin has been widely used to treat benign prostatic hyperplasia and prostatitis, and is claimed to be a selective agent for the lower urinary tract with low incidence of adverse side-effects and hypotensive changes. Recently, several randomized controlled trials have reported using Alfuzosin as an expulsive therapy of ureteral stones. Tamsulosin, another alpha blocker, has also been used as an agent for the expulsive therapy for ureteral stones. It is unclear whether alfuzosin has similar efficacy as Tamsulosin in the management of ureteral stones.

Objective

To perform a systematic review and analysis of literatures comparing Alfuzosin with Tamsulosin or standard conservative therapy for the treatment of ureteral stones less than 10 mm in diameter.

Methods

A systematic literature review was performed in December 2014 using Pubmed, Embase, and the Cochrane library databases to identify relevant studies. All randomized and controlled trials were included. A subgroup analysis was performed comparing Alfuzosin with control therapy on the management of distal ureteral stones.

Results

Alfuzosin provided a significantly higher stone-free rate than the control treatments (RR: 1.85; 95% confidence interval [CI], 1.35–2.55; p<0.001), and a shorter stone expulsion time (Weighted mean difference [WMD]: -4.20 d, 95%CI, -6.19 to -2.21; p<0.001), but it has a higher complication rate (RR: 2.02; 95% CI, 1.30–3.15; p<0.01). When Alfuzosin was compared to Tamsulosin, there was no significant difference in terms of stone-free rate (RR: 0.90; 95% CI, 0.79–1.02; p = 0.09) as well as the stone expulsion time (WMD: 0.52 d, 95%CI, -1.61 to 2.64; p = 0.63). The adverse effects of Alfuzosin were similar to those of Tamsulosin (RR: 0.88; 95% CI, 0.61–1.26; p = 0.47).

Conclusions

Alfuzosin is a safe and effective agent for the expulsive therapy of ureteral stones smaller than 10 mm in size. It is more effective than therapeutic regiment without alpha blocker. It is equivalent to Tamsulosin in its effectiveness and safety profile. Adverse effects should always be kept in mind when use this class of drugs.

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.

The differential pupillary response to 2.5% phenylephrine in patients taking tamsulosin

PURPOSE

To determine if a pharmacological test could be developed to determine iris dilator dysfunction in patients taking tamsulosin.

METHODS

Patients taking tamsulosin and controls were recruited from the Urology and Ophthalmology clinics at the Montefiore Medical Center. The patient's right eye (OD) was dilated with phenylephrine hydrochloride 2.5% and tropicamide 1%. The patient's left eye (OS) was dilated with tropicamide 1% alone. Forty minutes after dilation, pupillary diameter was measured in both eyes.

RESULTS

Thirty-eight tamsulosin subjects and 43 controls met the inclusion criteria for the study. The tamsulosin-treated patients dilated less with phenylephrine than controls (0.61±0.4 vs. 1.10±0.45 mm, respectively P<0.001). Receiver operating characteristic curves comparing maximal pupillary dilation versus differential pupillary dilation in tamsulosin patients relative to controls shows a greater area under the curve for differential dilation (0.8 vs. 0.6, respectively). A correlation between smooth muscle dysfunction and length of time on tamsulosin was observed. Patients using tamsulosin for <1 month had an average OD-OS difference of 0.85±0.5 mm. Patients who were on tamsulosin for >1 month had an average OD-OS difference of 0.52±0.32 mm (P<0.01, Mann-Whitney).

CONCLUSION

Patients treated with tamsulosin demonstrated a significantly decreased iris dilatory response to the selective adrenergic effects of phenylephrine compared to controls. Additionally, it appears that longer duration of exposure to tamsulosin increases the likelihood of dilator dysfunction.

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.

Current status of ureteroscopy for stone disease in pregnancy

Ureteroscopic management of urolithiasis in pregnancy has been on the rise. Technological advancements such as the development of the semi-rigid or flexible ureteroscope, improvements in the design of baskets used for retrieval and the availability of laser have enabled atraumatic fragmentation of stones. We did a systematic review of literature from January 1990 to December 2012. Data were analysed separately for the time period from January 1990 to June 2010 (Period 1) and for last 2.5 years from July 2010 to December 2012 (Period 2). Inclusion criteria were all English language articles with at least three patients reported. Data were extracted on the outcomes and complications reported in the literature. A total of 271 procedures (116 in period 1, 155 in period 2) across 21 studies were reported in the last 22 years. General anaesthesia was used in 38% (44/116) in period 1 and in 64% (99/155) in period 2. The average stone size (7.6 mm) and stone-free rate (SFR) (85%) were similar in both time periods. Fluoroscopy was used in 20% (23/116) and 24% (38/155) in period 1 and 2, respectively. There were fewer complications in period 1 (n = 9) than period 2 (n = 25). These complications were divided into obstetric (n = 5) and non-obstetric complications (n = 29). There were no maternal or foetal deaths during the 22 years. Stone treatment using ureteroscopic techniques in pregnancy can achieve a high success rate. Evidence suggests a rise in the risk of complications with increasing number of these procedures in pregnancy.

Does the endoscopic treatment of lower ureter stones affect uroflowmetric values? A prospective clinical trial

OBJECTIVES

The aim of this study was to document if stones at the lower ureter alter the micturition capability of the patients and to investigate whether endoscopic removal of these stones restores normal urinary flow rates or not in the 3 months of follow-up.

METHODS

Forty patients with lower ureteral stone (group 1) and 20 control subjects with proximal ureteral stone (group 2) were enrolled into the study. All patients underwent uroflowmetry testing before and 3 months after the treatment for endoscopic stone removal. The mean average and peak flow rates with a sufficient voided volume (≥150 ml) were evaluated before and after surgery and compared between the groups.

RESULTS

Mean values of the peak flow rates before and after surgery were 20.3 and 27.5 ml/s in group 1 and 22.5 and 23.6 ml/s in group 2, and the mean average flow rate values before and after surgery were 10.5 and 13.6 ml/s in group 1 and 11.4 and 12.1 ml/s in group 2. Statistically significant differences were determined between before and after ureteroscopy values were determined in terms of average (p < 0.05) and peak flow rates (p < 0.01) in group I; however, there no significant difference was seen in the control group.

CONCLUSION

We document for the first time in the literature that patients with lower ureteric stones have a reduction in their urinary stream which resolves with endoscopic removal of the stones.

Outcomes of ureteroscopy for stone disease in pregnancy: results from a systematic review of the literature

INTRODUCTION

Our aim was to evaluate the clinical efficacy and safety of ureteroscopy as a primary treatment for pregnant women with symptomatic ureteric stones who have failed conservative management.

MATERIALS AND METHODS

A systematic review of the literature from January 1990 to June 2011 was performed, including all English language articles. Outcome measures were clinical efficacy, in terms of stone clearance and need for additional procedures, and safety in terms of complications.

RESULTS

A total of 239 abstracts were screened and 15 studies were identified reporting on 116 procedures. The surgical methods of stone management employed were stone extraction with basket only (n = 55, 47%), laser fragmentation (n = 27, 23%; holmium, n = 20, pulse dye, n = 7), impact lithotripsy (n = 21, 18%), ureteroscopic lithotripsy (n = 6, 5%) and a combination of methods (n = 6, 5%). A post-operative stent was inserted in 64 of 116 procedures (55%). Complete stone clearance was seen in 100 of the 116 procedures (86%). There were 2 major complications (1 ureteral perforation and 1 case of premature uterine contraction) and 7 minor complications (5 urinary tract infections and 2 cases of post-operative pain).

CONCLUSION

This review suggests that stone clearance using ureteroscopy is a relatively safe option in pregnancy with a high success rate.