Effects of terazosin and tolterodine on ureteral stent related symptoms: a double-blind placebo-controlled randomized clinical trial

Comparison of the efficacy and complications of tolterodine and α-adrenergic receptor blockers in improving ureteral stent-related symptoms: A systematic review and meta-analysis

OBJECTIVE

We conducted a systematic evaluation of the therapeutic efficacy and complications of tolterodine and α-adrenergic receptor blockers in alleviating ureteral stent-related symptoms.

METHODS

Until August 2023, we conducted a comprehensive literature search on PubMed, Embase, Web of Science, and Cochrane Library to identify randomized controlled trials evaluating the efficacy and complications of tolterodine and α-adrenergic receptor blockers in treating ureteral stent-related symptoms. Two reviewers independently screened studies and extracted data. The scores from various domains of the Ureteral Stent Symptom Questionnaire (USSQ) were summarized and compared, and statistical analysis was performed using RevMan 5.4.0 software.

RESULTS

A total of 8 studies met the inclusion criteria for our analysis. These studies were conducted at different centers. All studies were randomized controlled trials, involving a total of 487 patients, with 244 patients receiving α-adrenergic receptor blockers and 243 patients receiving tolterodine. The results showed that tolterodine demonstrated significantly better improvement in body pain (MD, 1.56; 95% CI [0.46, 2.66]; p = 0.005) (MD, 0.46; 95% CI [0.12, 0.80]; p = 0.008) (MD, 3.21; 95% CI [1.89, 4.52]; p = 0.00001) among patients after ureteral stent placement compared to α-adrenergic receptor blockers at different time points. Additionally, at 4 weeks, tolterodine showed superior improvement in general health (MD, 0.15; 95% CI [0.03, 0.27]; p = 0.01) and urinary symptoms (MD, 1.62; 95% CI [0.59, 2.66]; p = 0.002) compared to α-adrenergic receptor blockers, while at 6 weeks, tolterodine showed better improvement in work performance (MD, -1.60; 95% CI [-2.73, -0.48]; p = 0.005) compared to α-adrenergic receptor blockers. Additionally, the incidence of dry mouth (RR, 4.21; 95% CI [1.38, 12.87]; p = 0.01) is higher with the use of tolterodine compared to α-adrenergic receptor blockers. However, there were no significant statistical differences between the two drugs in other outcomes.

CONCLUSION

This meta-analysis suggests that tolterodine is superior to α-adrenergic receptor blockers in improving physical pain symptoms after ureteral stent placement, while α-adrenergic receptor blockers are more effective than tolterodine in enhancing work performance. Additionally, the incidence of dry mouth is higher with the use of tolterodine compared to α-adrenergic receptor blockers. However, higher-quality randomized controlled trials are needed to further investigate this issue.

Treatment of Ureteral Stent-Related Symptoms

BACKGROUND

The aim of the study was to assess the effectiveness of the main classes of drugs used at reducing morbidity related to ureteric stents.

SUMMARY

After establishing a priori protocol, a systematic electronic literature search was conducted in July 2019. The randomized clinical trials (RCTs) selection proceeded in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and was registered (PROSPERO ID 178130). The risk of bias and the quality assessment of the included RCTs were performed. Ureteral Stent Symptom Questionnaire (USSQ), International Prostate Symptom Score (IPSS), and quality of life (QoL) were pooled for meta-analysis. Mean difference and risk difference were calculated as appropriate for each outcome to determine the cumulative effect size. Fourteen RCTs were included in the analysis accounting for 2,842 patients. Alpha antagonist, antimuscarinic, and phosphodiesterase (PDE) inhibitors significatively reduced all indexes of the USSQ, the IPSS and QoL scores relative to placebo. Conversely, combination therapy (alpha antagonist plus antimuscarinic) showed in all indexes of the USSQ, IPSS, and QoL over alpha antagonist or antimuscarinic alone. On comparison with alpha blockers, PDE inhibitors were found to be equally effective for urinary symptoms, general health, and body pain parameters, but sexual health parameters improved significantly with PDE inhibitors. Finally, antimuscarinic resulted in higher decrease in all indexes of the USSQ, the IPSS, and QoL relative to alpha antagonist.

KEY MESSAGE

Relative to placebo, alpha antagonist alone, antimuscarinics alone, and PDE inhibitors alone have beneficial effect in reducing stent-related symptoms. Furthermore, there are significant advantages of combination therapy compared with monotherapy. Finally, PDE inhibitors are comparable to alpha antagonist, and antimuscarinic seems to be more effective than alpha antagonist alone.

The efficacy of alpha-1A blocker (tamsulosin), antimuscarinic (solifenacin) and their combination in the management of double-J stent-related lower urinary tract symptoms: a randomized controlled study

Background

The insertion of a double-J (DJ) stent is considered a routine and necessary urological procedure. It can cause lower urinary tract symptoms (LUTS). Pharmacologic management is one of many trials that were done to improve these symptoms, particularly the administration of alpha-1A blockers and antimuscarinics medications. This trial aimed to evaluate the efficacy of alpha-1A blocker (tamsulosin), antimuscarinic (solifenacin), and their combination in managing DJ stent-related LUTS.

Methods

This prospective, randomized, comparative, and nonblinded trial was conducted between November 2016 and October 2018. Eligible patients were between 18 and 50 years of both genders who underwent temporary retrograde unilateral Double-J stent fixation. Patients were randomized to four groups; group I was control (drug-free), group II received tamsulosin 0.4 mg, group III received solifenacin 5 mg, and group IV received the combination of tamsulosin and solifenacin. All patients completed the IPSS, QoL, and VAS questionnaires at both pre-insertion day of the stent and 2 weeks postoperatively; the data obtained were compared to all four groups.

Results

The study included 143 patients (78 males, 65 females). There was no statistically significant difference between the four groups regarding age, sex, side, and DJ placement indications. In comparison with the control group, there were statistically significant differences in all scores in favor of groups II, III, and IV. Compared to groups II and III, there were statistically significant differences in overall IPSS, QoL, and VAS scores in group IV. No significant differences were found between the tamsulosin and solifenacin groups.

Conclusion

The alpha-1A blocker (tamsulosin) or antimuscarinic (solifenacin) monotherapy effectively improves the DJ stent-related LUTS and the QoL of patients with no advantage with either drug. The combination therapy of both pharmacotherapies is significantly effective than drug monotherapy.

Endoscopic Management of Ureteric Stones: Our Initial Experience

Aims:

The aim of this study is to present our initial experience with intracorporeal pneumatic ureterolithotripsy highlighting the pattern of patients’ clinical presentation, techniques, and limitation of the procedure.

Materials and Methods:

This is a retrospective study of cases of ureteric stones managed over a period of 18 months in a private hospital. Data obtained include patients’ sociodemography, clinical presentation, stone burden, procedural technique, complication, and need for a secondary procedure. Data were analyzed using the Statistical Package for the Social Sciences version 21.

Results:

The total number of patients managed was 20 with an age range of 28–75 years and a mean of 48.2 ± 12.4 years. Majority of them, i.e., 11 (55%) were middle aged. Female gender was more predominant, 11 (55%). Flank pain was the most common mode of presentation. Right-sided stone occurred in 9 (45%), left sided in 7 (35%), and bilateral in 4 (20%). Stone location was in the upper ureter in 4 (16.7%), mid-ureter in 7 (29.2%), and lower ureter in 13 (54.2%). The stone size ranged from 6 to 18 mm with a mean of 9.7 ± 2.5 mm. Four patients (20%) required initial bilateral ureteric stenting before definitive procedure to allow for recovery from sepsis and/or nephropathy. All patients had double-J stenting and were discharged 2 days after the procedure. The procedure was successful in 19 (95%) with 100% stone clearance rate and complete resolution of symptom without any complication. One patient (5%) had a very hard upper ureteric stone which retropulsed into the renal pelvis requiring open nephrolithotomy.

Conclusion:

Endoscopic treatment of ureteric stone with intracorporeal pneumatic lithotripsy is a safe and effective treatment modality. It is, however, limited in the management of hard upper ureteric stone, especially those that are close to the pelviureteric junction due to the risk of retropulsion of the stone into the kidney.

Effects of naftopidil on double-J stent-related discomfort: a multicenter, randomized, double-blinded, placebo-controlled study

To evaluate the effect of naftopidil 75 mg once daily for ureteral double-J (DJ) stent-related discomfort after a ureteroscopic procedure using a multicenter, randomized, double-blinded, placebo-controlled study. 100 patients with indwelled retrograde DJ ureteral stents after ureteroscopic stone removal or retrograde intrarenal surgery (RIRS) were randomized 1:1 to receive either placebo or naftopidil during the stenting period. At the time of stent removal, the Ureteral Stent Symptom Questionnaire (USSQ), the International Prostate Symptom Score and the total amount of used analgesics were reported. Of the 92 patients who completed the study, 49 patients were enrolled in the placebo group, and 43 patients in the naftopidil group. USSQ urinary symptom scores (30.90 vs. 29.23, p = 0.299) and USSQ body pain scores (22.28 vs. 19.58, respectively, p = 0.286) were lower in the naftopidil group than in the placebo group, but the difference was not significant. Multivariate analysis showed that the use of a ureteral access sheath during RIRS was the only significant predictor of postoperative DJ-related pain (OR = 2.736, p = 0.031). The use of naftopidil once daily did not significantly reduce DJ ureteral stent-related discomfort. Larger-scaled prospective studies should be conducted to evaluate the effects of naftopidil on DJ stent-related symptoms and surgeries.

Effects of Tamsulosin and Tolterodine on double J stent-related symptoms: A double-blind, randomized, placebo-controlled trial

Background:

Ureteral double J stent are routinely applied for urologic patients although stent-related symptoms are common. Several attempts have been reported to minimize these symptoms.

Objective:

To compare Tolterodine, Tamsulosin, and placebo effects on double J stent–related symptoms.

Material and method:

In all, 125 patients (82 males and 43 females) with double J stent were randomly divided into three groups (group 1, n: 42, group2, n: 40 and group 3, n: 43). Each patient randomly received one pack of drug in different colors by a nurse unaware of the content to take Tamsulosin 0.4 mg before sleep (MODALUSINE), Tolterodine 2 mg twice a day or placebo once daily (capsules filled with starch): group 1 received placebo, group 2 Tamsulosin and group 3 Tolterodine for 1 month in a double-blind manner. Ureteral stent-related morbidity indices which analyzed include urinary symptom, pain, general health, quality of work and sex scores. All of indices measured by Ureteral Symptom Score Questionnaire for first and fourth weeks after drug consumption and the first week after double J stent removal (labeled as w1, w4, and w5, respectively).

Result:

The mean age was 44.8 years (range: 15–83 years). There was no statistically significant difference in background characteristics between groups (p value > 0.05). The most important and statistically significant results were Tolterodine-reduced urinary symptom score (p value = 0.001) and improved general health score (p value = 0.007) of the fourth week. The pain score in groups of Tamsulosin and Tolterodine significantly reduced between weeks 4 and 1 and 5 and 1 (both with the p value < 0.05), but in other indices, there was no significant difference between them.

Conclusion:

According to our results, we suggest Tolterodine to minimize stent-related urinary symptom and improve general health in patients with double J stent.

PRISMA-combined α-blockers and antimuscarinics for ureteral stent-related symptoms: A meta-analysis

BACKGROUND

As a monotherpay, a-blockers and anti-muscarinics are both efficacy for ureteral stent-related symptoms (SRS). The aim of the study was to systematically evaluate their efficacy of a combination therapy for SRS.

METHODS

Relevant studies investigating α-blockers and/or anti-muscarinics for SRS were identified though searching online databases including PubMed, EMBASE, Cochrane Library, and other sources up to March 2016. The RevMan software was used for data analysis, and senesitivity analysis and inverted funnel plot were also adopted.

RESULTS

Seven randomized controlled trials (RCTs) and 1 prospective controlled trial including 545 patients were selected. Compared with α-blockers, the combination group achieved significant improvements in total International Prostate Symptom Score (IPSS) [-3.93 (2.89, 4.96), P < 0.00001], obstructive subscore [-1.29 (0.68, 1.89), P < 0.0001], irritative subscore [-2.93 (2.18, 3.68), P < 0.00001], and quality of life score [-0.99 (0.42, 1.55), P < 0.001]. Compared with antimuscarinics, there were also significant differences in total IPSS [-3.49 (2.43, 4.55), P < 0.00001], obstructive subscore [-1.40 (0.78, 2.01), P < 0.00001], irritative subscore [-2.10 (1.30, 2.90), P < 0.00001], and quality of life score [-1.18 (0.58, 1.80), P < 0.001] in favor of combination group. No significant difference was found in the visual analog pain score and the urinary symptoms score in Ureteral Stent Symptom Questionnaire (USSQ). No significant difference in complications was found.

CONCLUSIONS

Current analysis shows significant advantages of combination therapy compared with monotherapy of α-blockers or antimuscarinics alone mainly based on IPSS. More RCTs adopting validated USSQ as outcome measures are warranted to support the finding.

Combination therapy only shows short-term superiority over monotherapy on ureteral stent-related symptoms - outcome from a randomized controlled trial

Background

Controversy remains on the superiority of combination therapy over monotherapy on ureteral stent-related symptoms (SRSs). We tend to explore if there is a necessity of combination therapy.

Methods

One hundred cases of unilateral upper urinary tract calculi with stent insertion (pre and post flexible ureteroscopy) were randomized into 4 groups, given non-treatment, solifenacin, tamsulosin or combination respectively. Eight times of follow-ups were given after each insertion.

Results

SRSs released spontaneously within 4 days after insertion (p = 0.017) but then stay with no further improvement. Benefit of solifenacin on flank pain started showing after day4 (p = 0.002), which was comparable to that of tamsulosin and combination (p = 0.914 vs 0.195). Combination therapy showed superiority over both monotherapy before day4, but after then solifenacin and tamsulosin showed similar effectiveness with the combination therapy on both bladder pain (p = 0.229 vs 0.394) and urgency (p = 0.813 vs 0.974). No improvement on hematuria or frequency was observed in each group.

Conclusions

Combination therapy takes effect faster but shows no supervisory after the first few days compared with monotherapy.

Trial registration

The study protocol was registered on Chinese Clinical Trial Register on April 17th, 2013 (registration number: ChiCTR-TRC-13003148).

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-016-0186-y) contains supplementary material, which is available to authorized users.

Efficacy of α-blocker in improving ureteral stent-related symptoms: a meta-analysis of both direct and indirect comparison

Objective

To critically evaluate the efficacy of an α-blocker in improving ureteral-stent-related symptoms and preliminarily investigate the difference between different types of α-blockers.

Methods

Relevant randomized controlled trials were identified through searching PubMed, the Cochrane Library, Embase, and other sources. After quality assessment and data abstraction, direct comparison based on the Ureteral Stent-related Symptom Questionnaire (USSQ) between α-blockers and control was performed by RevMan 5.3. Indirect comparison between different types of α-blockers was performed by ITC 1.0. Sensitive and subgroup analyses were used to handle important clinical factors.

Results

Sixteen randomized controlled trials containing 1,489 cases were included. Compared with control, α-blockers significantly reduced the overall urinary symptom, pain index, general health index, and scores related to sexual matters, while no significant difference was found in work performance and additional problem scores. Subgroup analysis showed that the duration of stent insertion, patient’s age, stent size, and the type of α-blocker had the potential to influence the outcomes. Through indirect comparison, we found alfuzosin and terazosin to be better than tamsulosin in pain relief and general health improvement.

Conclusion

α-Blocker was effective in treating ureteral stent-related symptoms, as it improved the major indexes of USSQ post-insertion or post-removal. Alfuzosin and terazosin seemed to be better than tamsulosin, which needs further verification because of the lack of direct comparison currently.

α1-blockers for the reduction of ureteric stent-related symptoms: A systematic review and meta-analysis

The present meta-analysis aimed to evaluate the current evidence for the use of α₁-blockers in relieving ureteric stent-related symptoms (USS). Electronic databases, including PubMed, Embase and Cochrane Library, were searched and two independent reviewers identified relevant parallel randomized controlled trials (RCTs), assessed trial quality and extracted data. Review Manager (version 5.2) was used to conduct a meta-analysis of the data. Significant advantages were demonstrated in the treatment group based on International Prostate Symptom Score (IPSS), voiding symptom sub-scores [mean difference (MD), -2.66; 95% confidence interval (CI), (-4.36, -0.96)], Ureteral Stent Symptom Questionnaire (USSQ) urinary symptoms score (MD, -5.84; 95%CI, -9.35 to -2.33), IPSS quality of life score (MD, -1.46; 95%CI, -2.64 to -0.28) USSQ quality of life score (MD, -0.69; 95%CI, -1.10 to -0.28), USSQ pain score (MD, -3.97; 95%CI, -5.52 to -2.42), Visual Analog Pain Scale (MD, -1.53; 95%CI, -2.25 to -0.80) and USSQ general health score (MD, -1.82; 95%CI, -2.47 to -1.18). No significant differences were detected from the following results: IPSS storage symptom sub-score (MD, -0.93; 95%CI, -2.28 to 0.43), USSQ sexual matters score (MD, -0.10; 95%CI, -0.79 to 0.59), USSQ work performance score (MD, 1.64; 95%CI, -2.18 to 5.47) and USSQ additional problems score (MD, -2.02; 95%CI, -4.55 to 0.52). However, significant between-trial heterogeneity was detected following statistical analysis and there were insufficient data to trace its source. The existing RCT data supported the hypothesis that α₁-blockers beneficially influence pain, urinary symptoms and the quality of life of patients with an indwelling ureteral stent.

Effects of α-Blockers, Antimuscarinics, or Combination Therapy in Relieving Ureteral Stent-Related Symptoms: A Meta-Analysis

PURPOSE

We evaluated the effects of α-blockers, antimuscarinics, or a combination of both in reducing ureteral stent-related symptoms.

METHODS

The relevant studies were identified by searching MEDLINE, EMBASE and Cochrane Library Database from January 2000 to May 2014. Randomized controlled trials evaluating effects of α-blocker, antimuscarinic, and combination therapy for stent-related symptoms were included. Two reviewers independently screened studies and extracted data.

RESULTS

A total of 13 articles were identified including 1408 patients. There were statistically significant differences in urinary symptom (-6.37; P<0.0001) and body pain index score (-7.03; P=0.0008) of the Ureteral Stent Symptom Questionnaire (USSQ), total International Prostate Symptom Score (IPSS) (-4.16; P=0.0006), Visual Analogue Pain Scale (VAPS) score (-2.48; P<0.00001), and quality of life (QoL) (-1.42; P=0.0009) in favor of the α-blocker group. Antimuscarinics alone vs the control group showed significant improvement in total IPSS (mean difference [MD]: -3.76; 95% confidence interval [CI], -5.08 to -2.43; P<0.00001) and QoL (MD: -0.82; 95% CI, -1.31 to -0.32; P=0.001). Compared with α-blockers monotherapy, combination therapy has significant lower total IPSS (MD: -3.74; 95% CI, -4.94 to -2.54; P<0.00001), VAPS (MD: -0.50; 95% CI, -0.89 to -0.11; P=0.01), and QoL (MD: -0.93; 95% CI, -1.30 to -0.55; P<0.00001).

CONCLUSIONS

Our data showed the beneficial effect of α-blockers alone and antimuscarinics alone in reducing stent-related symptoms. Furthermore, we suggested significant advantages of combination therapy of α-blocker and antimuscarinic compared with α-blocker monotherapy. However, more high quality, randomized controlled trials are warranted to better address this issue, however.