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

John M Hollingsworth, Benjamin K Canales, Mary A M Rogers, Shyam Sukumar, Phyllis Yan, Gretchen M Kuntz, Philipp Dahm, John M Hollingsworth, Benjamin K Canales, Mary A M Rogers, Shyam Sukumar, Phyllis Yan, Gretchen M Kuntz, Philipp Dahm

Abstract

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.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf and declare: JMH received research grants from the Agency for Healthcare Research and Quality, the Urology Care Foundation, and Blue Cross Blue Shield of Michigan during the conduct of this study.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/5131734/bin/holj033443.f1_default.jpg
Fig 1 PRISMA diagram of trials investigating efficacy of treatment with alpha blocker in patients with ureteric stones
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/5131734/bin/holj033443.f2_default.jpg
Fig 2 Risk of bias summary showing study team’s judgments about each risk of bias domain
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/5131734/bin/holj033443.f3_default.jpg
Fig 3 Risk ratios for passage of ureteric stones in randomized controlled trials on efficacy of treatment with alpha blockers, stratified by baseline risk
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/5131734/bin/holj033443.f4_default.jpg
Fig 4 Risk ratios for passage of ureteric stones in randomized controlled trials on efficacy of treatment with alpha blockers, stratified by stone size
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/5131734/bin/holj033443.f5_default.jpg
Fig 5 Risk ratios for passage of ureteric stones in randomized controlled trials on efficacy of treatment with alpha blockers, stratified by stone location

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