α-blockers as medical expulsive therapy for ureteric stones: a Cochrane systematic review

Summary of the clinical practice guideline for the management of urinary stones, third edition

This third edition of the Japanese Clinical Practice Guidelines for Urinary stones (2023) has been developed under the leadership of the Japanese Urological Association, the Japanese Society of Endourology and Robotics, and the Japanese Society on Urolithiasis Research. This revision adheres to the Minds Manual for Guideline Development (2017) and incorporates new findings from a nationwide survey conducted in 2015, which highlighted the epidemiological characteristics of urolithiasis in Japan since the previous guidelines were published in 2013. A significant advancement in this edition is the systematic review (SR) methodology applied to formulate recommendations for 12 clinical questions (CQs). Both quantitative and qualitative SRs were performed, leading to recommendations determined through consensus among 21 members of the guideline development group. Additionally, nine algorithms were created to support clinical decision-making based on these findings. Topics not addressed by the CQs, considered as foundational knowledge, are outlined in an "Explanation of Related Matters" section, which includes 26 items. This article provides an overview of these guidelines. This section ensures that practitioners have access to comprehensive information, covering aspects of urolithiasis management beyond the scope of the systematic reviews. This article provides an overview of the guidelines, emphasizing their relevance and importance in improving the management and treatment outcomes for patients with urinary stones. The guidelines are designed to be a practical resource for clinicians, facilitating evidence-based care in the evolving landscape of urolithiasis treatment.

Evaluating the safety and effectiveness of α-blockers versus mirabegron for medical expulsive therapy in ureteral calculi: A Systematic review and meta-analysis

INTRODUCTION AND AIM

The main categories of drugs employed for medical expulsive therapy in patients with ureteral calculi (UC) are alpha-blockers (α-B) and beta-adrenoceptor agonists. This meta-analysis evaluated the safety and effectiveness of α-B versus mirabegron (MIR) in treating UC.

METHODS

From January 1980 to October 2024, we extensively searched the Pubmed, Web of science, Cochrane and EMBASE databases to identify randomized controlled trials (RCTs) that compared the effectiveness of α-B and MIR in managing UC. Furthermore, a systematic review and meta-analysis were carried out.

RESULTS

The meta-analysis included six publications with 592 patients, comparing α-B with MIR. The stone expulsion rate (SER) was found to be significantly greater in the α-B group than in the MIR group, as indicated by an odds ratio (OR) of 1.51 (95% confidence interval [CI]: 1.05 to 2.16, P = 0.03) in the meta-analysis. However, no significant differences were found between the α-B group and the MIR group for stone expulsion time (SET) (mean difference [MD]: 1.20; 95% CI, -2.71 to 5.10; P = 0.55), pain episodes (PE) (MD: 0.36; 95% CI, -0.04 to 0.76; P = 0.07), or analgesic requirements (MD: 0.79; 95% CI, -0.37 to 1.94; P = 0.18). The α-B group exhibited a significantly higher incidence of adverse events compared to the MIR group for orthostatic hypotension (OR 12.16, 95% CI 3.36 to 43.95, P = 0.0001), headache (OR 3.46, 95% CI 1.41 to 8.49, P = 0.007), and retrograde ejaculation (OR 16.30, 95% CI 5.87 to 45.31, P < 0.00001). While in the dizziness (OR 1.65, 95% CI 0.67 to 4.09, p = 0.28), it made no difference.

CONCLUSIONS

Our meta-analysis identified a substantial enhancement in the SER among patients with UC who received α-B therapy instead of those who were administered MIR therapy. Nonetheless, α-B therapy was connected to an increased risk of adverse events.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, ID CRD42024595934.

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

PURPOSE

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

METHODS

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

RESULTS AND CONCLUSIONS

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

Adrenoceptors in the Lower Urinary Tract

Adrenoceptors importantly contribute to the physiological regulation of lower urinary tract (LUT) function and have become a target of several clinically successful treatments for major LUT diseases. In the bladder dome, β-adrenoceptor subtypes are found in multiple cell types and mediate relaxation of detrusor smooth muscle, perhaps partly indirectly by acting on afferent nerves and cells of the mucosa. β3-adrenoceptor agonists such as mirabegron and vibegron are used to treat overactive bladder syndrome. In the bladder trigone and urethra, α1-adrenoceptors cause contraction and thereby physiologically contribute to bladder outlet resistance. α1-adrenoceptors in the prostate also cause contraction and pathophysiologically elevate bladder outlet resistance leading to voiding dysfunction in benign prostatic hyperplasia. α1-adrenoceptor antagonist such as tamsulosin is widely used as a first-line option to treat LUT symptoms in men, but it remains unclear to which extent and how smooth muscle relaxation contributes to symptom relief.

2022 Recommendations of the AFU Lithiasis Committee: Management of symptomatic urinary stones

The acute situation, caused by an obstructive stone, is defined by a renal colic that may be uncomplicated, complicated, or at risk in specific conditions. Its management may be medical or require interventional treatment by extracorporeal shockwave lithotripsy, endoscopic removal, or ureteroscopy. METHODOLOGY: These recommendations were developed using two methods, the Clinical Practice Recommendations (CPR) and the ADAPTE method, in function of whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they could be adapted to the French context.

A Comparison of Boron Supplement and Tamsulosin as Medical Expulsive Therapy for Urinary Stones After Extracorporeal Shock Wave Lithotripsy: a Randomized Controlled Clinical Trial

Treatment with alpha-blockers has been used in many studies to facilitate stone clearance after extra-corporeal shock wave lithotripsy (ESWL), based on mediating ureteral wall relaxation. Ureteral wall edema is another barrier against the stone passage. We aimed to compare the effectiveness of boron supplement (due to its anti-inflammatory effect) and tamsulosin in the passage of stone fragments after ESWL. Eligible patients after ESWL were randomly assigned to two groups and were treated with boron supplement (10 mg/BD) or tamsulosin (0.4 mg per night) for 2 weeks. The primary outcome was the stone expulsion rate according to the remained fragmented stone burden. The secondary outcomes were the time of stone clearance, pain intensity, drug side effects, and the need for auxiliary procedures. In this randomized control trial, 200 eligible patients were treated with boron supplement or tamsulosin. Finally, 89 and 81 patients in the two groups completed the study, respectively. The expulsion rate was 46.6% in the boron and 38.7% in the tamsulosin group, which there was no statistically significant difference between the two groups (p = 0.003), as well as the time of stone clearance (7.47 ± 22.4 vs 6.52 ± 18.45, days, p = 0.648, respectively), after 2-week follow-up. Moreover, pain intensity was the same in both groups. No Significant side effects were reported in the two groups. Boron supplement could be effective as adjuvant medical expulsive therapy after ESWL with no significant side effects in short-term follow-up. Iranian Clinical Trial Registration number and date of registration: IRCT20191026045244N3, 07/29/2020.

Silodosin versus Tamsulosin for Medical Expulsive Therapy of Ureteral Stones: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: This systematic review and meta-analysis of randomized controlled trials was performed to compare the therapeutic effects and safety profiles of silodosin and tamsulosin for medical expulsive therapy (MET) of ureteral stones. Materials and Methods: We searched PubMed, EMBASE, the Cochrane Library, and Web of Science to identify articles published before July 2022 that described randomized controlled trials comparing silodosin and tamsulosin for MET of ureteral stones. Endpoints were stone expulsion rate, stone expulsion time, and total complication rate. Results: In total, 14 studies were included in our analysis. The size of ureteral stones was <1 cm. Compared with tamsulosin, silodosin resulted in a significantly higher stone expulsion rate (p < 0.01, odds ratio (OR) = 2.42, 95% confidence interval (CI) = 1.91 to 3.06, I2 = 0%) and significantly shorter stone expulsion time (p < 0.01, mean difference = −3.04, 95% CI = −4.46 to −1.63, I2 = 89%). The total complication rate did not significantly differ between silodosin and tamsulosin (p = 0.33, OR = 1.15, 95% CI = 0.87 to 1.52, I2 = 7%). Conclusions: Compared with tamsulosin, silodosin resulted in significantly better expulsion of ureteral stones <1 cm. The total complication rate did not significantly differ between silodosin and tamsulosin. Thus, silodosin may be superior to tamsulosin for MET of ureter stones <1 cm.

Mirabegron attenuates porcine ureteral contractility via α1-adrenoceptor antagonism

The β₃-agonist mirabegron is thought to induce relaxation of the detrusor muscle, contributing to the improvement of overactive bladder symptoms. There has been recent interest in purposing mirabegron as a medical expulsive therapy drug to improve the passage of smaller kidney stones by relaxing the ureteral smooth muscles. The aim of this study was to determine the effects of mirabegron on the activity of the ureter. Additionally, we investigated the receptor and mechanisms through which mirabegron exerts these effects. In vitro agonist-induced responses of isolated porcine distal ureteral tissues were measured in the absence and presence of mirabegron in organ bath experiments. The responses were expressed as frequency, area under the curve and maximum amplitude. Mirabegron at concentrations of 100 nM and lower failed to suppress phenylephrine- or 5-HT-induced contractions in the porcine ureteral strip. Mirabegron at 1 μM and 10 μM produced a rightward shift of phenylephrine concentration–response curves in these tissues. This effect of mirabegron (10 μM) was not present in 5-HT concentration–response curves. The mirabegron effect on phenylephrine-induced contractions was also not abolished by β-adrenoceptor antagonist SR 59230A (10 μM), β-adrenoceptor antagonist propranolol (10 μM), α₂-adrenoceptor antagonist yohimbine (30 nM), and nitric oxide synthase inhibitor l-NNA (10 μM). The present results show that mirabegron suppresses ureteral contractile responses in the porcine ureter via α₁-adrenoceptor antagonism, since their effects were not present when the tissues were contracted with 5-HT. Furthermore, the inhibitory effects by mirabegron were not affected by β₃-adrenoceptor antagonists.

Gilaburu extract (Viburnum opulus Linnaeus) is as effective as Tamsulosin in medical expulsive therapy of distal ureteral calculi

BACKGROUND

To compare the extract of Gilaburu (Viburnum opulus Linnaeus) and Tamsulosin as a medical expulsive therapy (MET) in patients with distal ureteral calculi of 10 mm or less.

METHODS

Data of 86 patients were prospectively collected. The patients were divided into two groups. In the first group, Viburnum opulus 1000 mg peroral 3 × 2 and diclofenac 50 mg peroral on-demand (n = 43), in the second group Tamsulosin 0.4 mg peroral 1 × 1 and diclofenac 50 mg peroral on-demand (n = 43) was given for MET in patients with distal ureteral calculi. Stone expulsion rates, time until expulsion, additional analgesic requirement, need for emergency admission, need for additional treatment were evaluated. In addition, subgroup analyses of ≤5 and 5-10 mm were also performed.

RESULTS

There was no difference between the groups in terms of stone expulsion rates and time until the expulsion in all stones. Additional analgesic requirement and need for emergency admission were found to be lower in the Viburnum opulus group (37.2% vs 65.1%, P = .017 and 11.6% vs 34.8%, P = .02, respectively). In subgroup analyses, while stone expulsion rates were similar in subgroups, it was found shorter in the time until expulsion, lower additional analgesic requirement and need for emergency admission in V. opulus group than Tamsulosin group in 5-10 mm stone size subgroup (7.1 ± 4.2 vs 11.8 ± 5.2, P = .005, 32.2% vs 77.7%, P = .001 and 12.9% vs 40.7%, respectively).

CONCLUSION

V. opulus can be used effectively and safely for the treatment of MET in distal ureteral calculi.

Comparison of efficacy of various drugs used for medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis

OBJECTIVES

Medical expulsive therapy has been found to be effective for distal ureteric stones; however, which drug is most efficacious in terms of stone expulsion rate (SER) and stone expulsion time (SET) is not known. With this review we aimed to compare the efficacy of various drug treatments for distal ureter stones used as medical expulsive therapy in terms of SER and SET.

METHODS

Systematic literature search was conducted to include all the randomised study comparing various drug interventions for lower ureter stones. Standard preferred reporting items for systematic review and meta-analysis for network meta-analysis (PRISMA-NMA) were pursued.

RESULTS

In this review, 50 randomised studies with 12,382 patients were included. For stone expulsion rate (SER), compared with placebo all the treatment groups were more effective except nifedipine and sildenafil. According to the SUCRA values obtained, naftopidil plus steroid was the highest rank and nifedipine lowest. For stone expulsion time (SET), compared with placebo only tadalafil plus silodosin, nifedipine plus steroid, alfuzosin, silodosin, tadalafil and tamsulosin were more effective. SUCRA values were highest for tadalafil plus silodosin and least for naftopidil plus steroid. From subgroup analysis with individual drugs for SER, SUCRA values were highest for naftopidil followed by silodosin and SET was highest for silodosin and least for naftopidil.

CONCLUSION

For lower ureter stone, tadalafil plus silodosin is the best combination and silodosin best individual drug considering the SET and SER. Nifedipine as monotherapy is no more effective than control group.

Fragility index of urological literature regarding medical expulsive treatment

INTRODUCTION

The role of medical expulsive treatment (MET) is controversial. Fragility index is an additional metric to assess randomized controlled trials (RCTs) outcome validity and indicates how many patients would be required to convert a trial from being statistically significant, to not significant. The larger is the FI, the better the trial's data. The aim of this study is to assess FI of RCTs regarding MET for ureteral stones.

MATERIALS AND METHODS

A systematic literature search was performed. RCTs, reporting stone expulsion as a dichotomous outcome, showing statistical significance were eligible. FI (the number of patients needed to change from a non-event to event group, to lose statistical significance) and Fragility quotient (FI divided by total sample size), were calculated while Pearson's correlation and Mann-Whitney U test were used as appropriate.

RESULTS

Thirty-six RCTs were eligible, with median FI = 3.5 and fragility quotient = 0.042, median sample size = 81, median journal impact factor = 1.73 and median reported p value = 0.008. In 33.3% of the studies, number of patients lost during follow-up was larger than FI, while in 13.89% of the studies, FI was 0, indicating use of inappropriate statistical method. Pearson's correlation showed significant positive association between FI and sample size (r = 0.981), number of events (r = 0.982) and impact factor (r = 0.731), while no association was found with p value or publication year.

CONCLUSIONS

In this analysis, a calculated FI of 3.5 indicates that findings from RCTs on MET for ureteral stones are fragile and should be interpreted in combination with clinical thinking and expertise.

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.

Is physical therapy effective following extracorporeal shockwave lithotripsy and retrograde intrarenal surgery: a meta-analysis and systematic review

Background

Physical therapy, including percussion, inversion, vibration and combinations, was clinically performed to improve the stone free rate (SFR) following lithotripsy procedures. However, physical therapy is not widely accepted in clinical practice owing to lack of high level evidence support and a standard protocol. The present meta-analysis aimed to evaluate the efficacy and safety of physical therapy in improving SFR following extracorporeal shockwave lithotripsy (ESWL) and retrograde intrarenal surgery (RIRS).

Methods

Systematic review of literature from PubMed, Scopus, Cochrane library and Embase was performed in March 2019. The efficacy and safety of physical therapy after ESWL and RIRS were assessed by meta-analysis of SFR and complication rate.

Results

A total of 8 prospective studies with 1065 patients were enrolled. When compared to non-intervention, physical therapy provided a higher SFR (OR:3.38, 95% CI: 2.45–4.66, p < 0.0001) at all time points (week 1, week 2 and month 1), while there was no significant difference in complications such as hematuria, lumbago, dizziness and urinary tract infection (OR: 0.84; 95%CI: 0.62–1.13; p = 0.237). In subgroup analysis of different stone locations, lower calyx stone (OR: 3.51; 95%CI: 2.21–5.55; p < 0.0001), upper ureter and renal pelvic stones (OR:2.79; 95%CI:1.62–4.81; p = 0.0002) had a higher SFR after physical therapy, while there was no significant improvement in SFR in upper and middle calyx stones. In subgroup analysis of different techniques, EPVL (external physical vibration lithecbole, OR:3.47; 95%CI:2.24–5.37; p < 0.0001) and PDI (percussion, diuresis and inversion, OR:3.24; 95%CI:2.01–5.21; p < 0.0001) were both effective in improving SFR when compared to non-intervention.

Conclusions

Physical therapy is effective in improving the SFR after ESWL and RIRS, especially for lower calyx stones, upper ureter and renal pelvic stones, while without significant side effects. External physical vibration lithecbole (EPVL) might provide a relative uniformed and repeatable protocol for clinical practice of physical therapy.

Trial registration

PROSPERO 2019 CRD42019130228.

[Recommendations of the Urolithiasis Committee of the French Urology Association for the management and the treatment of the stone formers patients during the COVID-19 pandemic crisis]

Confrontés à une crise d’une ampleur exceptionnelle liée à la pandémie à coronavirus COVID-19 responsable d’une saturation selon les régions des urgences et des places en réanimation, le Comité Lithiase de l’Association Française d’Urologie (CLAFU) a élaboré pour la première fois les recommandations de prise en charge des calculs urinaires durant cette crise sanitaire.

Aktualisierung der S2k-Leitlinie zur Diagnostik, Therapie und Metaphylaxe der Urolithiasis (AWMF Registernummer 043-025)

Die Zunahme des medizinischen Wissens, technische Neuerungen gemeinsam mit demographischem Wandel stellen eine Herausforderung an die Neukonzeption von Leitlinien und klinischen Studien dar. Die vorliegende S2k-Leitlinie, die sich ausschließlich mit Nieren- und Harnleitersteinen beschäftigt, soll die Behandlung von Harnsteinpatienten in Klinik und Praxis unterstützen, aber auch Patienteninformationen zur Urolithiasis geben. Die zunehmende interdisziplinäre Zusammenarbeit in der Steintherapie zeigt sich auch an der Anzahl beteiligter Fachgruppen und Arbeitsgemeinschaften in der Erstellung des neuen Leitlinienupdates. Die vorliegende, aus einem interdisziplinären Konsensusprozess hervorgegangene S2k-Leitlinie stellt die aktuellen Empfehlungen praxisnah dar und gibt Entscheidungshilfen für Diagnostik‑, Therapie- und Metaphylaxemaßnahmen auf Basis von Expertenmeinungen und verfügbaren Evidenzgrundlagen aus der Literatur.

Narcotic Pain Control for Ureterolithiasis Is Associated With Unnecessary Repeat Imaging in the Emergency Department

A subset of patients with ureteral stones who present to the emergency department (ED) will return with recurring symptoms and will receive unnecessary repeat imaging. We retrospectively identified 112 patients from 2012 to 2016 diagnosed with at least one ureteral stone on computerized tomography (CT) at our institution who returned to the ED within 30 days. Patients were stratified based on the presence or absence of repeat CT scan imaging. Mean values were compared with independent t-test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of repeat imaging. Sixty-eight patients (60.7%) underwent repeat CT scan imaging upon representation to the ED within 30 days of being diagnosed with ureterolithiasis. Ureteral stone position changed in 34 patients (30.4%) who underwent repeat imaging. On univariate analysis, younger age, nondiabetics, narcotics prescribed on discharge from first ED visit, and longer mean time between ED visits were associated with repeat CT scan imaging being performed (p < .05). Only prescription of narcotic pain medications was an independent predictor of repeat CT scan imaging (odds ratio: 3.18, 95% confidence interval: 1.22-8.28; p = .018). Nonsteroidal anti-inflammatory drugs or nonnarcotic pain medications, therefore, should primarily be used for pain control in these patients to avoid unnecessary testing.