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

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6112 (Published 01 December 2016) Cite this as: BMJ 2016;355:i6112
  1. John M Hollingsworth, associate professor1,
  2. Benjamin K Canales, associate professor2,
  3. Mary A M Rogers, research associate professor3,
  4. Shyam Sukumar, house officer4,
  5. Phyllis Yan, statistician intermediate1,
  6. Gretchen M Kuntz, medical librarian5,
  7. Philipp Dahm, professor4
  1. 1Department of Urology, University of Michigan, 2800 Plymouth Rd, Building 16, 1st Floor, Ann Arbor, MI 48109, USA
  2. 2Department of Urology, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
  3. 3Department of Internal Medicine, Division of General Medicine, University of Michigan, 2800 Plymouth Rd, Building 16, 4th Floor, Ann Arbor, MI 48109, USA
  4. 4Minneapolis Veterans Administration Health Care System and Department of Urology, University of Minnesota, Mayo Memorial Building, 420 Delaware St SE, MMC 394, Minneapolis, MN 55455, USA
  5. 5Borland Library, University of Florida, 653-1 W 8th St, Jacksonville, FL 32209, USA
  1. Correspondence to: J M Hollingsworth kinks{at}med.umich.edu
  • Accepted 2 November 2016

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.

Footnotes

  • Contributors: JMH and BKC are joint first authors. All authors were involved in the conception and design of the review. JMH, BKC, GMK, and PD developed the search strategy and performed study selection. JMH, BKC, SS, PY, and PD extracted data from included studies. MAMR and PY were involved in the data analysis. JMH, BKC, MAMR, PY, and PD were involved in the interpretation and discussion of results. JMH drafted the manuscript, and MAMR, PY, and PD contributed to the drafting of the review. BKC, SS, and GMK revised it critically for important intellectual content. All authors approved the final version of the article. All authors had access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. JMH is guarantor.

  • Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

  • 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.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

  • Transparency: The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; no important aspects of the study have been omitted.

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