Medical Therapy to Facilitate the Passage of Stones: What Is the Evidence?

• Published in: European urology 2009-09, Vol.56 (3), p.455-471
• Main Authors: Seitz, Christian, Liatsikos, Evangelos, Porpiglia, Francesco, Tiselius, Hans-Göran, Zwergel, Ulrike
• Format: Article
• Language: English
• Subjects: Adrenergic alpha-Antagonists - therapeutic use; Biological and medical sciences; Calcium Channel Blockers - therapeutic use; Humans; Kidney Calculi - drug therapy; Medical sciences; Nephrology. Urinary tract diseases; Ureteral Calculi - drug therapy; Urinary lithiasis; Urology
• ISSN: 0302-2838; 1873-7560
• DOI: 10.1016/j.eururo.2009.06.012

Abstract Context Medical expulsive therapy (MET) for urolithiasis has gained increasing attention in the last years. It has been suggested that the administration of α-adrenoreceptor antagonists (α-blockers) or calcium channel blockers augments stone expulsion rates and reduces colic events. Objective To evaluate the efficacy and safety of MET with α-blockers and calcium channel blockers for upper urinary tract stones with and without prior extracorporeal shock wave lithotripsy (ESWL). Evidence acquisition A systematic review of the literature was performed in Medline, Embase, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews searched through 31 December 2008 without time limit. Efficacy and safety end points were evaluated in 47 randomised, controlled trials assessing the role of MET. Meta-analysis was conducted using Review Manager (RevMan) v.5.0 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). Evidence synthesis Pooling of α-blocker and calcium channel blocker studies demonstrated a higher and faster expulsion rate compared to a control group (risk ratio [RR]: 1.45 vs 1.49; 95% confidence interval [CI]: 1.34–1.57 vs 1.33–1.66). Similar results have been obtained after ESWL (RR: 1.29 vs 1.57; 95% CI: 1.16–1.43 vs 1.21–2.04). Additionally, lower analgesic requirements, fewer colic episodes, and fewer hospitalisations were observed within treatment groups. Conclusions Pooled analyses suggest that MET with α-blockers or calcium channel blockers augments stone expulsion rates, reduces the time to stone expulsion, and lowers analgesia requirements for ureteral stones with and without ESWL for stones ≤10 mm. There is some evidence that a combination of α-blockers and corticosteroids might be more effective than treatment with α-blockers alone. Renal stones after ESWL also seem to profit from MET. The vast majority of randomised studies incorporated into the present systematic review are small, single-centre studies, limiting the strength of our conclusions. Therefore, multicentre, randomised, placebo-controlled trials are needed.