LAUSR

Question In patients with ureteric stones, what are the efficacy and safety of -blockers? Review scope Included studies compared -blockers with placebo or control in patients with ureteric stones. Studies in which -blockers were adjuvant to surgery were excluded. Primary outcome was passage of stones. Secondary outcomes were surgical intervention, hospitalization, number of pain episodes, time to stone passage, and serious adverse events. Review methods MEDLINE, EMBASE/Excerpta Medica, Cochrane Central Register of Controlled Trials, Web of Science, and LILACS (all to Jul 2016); ClinicalTrials.gov; World Health Organization International Clinical Trials Registry Platform; reference lists; and abstracts from annual meetings of the World Congress of Endourology and SWL, European Association of Urology, and American Urological Association were searched for randomized controlled trials (RCTs). RCTs from a previous Cochrane Collaboration systematic review* were included. 55 RCTs (n =5990, mean age 41 y, 40% to 100% men), with follow-up durations of 7 to 42 days, met the selection criteria. Mean stone size was 5.7 mm. -blockers assessed were tamsulosin (40 RCTs), alfuzosin (6 RCTs), silodosin (6 RCTs), doxazosin (4 RCTs), terazosin (4 RCTs), and naftopidil (3 RCTs). 8 RCTs reported adequate allocation concealment, and 6 reported adequate blinding of outcome assessors. Main results Meta-analysis showed that -blockers increased the passage of stones and reduced the need for surgical intervention and hospitalization without increasing risk for serious adverse events (Table). -blockers also reduced time to stone passage (mean difference 3.8 d, 95% CI 4.5 to 3.1) and number of pain episodes (mean difference 0.74 episodes, CI 1.28 to 0.21). Conclusion In patients with ureteric stones, -blockers increase the passage of stones without increasing serious adverse events. *Campschroer T, Zhu Y, Duijvesz D, Grobbee DE, Lock MT. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane Database Syst Rev 2014;4:CD008509. 24691989 -blockers vs control for ureteric stones Outcomes Number of trials (n) Weighted event rates At 7 to 42 d -blockers Control RBI (95% CI) NNT (CI) Passage of stones 55 (5701) 72% 48% 49% (39 to 61) 5 (4 to 6) RRR (CI) Surgical intervention 32 (3758) 18% 41% 56% (48 to 63) 5 (4 to 6) Hospitalization 8 (1007) 3.4% 9.1% 63% (36 to 78) 18 (15 to 31) RRI (CI) NNH Serious adverse events 4 (1205) 0.73% 0.49% 49% (76 to 835) Not significant Abbreviations defined in Glossary. Weighted -blocker event rates, RBI, RRR, RRI, NNT, and CI calculated from risk ratios and control event rates in article or provided by author. Data provided by author. Commentary Current recommendations from the Canadian, American, and European urological associations support medical expulsive therapy (MET) in patients with ureteric calculi (1, 2). The systematic review by Hollingsworth and colleagues is the most comprehensive to date and shows an overall positive effect from MET. The effect was magnified in patients with larger stones (5 mm), and adverse effects were few and not severe. The major concern about this review is that the quality of a large proportion of included studies was poor. However, the benefit persisted in a sensitivity analysis including only trials with low to moderate risk for bias. The benefits of shorter time to stone passage and lower risks for hospital admission and surgical interventions outweigh the small costs and low risk for harm from the use of MET in patients with calculi 5 mm. Computed tomography (CT) scanning is required to accurately determine the size of ureteric calculi. Current evidence suggests that bedside ultrasound (US) by a trained emergency physician in lieu of initial CT in the setting of suspected nephrolithiasis results in lower cumulative radiation exposure without significant differences in high-risk diagnoses with complications (3). However, US cannot always accurately determine stone size. With this new evidence, front-line physicians are left with a choice: Increase CT imaging rates to accurately determine stone size and offer MET only to patients with stones 5 mm or treat all patients with clinical findings, including bedside US, that correlate with renal colic and risk treating some patients who will not benefit. The decision will rest on individual patient characteristics (previous stone size and need for intervention) and physician comfort with US diagnosis of renal colic and/or access to CT imaging. The associated costs, time, and ionizing radiation exposure do not justify CT imaging solely to determine patient selection for MET. This review intensifies the previously identified need for research focused on shared decision-making in renal colic (4). In the context of the systematic review by Hollingsworth and colleagues and in the absence of clinical decision rules or shared decision-making aids to identify individuals more or less likely to benefit from MET, it is reasonable to include -adrenergic antagonists as an adjunct to the conservative therapy of stone expulsion in all patients with renal colic.