EBQ:Alpha-blockers for ureteral stone expulsion: Difference between revisions
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===Trial 3===
===Trial 3===
==Conclusion==
*Alpha-blockers (tamsulosin) increase spontaneous stone passage rate for distal ureteral stones
*Number needed to treat (NNT) of approximately 4-5 for distal ureteral stones
*Benefit is most pronounced for stones 5-10mm in the distal ureter
==Major Points==
*Medical expulsive therapy (MET) with alpha-blockers facilitates stone passage by relaxing ureteral smooth muscle
*Tamsulosin 0.4mg daily is the most studied alpha-blocker for this indication
*The SUSPEND trial (2015) challenged prior positive meta-analyses, finding no benefit of tamsulosin or nifedipine
*Subsequent meta-analyses including SUSPEND still show overall benefit, primarily for larger distal stones
*Alpha-blockers also appear to reduce pain episodes and analgesic requirements during stone passage
==Study Design==
*Meta-analysis of randomized controlled trials
*Included multiple RCTs comparing alpha-blockers vs placebo or standard care for ureteral stone expulsion
==Population==
===Inclusion Criteria===
*Adults with confirmed ureteral stones (typically <10mm)
*Stones located in the distal ureter in most studies
===Exclusion Criteria===
*Stones requiring urgent intervention (complete obstruction, infection, renal failure)
*Pregnancy
*Stones >10mm in most studies
==Interventions==
*Alpha-blocker therapy (most commonly tamsulosin 0.4mg daily) for 2-4 weeks
*Control: placebo or standard analgesic care without alpha-blockers
==Outcomes==
===Primary Outcome===
*Stone passage rate: alpha-blockers associated with higher spontaneous passage rates (pooled RR approximately 1.4-1.5)
===Secondary Outcomes===
*Reduced time to stone passage
*Reduced analgesic use
*Lower rates of surgical intervention
*Side effects: orthostatic hypotension, dizziness (generally mild)
==Criticisms==
*Significant heterogeneity across included studies in terms of stone size, location, and treatment duration
*Many earlier studies were small and of lower methodological quality
*The SUSPEND trial (largest single RCT) was negative, raising questions about publication bias in earlier meta-analyses
*Benefit appears limited to larger stones (5-10mm) in the distal ureter; unclear benefit for smaller or proximal stones
*Alpha-blockers are used off-label for this indication
==Funding==
*Variable across included trials


==See Also==
==See Also==

Latest revision as of 22:50, 21 March 2026

Clinical Question

Do alpha-blockers expedite ureteral stone passage?

Pro Argument

  • Current Cochrane Review concludes: "the use of alpha-blockers in adult patients with ureteral stones appears to expedite spontaneous passage, with only minor potential adverse effects."[1][2]
  • There is evidence that the subgroup of large distal stones >5mm benefit from tamulosin (passage rate of 83.3% with tamulosin versus 61.0% with placebo)[3]

Trial 1

Trial 2

Trial 3

Con Argument

  • Although meta-analyses of previous randomized controlled trials concluded that the smooth muscle relaxant drugs tamsulosin and nifedipine assisted stone passage for people managed expectantly for ureteric colic, a randomized placebo-controlled trial demonstrated that no difference was noted between active treatment and placebo (p=0.78), or between tamsulosin and nifedipine (p=0.77).[4][5]


Trial 1

Trial 2

Trial 3

Conclusion

  • Alpha-blockers (tamsulosin) increase spontaneous stone passage rate for distal ureteral stones
  • Number needed to treat (NNT) of approximately 4-5 for distal ureteral stones
  • Benefit is most pronounced for stones 5-10mm in the distal ureter

Major Points

  • Medical expulsive therapy (MET) with alpha-blockers facilitates stone passage by relaxing ureteral smooth muscle
  • Tamsulosin 0.4mg daily is the most studied alpha-blocker for this indication
  • The SUSPEND trial (2015) challenged prior positive meta-analyses, finding no benefit of tamsulosin or nifedipine
  • Subsequent meta-analyses including SUSPEND still show overall benefit, primarily for larger distal stones
  • Alpha-blockers also appear to reduce pain episodes and analgesic requirements during stone passage

Study Design

  • Meta-analysis of randomized controlled trials
  • Included multiple RCTs comparing alpha-blockers vs placebo or standard care for ureteral stone expulsion

Population

Inclusion Criteria

  • Adults with confirmed ureteral stones (typically <10mm)
  • Stones located in the distal ureter in most studies

Exclusion Criteria

  • Stones requiring urgent intervention (complete obstruction, infection, renal failure)
  • Pregnancy
  • Stones >10mm in most studies

Interventions

  • Alpha-blocker therapy (most commonly tamsulosin 0.4mg daily) for 2-4 weeks
  • Control: placebo or standard analgesic care without alpha-blockers

Outcomes

Primary Outcome

  • Stone passage rate: alpha-blockers associated with higher spontaneous passage rates (pooled RR approximately 1.4-1.5)

Secondary Outcomes

  • Reduced time to stone passage
  • Reduced analgesic use
  • Lower rates of surgical intervention
  • Side effects: orthostatic hypotension, dizziness (generally mild)

Criticisms

  • Significant heterogeneity across included studies in terms of stone size, location, and treatment duration
  • Many earlier studies were small and of lower methodological quality
  • The SUSPEND trial (largest single RCT) was negative, raising questions about publication bias in earlier meta-analyses
  • Benefit appears limited to larger stones (5-10mm) in the distal ureter; unclear benefit for smaller or proximal stones
  • Alpha-blockers are used off-label for this indication

Funding

  • Variable across included trials

See Also

References

  1. ↑ Welch JL and Cooper DD. Systematic review Snapshot. Annals of Emergency Medicine. January 2016. 67(1):117-118.
  2. ↑ Campschroer et al. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane Databse Syst Rev. 2014(4):CD008509
  3. ↑ Furyk, JS, et al. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial. Annals of Emergency Medicine. 2016; 67(1):86-95.e2.
  4. ↑ Singh A, et al. A systematic review of medical therapy to facilitate the passage of ureteral calculi. Annals of Emerg Med. 2007; 552-563.
  5. ↑ Pickard R, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet. 2015; epub.
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