ArticlesMedical therapy to facilitate urinary stone passage: a meta-analysis
Introduction
The lifetime risk of urinary stone disease (urolithiasis) is estimated to be between 5% and 12% in Europe and the USA,1, 2, 3, 4 afflicting 13% of men and 7% of women.5 Since 50% of patients will have a recurrence of renal colic within 5 years of their first episode,6 urolithiasis is a chronic disease with substantial economic consequences and great public health importance. In the USA alone, nearly 2 million outpatient visits were needed for the disease in 2000, with expenditures for inpatient and outpatient claims totalling US$2·1 billion.7
Although patients with urolithiasis might be asymptomatic, many have pain and thus commonly present to emergency or outpatient departments. Provided that these patients do not need renal pelvic decompression—ie, they do not have a solitary kidney or obstructing pyelonephritis—and that pain relief can be obtained, a trial of conservative non-surgical therapy is warranted, since many of these stones pass spontaneously. Indeed, studies have shown spontaneous passage rates of 71%–98% for small (≤5 mm) distal ureteral stones,8, 9, 10 with urinary-stone size and location being the two most important predictors of stone passage.9 In view of this relation, investigators have sought ways of assisting the process with the use of drugs, thereby reducing the need for surgical intervention.
Use of calcium-channel blockers and adrenergic α-antagonists for expulsive medical therapy has been proposed as a way to enhance stone passage. Interest in these drug classes stems from our understanding of ureteral smooth-muscle physiology and urinary obstruction.11, 12, 13, 14, 15, 16, 17 Despite growing evidence from clinical trials in support of its efficacy, expulsive therapy is rarely used. Two explanations for underuse are: first, that minimally invasive surgical techniques, such as shock-wave lithotripsy and ureteroscopy have evolved to allow for resolution of stone burden,18, 19 but carry measurable risks and are costly;18, 20, 21, 22, 23, 24, 25, 26, 27 and second, that reports of empirical data for medical therapies have appeared only in urological publications, and therefore, the availability of such therapies might not be well known to physicians from other disciplines. Since many specialists—such as emergency-department physicians, internists, and family practitioners—serve as the initial conduit into the health-care system for patients with urolithiasis, a knowledge gap might exist. Therefore, we obtained data from clinical trials to derive a quantitative estimate of ureteral-stone expulsion associated with medical therapy.
Section snippets
Eligibility criteria
We used guidelines from the Quality of Reporting of Meta-Analyses conference.28 Inclusion criteria were established before the search. Randomised controlled trials of urolithiasis in any language were eligible. Only those studies in which a calcium-channel blocker or an adrenergic α-antagonist was used as the main therapy for ureteral-stone disease were included; therefore, we excluded trials in which medical therapy was examined as an adjuvant to surgery. For the purpose of ascertaining trial
Results
415 studies were identified in the electronic database search (figure 1). The review of meeting abstracts yielded 19 additional studies. We excluded from detailed review any articles that were either non-research reports, such as editorials or commentaries, or studies on the wrong topic—eg, trials that used different interventions, trials with different outcomes measured, or observational studies.
There were five additional randomised studies that made a substantial contribution to the
Discussion
The pooled results of the randomised trials suggest that pharmacotherapy helps with passage of distal ureteral stones. Patients treated medically with calcium-channel blockers or α blockers had a 65% greater likelihood of spontaneous stone passage than did patients not given these drugs. This beneficial effect was consistent for both types of medical therapy. With the low risk-profile of these drugs and their wide therapeutic window, our results suggest that treating physicians should consider
References (55)
- et al.
Ethnic and geographic diversity of stone disease
Urology
(1997) - et al.
Time trends in reported prevalence of kidney stones in the United States: 1976–1994
Kidney Int
(2003) - et al.
Urologic Diseases of America Project. Urologic diseases in America project: urolithiasis
J Urol
(2005) - et al.
Relation of spontaneous passage of ureteral calculi to size
Urology
(1977) - et al.
Extracorporeal shock wave lithotripsy for distal ureteral calculi: what a powerful machine can achieve
J Urol
(2003) - et al.
Ureteroscopy: current practice and long-term complications
J Urol
(1997) - et al.
Complications of ureteroscopy: analysis of predictive factors
J Urol
(2001) - et al.
Ureteroscopic results and complications: experience with 130 cases
J Urol
(1988) Ureteral perforation during ureterorenoscopy: treatment and management
J Urol
(1987)- et al.
Management of ureteral calculi: a cost comparison and decision making analysis
J Urol
(2002)
Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement
Lancet
The ‘file drawer problem’ and tolerance for null results
Psychol Bull
Nifedipine and methylprednisolone in facilitating ureteral stone passage: a randomized, double-blind, placebo-controlled study
J Urol
Efficacy of tamsulosin in the medical management of juxtavesical ureteral stones
J Urol
Randomized trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi
J Urol
Does methylprednisolone acetate increase the success rate of medical therapy for patients with distal ureteral stones
Eur Urol Suppl
Intensive medical management of ureteral calculi
Urology
Does tamsulosin enhance lower ureteral stone clearance with or without shock wave lithotripsy?
Urology
Effectiveness of nifedipine and deflazacort in the management of distal ureter stones
Urology
Nifedipine versus tamsulosin for the management of lower ureteral stones
J Urol
Increasing the success rate of medical therapy for expulsion of distal ureteral stones using adjunctive treatment with calcium channel blocker
Eur Urol Suppl
The comparison and efficacy of 3 different alpha1-adrenergic blockers for distal ureteral stones
J Urol
Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic
Ann Emerg Med
Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic
Ann Emerg Med
Alpha-1 receptor blocking therapy for lower ureteral stones: a randomized prospective trial
J Urol
Is newer always better? A comparative study of 3 lithotriptor generations
J Urol
Publication bias in meta-analysis: its causes and consequences
J Clin Epidemiol
Cited by (430)
Standardization of the management of pediatric urolithiasis in the emergency department
2024, Journal of Pediatric UrologyMedical Management of Renal and Ureteral Stones
2022, Comprehensive PharmacologyUreteral calculus treated with Chinese medicine after failure of extracorporeal shock wave lithotripsy<inf>:</inf> a report of 2 cases and network pharmacology analysis
2024, Chinese Journal of Clinical ResearchManagement of Pediatric Urolithiasis in an Italian Tertiary Referral Center: A Retrospective Analysis
2023, Medicina (Lithuania)