Elsevier

The Lancet

Volume 368, Issue 9542, 30 September–6 October 2006, Pages 1171-1179
The Lancet

Articles
Medical therapy to facilitate urinary stone passage: a meta-analysis

https://doi.org/10.1016/S0140-6736(06)69474-9Get rights and content

Summary

Background

Medical therapies to ease urinary-stone passage have been reported, but are not generally used. If effective, such therapies would increase the options for treatment of urinary stones. To assess efficacy, we sought to identify and summarise all randomised controlled trials in which calcium-channel blockers or α blockers were used to treat urinary stone disease.

Methods

We searched MEDLINE, Pre-MEDLINE, CINAHL, and EMBASE, as well as scientific meeting abstracts, up to July, 2005. All randomised controlled trials in which calcium-channel blockers or α blockers were used to treat ureteral stones were eligible for inclusion in our analysis. Data from nine trials (number of patients=693) were pooled. The main outcome was the proportion of patients who passed stones. We calculated the summary estimate of effect associated with medical therapy use using random-effects and fixed-effects models.

Findings

Patients given calcium-channel blockers or α blockers had a 65% (absolute risk reduction=0·31 95% CI 0·25–0·38) greater likelihood of stone passage than those not given such treatment (pooled risk ratio 1·65; 95% CI 1·45–1·88). The pooled risk ratio for α blockers was 1·54 (1·29–1·85) and for calcium-channel blockers with steroids was 1·90 (1·51–2·40). The proportion of heterogeneity not explained by chance alone was 28%. The number needed to treat was 4.

Interpretation

Although a high-quality randomised trial is necessary to confirm its efficacy, our findings suggest that medical therapy is an option for facilitation of urinary-stone passage for patients amenable to conservative management, potentially obviating the need for surgery.

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)

  • D Moher et al.

    Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement

    Lancet

    (1999)
  • R Rosenthal

    The ‘file drawer problem’ and tolerance for null results

    Psychol Bull

    (1979)
  • L Borghi et al.

    Nifedipine and methylprednisolone in facilitating ureteral stone passage: a randomized, double-blind, placebo-controlled study

    J Urol

    (1994)
  • M Dellabella et al.

    Efficacy of tamsulosin in the medical management of juxtavesical ureteral stones

    J Urol

    (2003)
  • M Dellabella et al.

    Randomized trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi

    J Urol

    (2005)
  • M Salehi et al.

    Does methylprednisolone acetate increase the success rate of medical therapy for patients with distal ureteral stones

    Eur Urol Suppl

    (2005)
  • JT Cooper et al.

    Intensive medical management of ureteral calculi

    Urology

    (2000)
  • B Kupeli et al.

    Does tamsulosin enhance lower ureteral stone clearance with or without shock wave lithotripsy?

    Urology

    (2004)
  • F Porpiglia et al.

    Effectiveness of nifedipine and deflazacort in the management of distal ureter stones

    Urology

    (2000)
  • F Porpiglia et al.

    Nifedipine versus tamsulosin for the management of lower ureteral stones

    J Urol

    (2004)
  • T Skrekas et al.

    Increasing the success rate of medical therapy for expulsion of distal ureteral stones using adjunctive treatment with calcium channel blocker

    Eur Urol Suppl

    (2003)
  • E Yilmaz et al.

    The comparison and efficacy of 3 different alpha1-adrenergic blockers for distal ureteral stones

    J Urol

    (2005)
  • WH Cordell et al.

    Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic

    Ann Emerg Med

    (1994)
  • WH Cordell et al.

    Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic

    Ann Emerg Med

    (1996)
  • A Tekin et al.

    Alpha-1 receptor blocking therapy for lower ureteral stones: a randomized prospective trial

    J Urol

    (2004)
  • R Gerber et al.

    Is newer always better? A comparative study of 3 lithotriptor generations

    J Urol

    (2005)
  • A Thornton et al.

    Publication bias in meta-analysis: its causes and consequences

    J Clin Epidemiol

    (2000)
  • Cited by (430)

    • Medical Management of Renal and Ureteral Stones

      2022, Comprehensive Pharmacology
    View all citing articles on Scopus
    View full text