Hollingsworth JM, Canales BK, Rogers MA, et al.   Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis.
BMJ. 2016 Dec 1;355:i6112. doi: 10.1136/bmj.i6112.   (Systematic Review)   PMID: 27908918
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Nephrology
Emergency Medicine
Surgery - Urology
General Internal Medicine-Primary Care(US)
General Practice(GP)/Family Practice(FP)

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Abstract
OBJECTIVE: To investigate the efficacy and safety of alpha blockers in the treatment of patients with ureteric stones.
DESIGN: Systematic review and meta-analysis.
DATA SOURCES: Cochrane Central Register of Controlled Trials, Web of Science, Embase, LILACS, and Medline databases and scientific meeting abstracts to July 2016. REVIEW
METHODS: Randomized controlled trials of alpha blockers compared with placebo or control for treatment of ureteric stones were eligible. : Two team members independently extracted data from each included study. The primary outcome was the proportion of patients who passed their stone. Secondary outcomes were the time to passage; the number of pain episodes; and the proportions of patients who underwent surgery, required admission to hospital, and experienced an adverse event. Pooled risk ratios and 95% confidence intervals were calculated for the primary outcome with profile likelihood random effects models. Cochrane Collaboration`s tool for assessing risk of bias and the GRADE approach were used to evaluate the quality of evidence and summarize conclusions.
RESULTS: 55 randomized controlled trials were included. There was moderate quality evidence that alpha blockers facilitate passage of ureteric stones (risk ratio 1.49, 95% confidence interval 1.39 to 1.61). Based on a priori subgroup analysis, there seemed to be no benefit to treatment with alpha blocker among patients with smaller ureteric stones (1.19, 1.00 to 1.48). Patients with larger stones treated with an alpha blocker, however, had a 57% higher risk of stone passage compared with controls (1.57, 1.17 to 2.27). The effect of alpha blockers was independent of stone location (1.48 (1.05 to 2.10) for upper or middle stones; 1.49 (1.38 to 1.63) for lower stones). Compared with controls, patients who received alpha blockers had significantly shorter times to stone passage (mean difference -3.79 days, -4.45 to -3.14; moderate quality evidence), fewer episodes of pain (-0.74 episodes, -1.28 to -0.21; low quality evidence), lower risks of surgical intervention (risk ratio 0.44, 0.37 to 0.52; moderate quality evidence), and lower risks of admission to hospital (0.37, 0.22 to 0.64; moderate quality evidence). The risk of a serious adverse event was similar between treatment and control groups (1.49, 0.24 to 9.35; low quality evidence).
CONCLUSIONS: Alpha blockers seem efficacious in the treatment of patients with ureteric stones who are amenable to conservative management. The greatest benefit might be among those with larger stones. These results support current guideline recommendations advocating a role for alpha blockers in patients with ureteric stones. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration No CRD42015024169.

Comments from Clinical Raters
Emergency Medicine
This article helps a lot to clarify the topic.
Emergency Medicine
The issue is still not clear as the quality of the included studies is low.
Emergency Medicine
Longstanding debate in our specialty. This SR makes a good argument for restricting the use of MET to larger stones, which is a practice-changer.
Emergency Medicine
Significant back-and-forth on this therapy for acute symptomatic nephrolithiasis over the past decade. Data seem to indicate limited role for this therapy to larger kidney stones, but urology consultants seem reluctant to abandon these medications. It would be compelling to understand why urology clings to this therapy given constellation of study findings.
Emergency Medicine
This is a nice overview of alpha blocker for ureteral stones/colic that helps refute previous under-powered studies suggesting that alpha-blockers do not work. In addition, these results support that alpha-blockers are most effective for larger stones, presumably because smaller stones will pass spontaneously anyway.
General Practice(GP)/Family Practice(FP)
Excellent article with very practical patient-oriented evidence.
Nephrology
This well conducted systematic review shows that alpha blockers facilitate passage of 5-10 mm diameter ureteric stones, mainly if located in the lower ureter. This treatment decreases pain, decreases the need for surgical treatment, and could shorten hospital stay. Four patients would need to be treated for one patient to realize benefit. This is a relatively low number, therefore, the treatment should be proposed to all patients who share the characteristics of those included in this review.
Surgery - Urology
This is a useful contribution to a subject that is still under debate.
Surgery - Urology
A very important topic. There has been lot of discussion about this recently after a few controversial publications on the subject. The limitations of the review are listed in the manuscript, but the authors have done the best possible review with the available data. The methodology is robust.