Efficacy and Safety of Alfuzosin as Medical Expulsive Therapy for Ureteral Stones: A Systematic Review and Meta-Analysis

Abstract

Background: Alfuzosin has been widely used to treat benign prostatic hyperplasia and prostatitis, and is claimed to be a selective agent for the lower urinary tract with low incidence of adverse side-effects and hypotensive changes. Recently, several randomized controlled trials have reported using Alfuzosin as an expulsive therapy of ureteral stones. Tamsulosin, another alpha blocker, has also been used as an agent for the expulsive therapy for ureteral stones. It is unclear whether alfuzosin has similar efficacy as Tamsulosin in the management of ureteral stones.

Objective: To perform a systematic review and analysis of literatures comparing Alfuzosin with Tamsulosin or standard conservative therapy for the treatment of ureteral stones less than 10 mm in diameter.

Methods: A systematic literature review was performed in December 2014 using Pubmed, Embase, and the Cochrane library databases to identify relevant studies. All randomized and controlled trials were included. A subgroup analysis was performed comparing Alfuzosin with control therapy on the management of distal ureteral stones.

Results: Alfuzosin provided a significantly higher stone-free rate than the control treatments (RR: 1.85; 95% confidence interval [CI], 1.35-2.55; p<0.001), and a shorter stone expulsion time (Weighted mean difference [WMD]: -4.20 d, 95%CI, -6.19 to -2.21; p<0.001), but it has a higher complication rate (RR: 2.02; 95% CI, 1.30-3.15; p<0.01). When Alfuzosin was compared to Tamsulosin, there was no significant difference in terms of stone-free rate (RR: 0.90; 95% CI, 0.79-1.02; p = 0.09) as well as the stone expulsion time (WMD: 0.52 d, 95%CI, -1.61 to 2.64; p = 0.63). The adverse effects of Alfuzosin were similar to those of Tamsulosin (RR: 0.88; 95% CI, 0.61-1.26; p = 0.47).

Conclusions: Alfuzosin is a safe and effective agent for the expulsive therapy of ureteral stones smaller than 10 mm in size. It is more effective than therapeutic regiment without alpha blocker. It is equivalent to Tamsulosin in its effectiveness and safety profile. Adverse effects should always be kept in mind when use this class of drugs.

Fig 1. Flow diagram for reference search and selection of studies for analysis.

Fig 2. Forest plot of Alfuzosin versus control therapy.

The central square of each horizontal line represents the RR or WMD for each study. The lines demonstrate the range of the 95% CI. The vertical line at an RR of 1 or at WMD of 0 is the line of no effect. % Weight indicates the influence exerted by each study on the pooled RR or WMD. CI = confidence interval; M-H = Mantel-Haenszel; IV = inverse variance; SD = standard deviation.

Fig 3. Funnel plot of Alfuzosin versus control therapy.

Funnel plot for evaluation of publication bias. Vertical solid line represents the logarithmic transformation of the overall estimated treatment effect (ie, log [RR]), diagonal dotted lines represent pseudo–95% confidence limits for estimated treatment effect, and the circles represent treatment effects of each of the 9 studies. In the absence of publication bias, graph should represent a funnel, with individual studies clustered around the overall estimated treatment effect symmetrically.

Fig 4. Forest plot of Alfuzosin versus Tamsulosin therapy.

Refer to legend in Fig 2 for explanation.

Fig 5. Forest plot of subgroup analysis categorized by stone locations.

Refer to legend in Fig 2 for explanation.