A network meta-analysis on the beneficial effect of medical expulsive therapy after extracorporeal shock wave lithotripsy

Abstract

We applied a newly introduced method, network meta-analysis, to re-evaluate the expulsion effect of drugs including tamsulosin, doxazosin, nifedipine, terazosin and rowatinex after extracorporeal shock wave lithotripsy (ESWL) as described in the literature. A systematic search was performed in Medline, Embase and Cochrane Library for articles published before March 2016. Twenty-six studies with 2775 patients were included. The primary outcome was the number of patients with successful stone expulsion. The data were subdivided into three groups according to duration of follow-up. A standard network model was established in each subgroup. In 15-day follow-up results, SUCRA outcome showed the ranking of effects was: doxazosin > tamsulosin > rowatinex > nifedipine > terazosin (88.6, 77.4, 58.6, 32.2 and 30.4, respectively). In 45-day follow-up results, SUCRA ranking was: tamsulosin > nifedipine > rowatinex (69.4, 67.2 and 62.6, respectively). In 90-day follow-up results, SUCRA ranking was: doxazosin > rowatinex > tamsulosin (84.1, 68.1 and 49.1, respectively). In conclusion, doxazosin and tamsulosin have potential to be the first choice for pharmacological therapy to promote the expulsion of urinary stone fragments after ESWL, with this doxazosin can improve the SFR in the long term, while tamsulosin may result more in accelerating the process of expulsion.

Figure 1

PRISMA study flow diagram.

Figure 2

Risk-of-bias analysis: (A) Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies. (B) Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.

Figure 3

Network meta-analysis and SUCRA rank of included medications for improving SFR after ESWL which the endpoint of revisit was less than or equal to 15 days. Tamsulosin, doxazosin, terazosin, nifedipine, rowatinex and control represented the outcome that was extracted and pooled from included studies within this subdivided period respectively. The forest plot (A) showed each MET treatment compared with control group or any two treatments compared with each other, and the mean difference with 95% CI of each comparison. Those mean differences greater than 1 favored the former one of the comparison, and those mean differences less than 1 favored the latter one. If the 95% CI was above or under than 1.00, the difference was statistically significant (p < 0.05). The SUCRA ranks were calculated through the standard network model and listed in order from high to low (B).

Figure 4

Network meta-analysis and SUCRA rank of included medications for improving SFR after ESWL which the endpoint of revisit was greater than 15 days but less than or equal to 45 days. Tamsulosin, nifedipine, rowatinex and control were involved in the forest plot (A) and the SUCRA rank calculation (B). If the 95% CI was above or under than 1.00, the difference was statistically significant (p < 0.05).

Figure 5

Network meta-analysis and SUCRA rank of included medications for improving SFR after ESWL which the endpoint of revisit was greater than 45 days but less than or equal to 90 days. Tamsulosin, doxazosin, rowatinex and control were involved in the forest plot (A) and the SUCRA rank calculation (B). If the 95% CI was above or under than 1.00, the difference was statistically significant (p < 0.05).