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Meta-Analysis
. 2020 Nov 12;11(11):CD013393.
doi: 10.1002/14651858.CD013393.pub2.

Alpha-blockers after shock wave lithotripsy for renal or ureteral stones in adults

Makinna C Oestreich  1 , Robin Wm Vernooij  2   3 , Niranjan J Sathianathen  4 , Eu Chang Hwang  5   6 , Gretchen M Kuntz  7 , Alex Koziarz  8 , Charles D Scales  9 , Philipp Dahm  10
Affiliations
Meta-Analysis

Alpha-blockers after shock wave lithotripsy for renal or ureteral stones in adults

Makinna C Oestreich et al. Cochrane Database Syst Rev. .

Abstract

Background: Shock wave lithotripsy (SWL) is a widely used method to treat renal and ureteral stone. It fragments stones into smaller pieces that are then able to pass spontaneously down the ureter and into the bladder. Alpha-blockers may assist in promoting the passage of stone fragments, but their effectiveness remains uncertain. OBJECTIVES: To assess the effects of alpha-blockers as adjuvant medical expulsive therapy plus usual care compared to placebo and usual care or usual care alone in adults undergoing shock wave lithotripsy for renal or ureteral stones.

Search methods: We performed a comprehensive literature search of the Cochrane Library, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, several clinical trial registries and grey literature for published and unpublished studies irrespective of language. The date of the most recent search was 27 February 2020.

Selection criteria: We included randomized controlled trials of adults undergoing SWL. Participants in the intervention group had to have received an alpha-blocker as adjuvant medical expulsive therapy plus usual care. For the comparator group, we considered studies in which participants received placebo.

Data collection and analysis: Two review authors independently selected studies for inclusion/exclusion, and performed data abstraction and risk of bias assessment. We conducted meta-analysis for the identified dichotomous and continuous outcomes using RevManWeb according to Cochrane methods using a random-effects model. We judged the certainty of evidence on a per outcome basis using GRADE.

Main results: We included 40 studies with 4793 participants randomized to usual care and an alpha-blocker versus usual care alone. Only four studies were placebo controlled. The mean age of participants was 28.6 to 56.8 years and the mean stone size prior to SWL was 7.1 mm to 13.2 mm. The most widely used alpha-blocker was tamsulosin; others were silodosin, doxazosin, terazosin and alfuzosin. Alpha-blockers may improve clearance of stone fragments after SWL (risk ratio (RR) 1.16, 95% confidence interval (CI) 1.09 to 1.23; I² = 78%; studies = 36; participants = 4084; low certainty evidence). Based on the stone clearance rate of 69.3% observed in the control arm, an alpha-blocker may increase stone clearance to 80.4%. This corresponds to 111 more (62 more to 159 more) participants per 1000 clearing their stone fragments. Alpha-blockers may reduce the need for auxiliary treatments after SWL (RR 0.67, 95% CI 0.45 to 1.00; I² = 16%; studies = 12; participants = 1251; low certainty evidence), but also includes the possibility of no effect. Based on a rate of auxiliary treatments in the usual care arm of 9.7%, alpha-blockers may reduce the rate to 6.5%. This corresponds 32 fewer (53 fewer to 0 fewer) participants per 1000 undergoing auxiliary treatments. Alpha-blockers may reduce major adverse events (RR 0.60, 95% CI 0.46 to 0.80; I² = 0%; studies = 7; participants = 747; low certainty evidence). Major adverse events occurred in 25.8% of participants in the usual care group; alpha-blockers would reduce this to 15.5%. This corresponds to 103 fewer (139 fewer to 52 fewer) major adverse events per 1000 with alpha-blocker treatment. None of the reported major adverse events appeared drug-related; most were emergency room visits or rehospitalizations. Alpha-blockers may reduce stone clearance time in days (mean difference (MD) -3.74, 95% CI -5.25 to -2.23; I² = 86%; studies = 14; participants = 1790; low certainty evidence). We found no evidence for the outcome of quality of life. For those outcomes for which we were able to perform subgroup analyses, we found no evidence of interaction with stone location, stone size or type of alpha-blocker. We were unable to conduct an analysis by lithotripter type. The results were also largely unchanged when the analyses were limited to placebo controlled studies and those in which participants explicitly only received a single SWL session.

Authors' conclusions: Based on low certainty evidence, adjuvant alpha-blocker therapy following SWL in addition to usual care may result in improved stone clearance, less need for auxiliary treatments, fewer major adverse events and a reduced stone clearance time compared to usual care alone. We did not find evidence for quality of life. The low certainty of evidence means that our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.

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Conflict of interest statement

MO: none.

RV: none.

NS: none.

EH: none.

GK: none.

AK: none.

CS: none.

PD: none.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
3
3
Forest plot: alpha blocker and usual care versus usual care alone for stone clearance.
4
4
Funnel plot: stone clearance.
5
5
Forest plot: alpha blocker and usual care versus usual care alone for auxiliary treatment.
6
6
Funnel plot: auxiliary treatment.
7
7
Forest plot: alpha blocker and usual care versus usual care alone for major adverse events.
8
8
Funnel plot: stone clearance time.
1.1
1.1. Analysis
Comparison 1: Alpha‐blocker and usual care versus usual care alone, Outcome 1: Stone clearance
1.2
1.2. Analysis
Comparison 1: Alpha‐blocker and usual care versus usual care alone, Outcome 2: Auxiliary treatment
1.3
1.3. Analysis
Comparison 1: Alpha‐blocker and usual care versus usual care alone, Outcome 3: Major adverse events
1.4
1.4. Analysis
Comparison 1: Alpha‐blocker and usual care versus usual care alone, Outcome 4: Stone clearance time
2.1
2.1. Analysis
Comparison 2: Alpha‐blocker and usual care versus usual care: stone location subgroup (renal and proximal ureter versus distal ureter), Outcome 1: Stone clearance
2.2
2.2. Analysis
Comparison 2: Alpha‐blocker and usual care versus usual care: stone location subgroup (renal and proximal ureter versus distal ureter), Outcome 2: Auxiliary treatment
2.3
2.3. Analysis
Comparison 2: Alpha‐blocker and usual care versus usual care: stone location subgroup (renal and proximal ureter versus distal ureter), Outcome 3: Major adverse events
3.1
3.1. Analysis
Comparison 3: Alpha‐blocker and usual care versus usual care: stone location subgroup (renal versus ureter; post hoc), Outcome 1: Stone clearance
3.2
3.2. Analysis
Comparison 3: Alpha‐blocker and usual care versus usual care: stone location subgroup (renal versus ureter; post hoc), Outcome 2: Auxiliary treatment
3.3
3.3. Analysis
Comparison 3: Alpha‐blocker and usual care versus usual care: stone location subgroup (renal versus ureter; post hoc), Outcome 3: Major adverse events
4.1
4.1. Analysis
Comparison 4: Alpha‐blocker and usual care versus usual care: stone size subgroup, Outcome 1: Stone clearance
5.1
5.1. Analysis
Comparison 5: Alpha‐blocker and usual care versus usual care: alpha‐blocker type subgroup, Outcome 1: Stone clearance
5.2
5.2. Analysis
Comparison 5: Alpha‐blocker and usual care versus usual care: alpha‐blocker type subgroup, Outcome 2: Auxiliary treatment
5.3
5.3. Analysis
Comparison 5: Alpha‐blocker and usual care versus usual care: alpha‐blocker type subgroup, Outcome 3: Major adverse events
6.1
6.1. Analysis
Comparison 6: Alpha‐blockers and usual care versus usual care: risk of bias (sensitivity analysis), Outcome 1: Stone clearance
6.2
6.2. Analysis
Comparison 6: Alpha‐blockers and usual care versus usual care: risk of bias (sensitivity analysis), Outcome 2: Auxiliary treatment
6.3
6.3. Analysis
Comparison 6: Alpha‐blockers and usual care versus usual care: risk of bias (sensitivity analysis), Outcome 3: Major adverse events
7.1
7.1. Analysis
Comparison 7: Alpha‐blocker and usual care versus usual care: single SWL session (sensitivity analysis), Outcome 1: Stone clearance
7.2
7.2. Analysis
Comparison 7: Alpha‐blocker and usual care versus usual care: single SWL session (sensitivity analysis), Outcome 2: Auxiliary treatment
7.3
7.3. Analysis
Comparison 7: Alpha‐blocker and usual care versus usual care: single SWL session (sensitivity analysis), Outcome 3: Major adverse events
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD013393

References

References to studies included in this review

Agarwal 2009 {published data only}
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Bhagat 2007 {published data only}
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Hammoud 2014 {published data only}
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Han 2006 {published data only}
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Hong 2012 {published data only}
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Janane 2014 {published data only}
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Kang 2009 {published data only}
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Kim 2008 {published data only}
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Kobayashi 2008 {published data only}
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Küpeli 2004 {published data only}
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Lanchon 2017 {published data only}
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Liu 2009 {published data only}
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Micali 2007 {published data only}
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Mohamed 2013 {published data only}
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Naja 2008 {published data only}
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Park 2013 {published data only}
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Qadri 2014 {published data only}
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Rakesh 2015 {published data only}
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Seungok 2009 {published data only}
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Shaikh 2018 {published data only}
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Sighinolfi 2010 {published data only}
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Singh 2011a {published data only}
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Singh 2011b {published data only}
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Tajari 2009 {published data only}
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Teleb 2015 {published data only}
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Vicentini 2011 {published data only}
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Wang 2008 {published data only}
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References to studies excluded from this review

2nd ESD "Experts in Stone Disease" Conference {published data only}
    1. N/A. 2nd ESD "Experts in Stone Disease" Conference. Urolithiasis 2014;42(6):not provided.
Choi 2008 {published data only}
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Georgiev 2011 {published data only}
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Hussein 2010 {published data only}
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NCT00209131 {published data only}
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NCT00409227 {published data only}
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NCT00454402 {published data only}
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NCT00478998 {published data only}
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NCT01010048 {published data only}
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NCT01560091 {published data only}
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Pirzada 2011 {published data only}
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Wang 2009 {published data only}
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References to other published versions of this review

Oestreich 2019
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