Can drug treatment improve passage of ureteral stones?

This meta-analysis of low-quality studies shows that ureteral stone passage can be enhanced by treating patients with an alpha-blocker such as tamsulosin (Flomax) or the calcium channel blocker nifedipine (Procardia). Better studies may refute these findings, but for now either approach is an option. (LOE = 1a-)

Singh A, Alter HJ, Littlepage A. A systematic review of medical therapy to facilitate passage of ureteral calculi. Ann Emerg Med 2007;50(5):552-563.  [PMID:17681643]

Meta-analysis (randomized controlled trials)

Self-funded or unfunded

Various (meta-analysis)

The researchers conducting this study combined the results of small studies evaluating the effectiveness of alpha-blockers, a calcium channel blocker, or both, to increase the passage of ureteral calculi. The meta-analysis was well done. Two authors independently searched several databases, including the Cochrane database, to find randomized studies. They also conducted a hand search of urologic journals and conference proceedings. Two authors also independently abstracted data. They identified 22 studies. Only 1 study was considered to be of good quality with a Jadad score of 3 (out of a possible 5), with all the rest scoring 1 or 2. All but 1 of the studies was unblinded, and the researchers did not report on whether allocation was concealed in the studies. There was mild heterogeneity found among the alpha-blocker studies, as well as evidence of publication bias. Alpha-blockers, primarily tamsulosin, were studied in 16 trials enrolling 1235 men. Nine trials evaluated the time to stone expulsion in patients with stones of 3 mm to 18 mm in size and located in the distal portion of the ureter, with a 2-day to 6-day average improvement in time to stone passage. The calcium channel blocker was studied in 9 trials of 686 patients with an average stone size of greater than 5 mm located in all aspects of the ureter. The average reduction in time to stone expulsion was not reported, though stone passage was more likely, on average, with treatment (relative risk = 1.50; 95% CI, 1.34-1.68) over the various periods of follow-up.