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Three Part Question

In [patients presenting to the Emergency Department with urinary calculi] does [tamsulosin (Flomax)] compared to conservative therapy [increase the rate of spontaneous stone passage]?

Clinical Scenario

A patient presents to the Emergency Department with a 6 mm calculi in the left distal ureter. You wonder if the use of tamsulosin would improve the chances of spontaneous stone passage.

Search Strategy

Medline 1950-05/07 using the OVID interface, Cochrane Library (2007), PubMed clinical queries.
[(exp ureteral obstruction/ or exp ureteral calculi/) AND (exp adrenergic alpha-antagonists/ or tamsulosin.mp.)]. LIMIT to human AND English

Search Outcome

21 papers were found, of which 11 papers were irrelevant to the study question or of insufficient quality for inclusion. One paper was a recent meta-analysis (2006) which included all the relevant RCTs on tamsulosin.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Parsons JK, Hergan LA, Sakamoto K, Lakin C March 2007 USA	911 participants with the use of any alpha-blocker in the therapy arm and use of conservative therapy (ie fluids and pain control) in at least 1 control arm.	Meta-analysis of randomized, controlled clinicals trial that assessed spontaneous stone expulsion as either a primary or secondary outcome.	Conservative therapy vs. conservative therapy plus alpha blocker	44% more likely to spontaneously expel the stones with alpha-blocker(RR 1.44, 95% CI 1.31 to 1.59)	Funnel plot was asymmetric. Did not specifically study tamsulosin, but alpha-blockers as a whole.

Comment(s)

This well designed, meta-analysis has reviewed all prospective, randomized controlled clinical trials that used only alpha-blockers in the treatment of ureteral stone patients, and included at least one control arm. This meta-analysis compiled 11 studies meeting these strict criteria and confirms the beneficial effect of this treatment implied by these small individual studies. The majority of the studies used tamsulosin 0.4 mg daily and half of them showed a significant benefit of therapy within two weeks. Medical therapy to promote spontaneous expulsion of ureteral stones may potentially diminish health care expenditures associated with shock wave lithotripsy and ureteroscopy. Tamsulosin's proposed mechanism is selective relaxation of ureteral smooth muscle, with subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen.

Clinical Bottom Line

Tamsulosin may be useful during periods of watchful waiting to enhance ureretal stone expulsion. Further studies are needed to identify which patients in terms of stone size, location, duration of colic, and degree of impaction and obstruction are most likely to benefit from alpha-blocker therapy.

References

1. Parsons JK, Hergan LA, Sakamoto K, Lakin C Efficacy of Alpha-Blockers for the Treatment of Ureteral Stones Journal of Urology 2007 (Mar); 177 (3):983-987