Preoperative Alpha-Blockers for Ureteroscopy for Ureteral Stones: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction: Preoperative alpha-blockers have been proposed to improve intraoperative outcomes and patient stone-free status after ureteroscopy for ureteral stones. Materials and Methods: We searched six databases, including Medline, Embase, and Web of Science, for randomized controlled trials (RCTs) evaluating alpha-blocker use before planned ureteroscopy for the management of ureteral calculi. Meta-analysis was performed using DerSimonian and Laird method with inverse variance weighting. Quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. Results: Of 3338 records, 26 were screened as full text and 12 RCTs were included totaling 1352 patients. Meta-analysis demonstrated a 61% risk reduction in need for intraoperative ureteral dilatation in patients administered preoperative alpha-blockers (relative risk [RR]: 0.39 [95% confidence interval, CI: 0.31-0.48], p < 0.00001), as well as increased stone-free status for patients at 4 weeks postoperatively (RR: 1.17 [95% CI: 1.08-1.26], p < 0.0001), and at final follow-up (RR: 1.18 [95% CI: 1.11-1.24], p < 0.00001; median final follow-up 4 weeks [range: 2-8 weeks]). Urologists were more likely to reach the stone with the ureteroscope in patients administered alpha-blockers (RR: 1.16 [95% CI: 1.10-1.23], p < 0.00001). A statistically significant reduction in operative time (mean difference [MD]: -6.05 [95% CI: -10.17 to -1.93] minutes, p = 0.004) and length of hospital stay (weighted MD: -0.34 [95% CI: -0.55 to -0.13] days, p = 0.001) was also demonstrated. Main reported side effects of treatments were abnormal ejaculation, postural hypotension, and dizziness. Outcomes were robust to sensitivity analyses. Results were rated moderate quality evidence using the GRADE framework. Conclusions: Among patients scheduled for semirigid ureteroscopy of ureteral stones, use of preoperative alpha-blockers demonstrated a significant reduction in the need for ureteral orifice dilation and an increase in patient stone-free status at follow-up, and facilitates higher rate of ureteroscopic access to stones, although reducing operative time. An adequately powered trial is needed to definitively address the safety and efficacy of preoperative alpha-blockers for ureteroscopy of ureteral stones.