Pharmacologic Management of Ureteral Stent–related Symptoms Should Be Personalized
Key findings
- This network meta-analysis of 26 studies stratified the effectiveness of 23 pharmacologic regimens for addressing bothersome symptoms related to ureteral stents
- The combination of silodosin and solifenacin was most effective for urinary symptoms and pain, whereas triple therapy with silodosin, solifenacin and tadalafil was associated with the best general health score on the Ureteral Stent Symptom Questionnaire
- Tadalafil monotherapy ranked highest for improving sexual performance and solifenacin monotherapy ranked highest for work performance
- Urologists should consider these data along with the known side effects and contraindications of these drugs so they can tailor therapeutic regimens to each patient's chief complaint and tolerance
Most recipients of ureteral stents develop symptoms such as urinary urgency and pain that can substantially affect quality of life and work capacity. The mainstays of therapy are α-blockers and anticholinergic medications, but other drug classes have had promising results, and numerous drug and dosage combinations are being studied.
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Various meta-analyses have compared each drug class's efficacy with placebo, but a traditional meta-analysis doesn't allow adequate multigroup comparisons. Furthermore, different formulations and dosages of drugs in the same class are sometimes grouped together, even though agents in the same class can vary in efficacy.
Massachusetts General Hospital researchers recently made the first head-to-head comparison of all published medication regimens for ureteral stent-related symptoms using a network meta-analysis. A systematic review and network meta-analysis allow comparisons of multiple treatments both directly (within randomized controlled trials) and indirectly (across trials based on a common comparator).
The most effective drug therapy proved to differ by symptom domain, as Brian H. Eisner, MD, co-director of the Kidney Stone Program in the Department of Urology, David Eugenio Hinojosa-Gonzalez, MD, a former research fellow in the Department, and a colleague describe in The Journal of Urology.
Methods
In August 2021, the researchers searched PubMed, MEDLINE, Scopus, Web of Science, and Google Scholar for randomized, controlled trials that (a) evaluated pharmacological interventions for managing ureteral stent–related symptoms, and (b) reported outcomes using the Ureteral Stent Symptom Questionnaire (USSQ).
They included 26 studies (n=2,900) that involved 23 interventions other than placebo: various dosages and combinations of tamsulosin, alfuzosin, silodosin, naftopidil, solifenacin, mirabegron, oxybutynin, tolterodine, tadalafil, sildenafil, and pregabalin. In each domain of the USSQ, the team ranked the efficacy using a 24-node Bayesian network meta-analysis framework.
Treatment Ranking
According to the surface under the cumulative ranking (SUCRA) curve, the top two regimens in each domain were:
Urinary symptoms
- Silodosin 8 mg + solifenacin 10 mg—SUCRA, 88%; mean difference (MD) vs. placebo, −17.0
- Silodosin 8 mg + solifenacin 10 mg + tadalafil 5 mg—SUCRA, 84%; MD vs. placebo, −16.0
Pain
- Silodosin 8 mg + solifenacin 10 mg—SUCRA, 95%; MD vs. placebo, −13.0
- Silodosin 8 mg monotherapy—SUCRA, 94%; MD vs. placebo, −12.0
General health
- Silodosin 8 mg + solifenacin 10 mg + tadalafil 5 mg—SUCRA, 98%; MD vs. placebo, −13.0
- Silodosin 8 mg + solifenacin 10 mg—SUCRA, 97%; MD vs. placebo, −13.0
Work performance
- Solifenacin 10 mg monotherapy—SUCRA, 91%; MD vs. placebo, −8.0
- Silodosin 8 mg + solifenacin 10 mg—SUCRA, 91%; MD vs. placebo, −7.9
Sexual performance
- Tadalafil 5 mg monotherapy—SUCRA, 90%; MD vs. placebo, −4.4
- Silodosin 8 mg + solifenacin 10 mg + tadalafil 5 mg—SUCRA, 90%; MD vs. placebo, −4.5
Personalizing Therapy
Tailoring pharmacologic management according to chief complaint may be the best approach to stent-related discomfort. An important caveat is that only half the studies included in this study reported side effects, so it wasn't possible to fully analyze medication-associated complications. Clinicians must consider tolerability and potential risks for individual patients, especially if polypharmacy is being considered.
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