Efficacy of alpha-blockers in medical expulsive therapy for ureteral stones: A systematic review and meta-analysis of randomized controlled trials between 2010 and 2025

Introduction: Alpha-blockers are widely used in medical expulsive therapy (MET) for ureteral stones; however, the current evidence regarding their comparative effectiveness remains inconsistent. We aimed to evaluate the efficacy and safety of different alpha-blockers in facilitating ureteral stone passage and identify factors influencing treatment outcomes. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) published between 2010 and 2025. We searched multiple databases for studies comparing alpha-blockers with control interventions or other alpha-blockers for ureteral stones ≤10 mm. Primary outcome was stone expulsion rate; secondary outcomes included time to expulsion, pain episodes, analgesic use, and adverse events. We performed subgroup analyses by alpha-blocker type, stone size, location, and treatment duration. Network meta-analysis assessed comparative effectiveness between agents. Results: Twenty-nine RCTs with a total of 4,256 patients were included. Alpha-blockers significantly increased stone expulsion rates compared to controls (70.9% vs. 56.5%; RR 1.25, 95% CI 1.20-1.32; Number Needed to Treat (NNT) = 7) and reduced expulsion time by approximately three-days. Efficacy was greatest for distal ureteral stones (RR 1.52; Number Needed to Treat (NNT) = 4) and stones 5-10 mm (RR 1.35; NNT = 6). Network meta-analysis revealed efficacy ranking favoring at first terazosin, followed by doxazosin then, silodosin then, tamsulosin then, alfuzosin and last the least effective was naftopidil. Alpha-blockers significantly reduced pain episodes and analgesic requirements. Adverse events were infrequent (Number Needed to Harm (NNH) = 38), with retrograde ejaculation being most common with silodosin. Conclusion: Alpha-blockers significantly improve the stone expulsion rates and reduce expulsion time, especially for distal ureteral stones 5-10 mm in size. While tamsulosin remains the most studied agent, our network meta-analysis suggests terazosin and doxazosin may offer superior efficacy. The favorable risk-benefit profile supports routine use of alpha-blockers for appropriately selected patients with ureteral stones.