Ambulatory & Office Urology Prospective Randomized Trial Comparing Efficacy of Alfuzosin and Tamsulosin in Management of Lower Ureteral Stones Madhusudan Agrawal, Manoj Gupta, Apurva Gupta, Akash Agrawal, Avijit Sarkari, and Prashant Lavania OBJECTIVES To study the efficacy of alfuzosin compared with tamsulosin in the management of lower ureteral stones. METHODS A total of 102 patients with stones 1 cm size and located in the lower ureter were enrolled in the present study and randomized into 3 equal groups. Group 1 patients (n = 34) received 0.4 mg tamsulosin daily, group 2 patients (n = 34) received 10 mg alfuzosin daily, and group 3 patients (n = 34) received placebo (control group). The patients were given 75 mg diclofenac injection intramuscularly on demand and were followed up for 4 weeks. RESULTS The average stone size for groups 1, 2, and 3 was comparable (6.17, 6.70, and 6.35 mm, respectively). Stone expulsion was observed in 28 of 34 patients (82.3%) in group 1, 24 of 34 patients (70.5%) in group 2, and 12 of 34 patients (35.2%) in group 3. The average expulsion time for groups 1, 2, and 3 was 12.3, 14.5, and 24.5 days, respectively. The results of both study groups (groups 1 and 2) were superior to those in the placebo group (P = .003 and P = .001, respectively), but the study failed to show any statistically significant differences between tamsulosin and alfuzosin (P = .25). Alfuzosin was associated with fewer side effects than tamsulosin, especially in terms of retrograde ejaculation. CONCLUSIONS Medical treatment of lower ureteral calculi with tamsulosin and alfuzosin resulted in a signifi- cantly increased stone expulsion rate, decreased expulsion time, and a reduced need for analgesic therapy. UROLOGY 73: 706 –709, 2009. © 2009 Elsevier Inc. S ymptomatic ureterolithiasis represents the most common condition observed by urologists in an emergency setting. 1 Of all ureteral stones, 70% are found in the lower third of ureter at presentation. Al- though a watchful waiting approach can be used success- fully for a large number of patients, 2,3 it can also result in complications such as urinary tract infection, hydrone- phrosis, and renal function deterioration. The use of the watchful waiting approach has been extended with the use of pharmacologic therapy in the form of -adrenergic blockers to provide relief from colic pain and facilitate stone expulsion. 4-6 Studies have revealed the presence of  1 -adrenergic receptors in the ureter. The density of  1 -adrenergic receptors in ureteral smooth muscle cells is significantly greater than other adrenergic receptors.  1 -Adrenergic antagonists have been proved to inhibit basal tone, peri- staltic frequency, and ureteral contractions in the intra- mural part of ureter. 6 Several clinical trials have shown good results with the use of selective -blockers in the treatment of lower ureteral stones. 7-9 Most of these trials have studied the efficacy of tamsulosin on lower ureteral stones. We performed a pro- spective randomized study comparing alfuzosin and tamsu- losin for the relief of ureteral colic and in facilitating the spontaneous expulsion of distal ureteral stones. MATERIAL AND METHODS From September 2004 to August 2007, 102 patients presenting with stone 1 cm in size located in the distal part of the ureter (juxtavesical part and ureterovesical junction) were included in the present study. The exclusion criteria included urinary tract infection, severe hydroureteronephrosis, diabetes mellitus, mul- tiple stones, hypotension, pregnancy, previous spontaneous stone expulsion, distal ureteral surgery, and history of intake of any of the following drugs: warfarin, -adrenergic blockers, calcium antagonist, steroids, and cimetidine. All patients were evaluated with plain x-rays of the abdomen, ultrasonography of the urinary system, intravenous urography, and noncontrast computed tomography in selected patients. From the Division of Urology, Department of Surgery and Department of Surgery, S N Medical College, Agra, India Reprint requests: Madhusudan Agrawal, M.Ch., Division of Urology, Department of Surgery, S N Medical College, 4/18c, Bagh Farzana, Civil Lines, Agra, Utter Pradesh 282002 India. E-mail: dr.madhu.agra@gmail.com Submitted: March 21, 2008, accepted (with revisions): November 4, 2008 706 © 2009 Elsevier Inc. 0090-4295/09/$34.00 All Rights Reserved doi:10.1016/j.urology.2008.11.013