Medical Expulsive Therapy: Is It Time to SUSPEND Judgement?

Abstract

Medical expulsive therapy (MET) has been a matter of debate for many years. A number of randomised controlled trials (RCTs) and meta-analyses have been conducted, but outcomes have been varied. This makes it challenging to determine the benefit of using MET as an adjunct in patients with expectantly managed ureteric stones. This article aimed to summarize both the historic and the more contemporary literature in this area by focusing on published meta-analyses and recent RCTs. Studies of interest were those comparing either an α-blocker or a calcium channel blocker with a control. Outcome measures of interest were expulsion rates, expulsion times, and medication-related side effects. All systematic reviews included are in favour of MET versus controls. However, many of the component RCTs had limitations such as a high risk of bias, incomplete blinding and heterogeneous inclusion criteria. A recent well-powered RCT found no benefit of MET for the purpose of conservatively managed ureteric stones. This study had some limitations that stimulated further research in the area, adding to the uncertainty. The most recent RCT and meta-analysis indicates MET is more beneficial in both larger (>5 mm) and distal stones. Uncertainty remains in this arena, and there is a need for a robust multi-institution study to assess MET in a cohort of patients who are expectantly managed with ureteric stones. This should serve to counter the marked heterogeneity and limitations of existing trials and meta-analyses.