Medical Expulsive Therapy for Ureterolithiasis: The EAU Recommendations in 2016.

Medical expulsive therapy (MET), in particular α-blockers, have been recommended as supportive medication if observational treatment of a ureteral stone was an option. Over the years, a considerable number of randomized controlled trials (RCT) as well as several meta-analyses have been published on MET, supporting the use of α-blockers. However, several recently published high quality, large, placebo-controlled randomized trials raised serious doubts about the effectiveness of α-blockers. The contradictory results of meta-analyses of small RCTs versus the findings of large, well conducted multicenter trials show the methodological vulnerability of meta-analyses, in particular if small single center, lower quality, papers have been included. Small single center trials, for instance, tend to show larger treatment effects compared to multicenter RCTs. It also shows the responsibility of careful planning when conducting a RCT. Trial registration as a prerequisite for approval by ethics committees could in addition minimize publication bias. Weighting the current evidence on whether to use MET, or not, it seems that in distal ureteral stones larger than 5mm, there may be a potential therapeutic benefit for the use of α-blockers. Patients should be informed about the possible, but as yet unproven benefit of using α-blockers in this situation, as well as their off-label use and potential side effects.