Medical Expulsive Therapy: Worthwhile or Wishful Thinking

We set out to provide an overview of the most recent evidence for medical expulsive therapy (MET). Conflicting level 1 evidence for and against the use of MET has been published.

The largest double-blind randomized control trial (1110 patients) comparing placebo, tamsulosin, and nifedipine found no benefit for MET in preventing the need for secondary intervention. A recent meta-analysis of 55 randomized trials using alpha-blockers suggests that no benefit is seen with smaller ureteric calculi, but patients with larger ureteric calculi experience shorter times to stone passage, fewer episodes of pain, require less surgical intervention, and fewer hospital admissions. All the major urological organizations (American Urological Association, European Association of Urology, Canadian Urological Association) suggest offering MET as part of conservative management for appropriate patients with ureteric calculi. MET is a reasonable option for conservative management of ureteric calculi that may avoid the need for surgical intervention. The greatest benefit is likely seen with alpha-blockers and calculi ≥5 mm in the distal ureter. Expanding indications for the use of MET include facilitating stone fragment clearance after SWL. MET appears to be safe for use in pregnant and pediatric patients.