504 692
[2_TD$DIFF]
EAU Recommendation
Medical Expulsive Therapy
[3_TD$DIFF]
for
[4_TD$DIFF]
Ureterolithiasis: The EAU
[5_TD$DIFF]
Recommendations in 2016
Christian Tu¨rk
a , * ,Thomas Knoll
b ,Christian Seitz
c ,Andreas Skolarikos
d ,Chris Chapple
e ,Sam McClinton
f ,on behalf of the European Association of Urology
a
Urologische Praxis und Steinzentrum, Vienna, Austria;
b
Department of Urology, Sindelfingen-Bo¨blingen Medical Center, University of Tu¨bingen,
Sindelfingen, Germany;
c
Department of Urology, Medical University of Vienna, Vienna, Austria;
d
Second Department of Urology, Sismanoglio Hospital,
Athens Medical School, Athens, Greece;
e
Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK;
f
Aberdeen Royal Infirmary, NHS Grampian and
University of Aberdeen, Aberdeen, UK
Observational treatment is an option for small ureteral
stones in patients with controlled symptoms. In particular,
a
-blockers have been recommended as supportive,
so-called medical expulsive therapy (MET)
[1,2]. In 1996,
a Russian group demonstrated a positive effect of the
a
1-adrenoblocker doxazosin on urine outflow disorders
[3] .To our knowledge, Cervenakov et al were the first, in
2002, to describe possible acceleration of stone expulsion
with the use of the
a
1-blocker tamsulosin
[4]. Since then,
many randomized trials and several meta-analyses have
been published
[5–7]. Most have encouraged the use of
a
-blockers or calcium channel blockers to facilitate stone
expulsion of ureteral calculi. Eventually, most treatment
guidelines recommended
a
-blockers for MET. Nevertheless,
some recently published high-quality and large placebo-
controlled randomized trials have raised serious doubt
E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 5 0 4 – 5 0 7available at
www.scienced irect.comjournal homepage:
www.europeanurology.comArticle info
Article history:
Accepted July 15, 2016
Associate Editor:
James Catto
Keywords:
Urinary calculi
MET
EAU guidelines
Abstract
Medical expulsive therapy (MET), in particular
a
-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
a
-blockers. However,
several recently published high quality, large, placebo-controlled randomized trials
raised serious doubts about the effectiveness of
a
-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 5 mm, there may be a potential therapeutic benefit for
the use of
a
-blockers. Patients should be informed about the possible, but as yet
unproven benefit of using
a
-blockers in this situation, as well as their off-label use
and potential side effects.
#
2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Ziehrerplatz 7/7, 1030 Vienna, Austria. Tel. +43 1 7126574.
E-mail address:
office@tuerk.at(C. Tu¨ rk).
http://dx.doi.org/10.1016/j.eururo.2016.07.0240302-2838/
#
2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.