Should we SUSPEND MET? Not really

Medical expulsive therapy (MET) in ureteric stones has 2 goals: 1) accelerate stone passage and therefore avoid surgery and 2) reduce analgesic requirement. In this setting, a RCT [1] done prior to the publication of the SUSPEND trial [2] is published in this issue of the CEJU, comparing the efficacy of tadalafil against tamsulosin in MET. It is regrettable that a placebo arm was not included in this trial. Nevertheless, even if one were to presume that tamsulosin is only as good as placebo, a robust case is made for the superiority of tadalafil – the mean stone size in this trial is 7 mm; all the stones were in the distal ureter; stone passage was confirmed with CT scan; the tadalafil group had a 84% passage rate compared to 68% in the tamsulosin group; mean analgesic requirement and time to stone expulsion were significantly reduced in the tadalafil group. Tamsulosin and nifedipine are supposed to be beneficial in MET, but high-quality RCTs in this area were lacking [3, 4]. PDE-5 inhibitors have been investigated as alternative agents in MET [5]. The SUSPEND trial concluded that there is no benefit t o using tamsulosin or nifedipine in MET, compared to placebo. However, the conclusions were not supported by its methodology. Trials are scientifically rigorous pursuits; if diluted with ‘real-world’ or ‘pragmatic’ Should we SUSPEND MET? Not really