Abstract
OBJECTIVE: Medical expulsive therapy (MET) facilitates the passage of distal ureteric stones. Alpha-blockers are the standard MET strategy. However, there has been growing interest in using tadalafil, a Phosphodiesterase type 5 (PDE5) inhibitor, to facilitate ureteral stone passage. Therefore, a systematic review and meta-analysis comparing tadalafil versus tamsulosin or silodosin was conducted as MET options for patients with distal ureteral stones. METHODS: PubMed, Embase, and Cochrane Library were systematically searched in September 2023 for randomized controlled trials (RCTs) comparing tadalafil with alpha-blockers (tamsulosin or silodosin) for distal ureteric stones. Outcomes included stone expulsion rate (SER), stone expulsion time (SET), colic episodes, analgesic use, and side effects. Review Manager 5.4.1 was used for statistical analysis, applying a random-effects model. RESULTS: Eleven RCTs were included with 1345 patients, 579 (43%) randomized to tadalafil. No significant differences were found between groups for SER (risk ratio [RR] 1.07; 95% CI 0.98-1.18; P = .14), SET (RR −0.68; 95% CI −1.75 to 0.38; P = .21), colic episodes, or analgesic use. Headaches were significantly less frequent with alpha-blockers (RR 1.50; 95% CI 1.09-2.04; P = .01), while abnormal ejaculation was significantly less frequent in the tadalafil group (RR 0.38; 95% CI 0.19-0.74; P = .005). CONCLUSION: Given the comparable efficacy in stone expulsion and the distinct side-effect profiles, the choice between tadalafil and alpha-blockers for MET can be individualized. Tadalafil emerges as a strong MET alternative, particularly when alpha-blockers are contraindicated or poorly tolerated.