Abstract
Purpose
Medical expulsive therapy (MET) after extracorporeal shock wave lithotripsy (ESWL) remains a subject of debate. We aimed to evaluate the comparative efficacy and safety of various pharmacological interventions using a network meta-analysis (NMA) of 21 randomized controlled trials (RCTs).Materials and methods
A systematic search of PubMed, EMBASE, and the Cochrane Library was conducted through 2024 (Open Science Framework registered). We included only purely pharmacological RCTs, strictly excluding non-randomized studies and device-assisted trials. A Bayesian NMA was performed to estimate odds ratios and the surface under the cumulative ranking curve (SUCRA) for stone-free rates and complications.Results
Twenty-one RCTs involving 3262 patients were analyzed. The tamsulosin-tadalafil combination was identified as the most effective strategy (SUCRA: 93.8%), followed by tamsulosin-corticosteroid (78.2%) and boron supplementation (67.9%). Notably, while silodosin is often superior for single intact stones, it ranked relatively low in the post-ESWL setting (SUCRA: 20.9%). All agents showed acceptable safety profiles without significant serious adverse events compared to controls.Conclusion
The tamsulosin-tadalafil combination represents the optimal pharmacological adjunct to ESWL. Our findings suggest that effective post-ESWL MET requires a broad therapeutic approach targeting multi-segmental ureteral relaxation and inflammation to clear fragment "showers," distinguishing it from the management of solitary ureteral stones.