LAUSR

To the Editor: The debate continues regarding whether a-blockers should be recommended as medical expulsive therapy in patients with symptomatic ureteral stones. Early randomized controlled trials (RCTs) supported use of a-blockers but most were limited by small sample size and/or methodological shortcomings. Some of the recently published high quality RCTs have not demonstrated that a-blockers improve stone clearance compared to placebo. In contrast, in a large multicenter RCT that included more than 3,000 participants Ye et al observed that use of tamsulosin led to a higher clearance rate for distal ureteral stones larger than 5 mm with shorter stone expulsion time vs placebo. Due to the conflicting data in the latest large RCTs, the role of a-blockers has once again been called into question. The current study illustrates the effectiveness and safety of tamsulosin for treating ureteral stones. Interestingly we published an update of the Cochrane Review on this topic in April 2018, which preceded the PROSPERO (International Prospective Register of Systematic Reviews) registration by the authors in August 2018. We suspect that they came across our study since the Cochrane Central Search Library was included in their search strategy. The conclusions of both meta-analyses were exactly the same, ie tamsulosin is effective and relatively safe, especially for distal ureteral stones larger than 5 mm, with major adverse events in only a small number of patients. Thus, one could question the added scientific value of the current study. In the last 2 years we have been overwhelmed with meta-analyses of a-blockers for ureteral stones. Unfortunately in this period no large prospective RCT has been published that contained any new insights or altered the conclusions of the earlier published reviews in this field. Performing meta-analyses regardless of already available evidence while ignoring welldesigned comparable reviews with the same conclusions has become a growing epidemic in the field of urology and beyond. The purpose of a systematic review is to sensitize people to changing clinical practice if applicable and conducting further study where needed. Authors of reviews show other scientists the pitfalls of the available evidence and provide a stepping-stone for improving the quality of evidence with new prospective randomized studies, preferably in a well-designed network. In this day and age we would like to advocate more international networking and cooperation to prevent unnecessary duplication of effort. Furthermore, retrospective systematic reviews should gradually be replaced by prospective network designs with a planned geometry of comparisons. That is the only way to fight and control this widespread epidemic. LETTERS TO THE EDITOR/ERRATA 1217