Re: Ramadhani MZ, Kloping YP, Rahman IA, Yogiswara N, Soebadi MA, Renaldo J. Silodosin as a medical expulsive therapy for distal ureteral stones: A systematic review and meta-analysis. Indian J Urol 2023;39:21-6.

I read with great interest an article published by Ramadhani et al.[1] in the latest edition of the Journal. In this study, the authors have performed a systematic review and meta-analysis of the studies examining the role of silodosin as a medical expulsive therapy for distal ureteric stones. I would like to congratulate the authors on their publication. Multiple randomized control trials have established the efficacy of alpha-blockers as a part of medical expulsive therapy for distal ureteric stones. Most of the studies conducted in this field have been small, single-center, poor-quality randomized studies. Therefore, there is still a scope for a well-conducted multicentric randomized control trial to close this debate. This is where systematic reviews and meta-analyses have proved handy by performing a pooled analysis of these small randomized studies. However, this pooling of data may not be without limitations as there would be heterogeneity in the patient population and outcomes studied. In the present meta-analysis, the authors have tried to handle this delicate issue; however, there are still limitations that need to be addressed. One important limitation of this study that needs to be highlighted is the fact that the placebo or control group was different in the included studies. Most of the included studies did not include a classical “placebo” group but instead had a no-treatment group with hydration with or without anti-inflammatory drugs as control. Second, the authors have included a study by Rathi et al.,[2] which was actually a conference abstract. In the methods’ section, the authors have not adequately highlighted how they handled conference abstracts. Were the data readily available from the study by Rathi et al. to perform pooled and risk-of-bias analysis or did the authors have to contact the original study author for full-text? In any situation, it is generally recommended that conference abstracts should not be included in the systematic reviews as they do not undergo a stringent peer-review process. Furthermore, I have reservations over the inclusion of a study by Cholaraju et al.[3] in the present review. This study did not clearly define the randomization technique and outcome parameters. None of the previous reviews have included this study and we also excluded this study from our two published reviews on the topic due to the reasons mentioned above.[4–6] Heterogeneity due to imaging modality and duration for determining stone-free rate is also an important factor to consider and should have been highlighted in the limitations section. Finally, the authors have not clarified in the introduction section regarding the need for this study. What was the knowledge gap in the literature for which they developed the research question for this study? In my opinion, the study question has been a part of multiple reviews with similar findings published in the past, thereby suggesting redundancy of the current review.[5–10] Furthermore, the authors have not compared their results with the results of previous studies in the discussion section, which in my opinion are not much different from that of the present study. For instance, in a previous network meta-analysis by Sharma et al., comparing three commonly used alpha-blockers for distal ureteric stones, silodosin was noted to be the most efficacious drug.[6] Further minor issues that need rectification/clarification include: References to the included studies cited in Table 1 seem to be incorrect The authors have been quite generous in the risk of bias analysis as most of the included studies were of low quality In Figure 3, instead of fixed-effect analysis, the random-effect analysis should have been used as there was a significant statistical heterogeneity. The authors should also include publication bias either by Funnel plot or by Egger’s method. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.