Introduction: Distal ureteric calculi remain a widely debated topic without clear consensus on expectant management. This systematic review aims to assess the placebo arms of RCTs to extrapolate data on the natural history of distal ureteral stones and ascertain the success rate of expectant management. Methods: A literature search was performed, and 3 reviewers used a predefined inclusion criterion to independently select articles for inclusion. A cumulative analysis was undertaken, and risk of bias assessed using the Cochrane tool. Results: Stone expulsion was recorded in 1,823/2,447 (74.5%) patients overall. The expulsion rate of study participants receiving placebo varied widely from 35.2 to 88.9%. The overall expulsion rate of stones ≤5 mm was 486/561 (87%) as opposed to 814/1,093 (75%) in stones >5 mm in size. Time to stone expulsion varied from 8.54 to 24.5 days. A re rate of 2% was reported. Conclusions: Spontaneous passage of distal ureteric calculi is dependent on stone size and location within the ureter. Provided a patient does not portray symptoms of uncontrollable pain, infection, obstruction, or declining renal function, it is reasonable to trial a period of expectant management. Follow-up should be arranged to ensure symptom resolution, and alternative treatment can be offered if required.

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