Lower pole stones (LPSs) frequently cause significant morbidity, necessitating effective intervention strategies. We systematically reviewed the evidence for treatment of LPSs with extracorporeal shock wave lithotripsy (ESWL), flexible ureterorenoscopy (FURS), and percutaneous nephrolithotomy (PCNL) previously in 2015. In this update, we have included 16 new randomised controlled trials plus eight from our original review (24 in total). Despite the increase in available trials, the certainty of evidence remains moderate for stone-free rates (SFRs), underscoring the on-going need for more robust trials in this domain. FURS demonstrated superior efficacy in achieving SFRs to ESWL (risk ratio [RR] 1.19, 95% confidence interval [CI] 1.05, 1.35), although the absolute difference remains modest. ESWL may lead to fewer complications, and FURS could result in more unplanned procedures and retreatments. It remains unclear whether there are differences in quality of life and cost estimates vary depending on the country. PCNL offers a marginal yet statistically significant advantage over FURS in terms of SFRs (RR 1.07, 95% CI 1.01, 1.12), but it is unclear whether there are differences in unplanned procedures, retreatments, or complications, and there was conflicting evidence about health status and return to normal activities. SFRs were superior with PCNL to those with ESWL (RR 1.42 95% CI 1.28, 1.58). Unplanned procedures and retreatments were generally fewer for PCNL, and complications were fewer for ESWL. The cost effectiveness of each modality is highly dependent on the health care system and country-specific economic factors. The overall certainty of the evidence remains unchanged, with only moderate improvements in certain domains.
European urology. 2025 Mar 12 [Epub ahead of print]
Steven MacLennan, Oliver Wiseman, Daron Smith, Kathryn Starr, Lorna Aucott, Rodolfo Hernández, Paul Manson, Ruth Thomas, Charles Terry Clark, Graeme MacLennan, Dawn McRae, Victoria Bell, Seonaidh Cotton, Zara Gall, Ben Turney, Sam McClinton
Academic Urology Unit, University of Aberdeen, Aberdeen, UK. Electronic address: ., Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK., Stone and Endourology Unit, University College Hospital, University College Hospitals NHS Foundation Trust, London, UK., Warwick Medical School, University of Warwick, Warwick, UK., Health Services Research Unit, University of Aberdeen, Aberdeen, UK., Health Economics Research Unit, University of Aberdeen, Aberdeen, UK., Centre for Healthcare Randomised Trials, Health Services Research Unit, Aberdeen, UK., Patient Advocate, University of Aberdeen, UK., Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK., Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK., Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Centre for Healthcare Randomised Trials, Health Services Research Unit, Aberdeen, UK.