Updated Systematic Review and Meta-analysis of Extracorporeal Shock Wave Lithotripsy, Flexible Ureterorenoscopy, and Percutaneous Nephrolithotomy for Lower Pole Renal Stones

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.