title: Systematic review and meta-analysis of the clinical effectiveness of shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy for lower-pole renal stones.
abstract: The prevalence of urolithiasis is increasing. Lower-pole stones (LPS) are the most common renal calculi and the most likely to require treatment. A systematic review comparing shock wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PNL) in the treatment of ≤20 mm LPS in adults was performed. Comprehensive searches revealed 2741 records; 7 randomised controlled trials (RCTs) recruiting 691 patients were included. Meta-analyses for stone-free rate (SFR) at ≤3 mo favoured PNL over SWL (risk ratio [RR]: 2.04; 95% confidence interval [CI], 1.50-2.77) and RIRS over SWL (RR: 1.31; 95% CI, 1.08-1.59). Stone size subgroup analyses revealed PNL and RIRS were considerably more effective than SWL for >10 mm stones, but the magnitude of benefit was markedly less for ≤10 mm stones. The quality of evidence (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]) for SFR was moderate for these comparisons. The median SFR from reported RCTs suggests PNL is more effective than RIRS. The findings regarding other outcomes were inconclusive because of limited and inconsistent data. Well-designed, prospective, comparative studies that measure these outcomes using standardised definitions are required, particularly for the direct comparison of PNL and RIRS. This systematic review, which used Cochrane methodology and GRADE quality-of-evidence assessment, provides the first level 1a evidence for the management of LPS.
  
  
  RESULTS
  We thoroughly examined the literature to compare the benefits and harms of the different ways of treating kidney stones located at the lower pole. PNL and RIRS were superior to SWL in clearing the stones within 3 mo, but we were unable to make any conclusions regarding other outcomes. More data is required from reliable studies before firm recommendations can be made.
authors.affiliation: Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK. Electronic address: james.donaldson@doctors.org.uk.
authors.forename: James F
authors.initials: JF
authors.lastname: Donaldson
authors.affiliation: Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Lardas
authors.affiliation: Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK.
authors.forename: Duncan
authors.initials: D
authors.lastname: Scrimgeour
authors.affiliation: Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Stewart
authors.affiliation: Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Steven
authors.initials: S
authors.lastname: MacLennan
authors.affiliation: Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Thomas B L
authors.initials: TB
authors.lastname: Lam
authors.affiliation: Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Samuel
authors.initials: S
authors.lastname: McClinton
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007669:Kidney Calculi / Q000601:surgery / Q000628:therapy*; D008096:Lithotripsy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous / Q000379:methods*; D016896:Treatment Outcome; D018666:Ureteroscopy / Q000379:methods*; D013520:Urologic Surgical Procedures / Q000379:methods
keywords: Extracorporeal shock wave lithotripsy; Kidney stones; Lithotripsy; Nephrolithiasis; Percutaneous nephrolithotomy; Retrograde intrarenal surgery; Shock wave lithotripsy; Ureterorenoscopy; Urolithiasis