The best treatment approach for lower calyceal stones ≤20 mm in maximal diameter: mini percutaneous nephrolithotripsy, retrograde intrarenal surgery or shock wave lithotripsy A systematic review and meta-analysis of the literature conducted by the European Section of Uro-Technology and Young Academic Urologists

INTRODUCTION: The highest in quality data in the literature which compared mini percutaneous nephrolithotripsy (mPCNL), retrograde intrarenal surgery (RIRS) and shock wave lithotripsy (SWL) for the management of lower pole stone (LPS) with a maximal diameter <20 mm were investigated by means of systematic review (SR) and meta-analysis. EVIDENCE ACQUISITION: A SR of the literature was conducted on PubMed, Cochrane, SCOPUS and EMBASE in January 2020. The study complied with the PRISMA statement and recommendations of the EAU Guidelines office. Only randomized controlled trials (RCTs) comparing retrograde intrarenal surgery (RIRS), shock wave lithotripsy (SWL) and mini-percutaneous nephrolithotripsy (mPCNL) were selected for the meta-analysis. The endpoints were the efficacy of each modality, measured by stone-free rate (SFR), operative time and retreatment rate and the safety of each method, based on hospitalization time and complications. Subgroup analyses for stones with a maximal diameter <10 mm and 10-20 mm were performed. EVIDENCE SYNTHESIS: Twenty-one RCTs were included in the meta-analysis. mPCNL had the highest SFR and the lowest retreatment rate among the three modalities, while SWL had the lowest SFR and the highest retreatment rate. The operative and hospitalization time were shorter in the case of SWL, whereas they were similar in the case of mPCNL and RIRS. The highest complication rate was observed in mPCNL group, which accounted for 8.3-22.4%, while RIRS and SWL had similar complication rates, which ranged between 1.3-31.4% and 0-48.5%, respectively. Further classification of the complications according to Clavien-Dindo system revealed that SWL had lower grade II complication rates compared to mPCNL and RIRS. Regarding stones <10 mm, SWL and RIRS had similar SFR, complication rate, operation and hospitalization time. SWL had higher retreatment rate. CONCLUSIONS: For LPSs <= 20 mm, mPCNL provides the highest SFR and the lowest retreatment rate. This modality has a higher complication rate and longer hospital stay in comparison to the other modalities. SWL provides the lowest SFR with the highest retreatment rate. RIRS has similar complication rate to SWL and could be preferred over SWL. For stones up to 10 mm, SWL may provide a valid alternative. Despite a higher retreatment rate, its SFR is similar to RIRS.

Automated summary

For lower pole stones with a diameter <20 mm, mPCNL has the highest stone-free rate and the lowest retreatment rate, but also a higher complication rate; SWL provides the lowest SFR and the highest retreatment rate; RIRS has a similar complication rate to SWL and may be preferred over SWL.