Awedew AF. et al., 2023: Efficacy and safety of surgical treatment for 1-2 cm sized lower pole of renal stone: network meta-analysis of randomized control trials.
Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia.
Abstract
The management of medium-sized (1-2 cm) lower poles renal stone has been a contentious topic for endourologists. There are limited evidences to answer the best management options for medium-sized lower pole renal stone. This network meta-analysis provided high-level evidences on efficacy and safety of profile of PCNL, Mini-PCNL, Ultra-PCNL, RIRS, Micro-PCNL, SWL for management of medium-sized lower pole renal stone. Systemic review and network meta-analysis (NMA) of randomized control trials was conducted. The PICOS (Population, Interventions, Comparison, Outcomes, and Study) approach was used to look for relevant studies. Searches were conducted at major electronic databases like Medline via PubMed, Embase, Google Scholar, SCOPUS, ScienceDirect, Cochrane library, Web of Science, and ClinicalTrials.gov to find relevant articles from the inception to April 19, 2023. Fourteen randomized control trials involving 2194 patients were among these studies that met the eligibility criteria. Pooled SFR was Mini-PNCL 98% (95% CI 96-99%), Ultara-PCNL 96% (95% CI 93-98%), RIRS 90% (95% CI 88-92%), PCNL 88% (95% CI 85-92%), Micro-PCNL 77% (61-88%) and SWL 69% (95% CI 65-74%). Mini-PCNL provided a statistically significant higher SFR compared to RIRS (RR = 2.43 91.52; 3.89)), Micro-PCNL (RR = 3.19 (1.09; 9.38)), and SWL (RR = 6.17 (3.65; 10.44)), but there was no statistical significance with standard PCNL (RR = 1.06 (0.52; 2.16)) and Ultra-PCNL (RR = 1.37 (0.75; 2.51)) for management of medium-sized lower pole renal stone. The order of SUCRA values for complication rate was as follows: PCNL(90%), Micro-PCNL(70%), Mini-PCNL(50%), Ultra-PCNL(50%), RIRS(40%), and SWL(10%). The current pooled evidence from fourteen randomized control trials revealed that Mini-PCNL, Ultra-PCNL, and standard PCNL are likely the best treatments for medium-sized lower poles when SFR over a short period of minimal session is a priority. These treatment options have a higher rate of complications, longer hospital stays, and acceptable operations time. RIRS and SWL treatment have acceptable efficacy stone-free rate with low complication rate, short hospital stays, and operation time. These treatment option would be the best fit for solitary kidney, coagulopathy, and comorbidity.
Urolithiasis. 2023 May 15;51(1):82. doi: 10.1007/s00240-023-01454-2.PMID: 37184592
Comments 1
How medium sized lower pole renal stones best should be removed has remained a matter of concern. The choice of method depends on treatment expectations such as: stone-free rate, number of treatment sessions required, analgesia/anesthesia, rate of complications, hospital stay, and cost. Although the problem has been subject to previous analyses, the concept is complicated by the fact that endoscopic procedures have undergone a considerable technical development during past years, whereas the SWL method has changed only marginally.
22 Fr
UM-PCNL 
PCNL 
RIRS 
Micro-PCNL 
SWL
RIRS 
UM-PCNL 
PCNL 
Mini-PCNL
The endoscopic technology comprises the following alternatives based on instrument size:
Standard PCNL
Mini-PCNL 14-22 Fr
Ultra-mini-PCNL 11-13 Fr
Micro-PCNL 4.85-10 Fr
RIRS (retrograde intrarenal surgery)
Each one of these instruments is used with various fragmentation tools.
Important is also that the mechanism of lower pole clearance comprises anatomical and gravitational issues.
The table below summarizes the essential findings in this article.
The stone-free rates were as follows:
Mini-PCNL
Interesting is it that the best stone clearance was achieved with Mini-PCNL.
Unfavorable anatomical factors: IPA, calyx diameter, calyx length and SSD.
Of importance are the recordings of complications:
SWL
The basic information is that with miniaturized endourology, the operation time increases.
Mini-PCNL, Ultra-mini-PCNL and PCNL offers the best results in terms of stone-free rates, but both SWL and RIRS have acceptable stone-free rates, low rate of complications, short op-time and short hospital stay.
In summary: The choice of treatment modality is a balance between what can be accomplished and what the patient has to endure.
Hans-Göran Tiselius