MacLennan S. et al., 2025: Updated Systematic Review and Meta-analysis of Extracorporeal Shock Wave Lithotripsy, Flexible Ureterorenoscopy, and Percutaneous Nephrolithotomy for Lower Pole Renal Stones.

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
Eur Urol. 2025 Sep;88(3):231-239. doi: 10.1016/j.eururo.2025.01.020.  FREE ARTICLE

Abstract

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.

Comment Peter Alken

Another consensus-disturbing dust-cleaning article from this working group. It has already been selected as “Editor’s choice” by European Urology and I refrain from additional comments, but would like to encourage the customer to read this paper by quoting from European Journal
“ADVANCING PRACTICE What does this study add?
This systematic review and meta-analysis report is the most up-to-date, comprehensive, and rigorous overview of the options for treating lower pole stones and is of importance to guideline developers and practising urologists. Although some recent randomised controlled trials with a low risk of bias and adequate power are available, their signal is diluted in the remaining evidence base, which is generally of moderate to low certainty for most outcomes due to imprecision and high risks of bias. Flexible ureterorenoscopy (FURS) appears more effective than extracorporeal shock wave litho-tripsy (ESWL) for stone-free rate (SFR) and may have fewer complications, but may result in more unplanned procedures, although quality of life is not different. ESWL was cheaper in the UK and China, although it is unclear whether this is generalisable. Percutaneous nephrolithotomy (PCNL) confers a slight SFR advantage to FURS, but it is unclear whether there are differences in unplanned procedures, retreatments, and complications, and there was conflicting evidence about health status and return to normal activities. SFR was better with PCNL than with ESWL unplanned procedures, and retreatments were generally fewer for PCNL, complications were fewer for ESWL, and costs were country dependent.”
This is an important message. The problem is if it will have an impact on stone treatment. Clinicians are deeply imbedded in their routine and difficult to move.

Peter Alken