Lower-pole Stones: Do We Finally Have More Answers Than Questions?

In this month’s issue of European Urology, Donaldson et al [1] have addressed the holy grail of endourology in producing level 1a evidence for the management of lower-pole stones (LPS). Theirmeta-analysis and systematic review gives credence to guidelines that have been based conventionally around small trials or evidence by expert panels [2]. Randomised controlled trial (RCT) data in stone disease has traditionally been limited and criticised, but by analysing and comparing the studies using Cochrane methodology, Donaldson et al have significantly improved the current evidence base for our practice. In 2009, a Cochrane systematic review tried to address the role of shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PNL), and retrograde intrarenal surgery (RIRS) in the management of renal stones, but because of a lack of well-designed RCTs, no meaningful outcomes were concluded [3]. This review highlighted the importance of further RCTs, and it is reassuring that the past 5 yr have delivered another five RCTs on LPS. Donaldson et al now present their up-to-date meta-analysis of these data and must be congratulated for doing so [1]. Despite searching a plethora of manuscripts regarding stone treatment, it is a somewhat sad indictment of contemporary endourologic practice that we have such limited numbers of RCTs for such a commonly encountered clinical scenario. Only seven RCTs were identified addressing LPS, two comparing PNL with SWL and five comparing RIRSwith SWL. Interestingly, the role of PNL versus SWL has only ever been addressed in a randomised fashion in two RCTs (Lower Pole I and II studies) [4,5]. These studies clearly support the role of PNL over that of SWL, but one must