Retrograde Intrarenal Surgery vs. Percutaneous Nephrolithotomy vs. Extracorporeal Shock Wave Lithotripsy for Lower Pole Renal Stones 20-10 mm : A Meta-analysis and Systematic Review

To conduct a comprehensive meta-analysis of existing evidence to quantify and compare the safety and efficacy of PCNL (percutaneous nephrolithotomy), RIRS (retrograde intrarenal surgery) and ESWL (extracorporal shockwave liithotrispy) for lower pole renal stones 10-20mm. We conducted a systematic literature search in the EMBASE, MEDLINE, Cochrane databases and Google Scholar to identify relevant studies published in English up to May 2018. Literature reviewed included meta-analyses, and randomized and nonrandomized studies. The subject in the management of PCNL, RIRS and ESWL of studies which included patients with lower pole renal stones 10-20mm. The odd ratio (OR) and mean difference(MD) with its 95% confidence interval (CI) using fixed-or-random-model were calculated to estimate the safety and efficacy of PCNL, RIRS and ESWL for lower pole renal stones 10-20mm. Two reviewers independently assessed the quality of all included studies, and the RevMan 5.3 software was used to analyze the included studies. Three randomized controlled trials and five retrospective case control studies were included, involving a total of 1615 patients in our meta-analysis. Our results suggest that, for lower pole renal stones 10-20mm, PCNL has a great advantage to RIRS(OR=1.95, 95% CI: 1.22-3.12, P = .005, I2 = 39%) and ESWL(OR=0.22, 95% CI: 0.15-0.34, P < .00001, I2 = 0%) in stone-free rate. Comparing PCNL(MD=-24.97, 95% CI: -40.90--9.04, P = .002; I2 = 76%) (MD=-2.43, 95% CI:-4.70--0.17, P = .04, I2 = 99%) and RIRS(MD= -15.39, 95% CI: -25.54--5.25, P = .003, I2 = 99%) (MD=-0.95, 95% CI: -1.29--0.61, P < .00001, I2 = 96%), ESWL owns some advantages in shorter operative time and hospital stay. Both of PCNL (OR=70.21,95%CI:25.01-197.11, P < .00001) (OR=4.01,95%- CI:2.04-7.89, P < .0001) and RIRS (OR=32.31,95%CI:18.39-56.76, P < .00001, I2=0%) (OR=3.06, 95%CI:1.94- 4.84, P < .00001, I2=19%) have some strong points in lower retreatment rate and auxiliary procedure rate comparing ESWL, but no statistical significant difference is found between them(OR=0.46,95% CI:0.15-1.42, P =.18, I2=0%)(OR=0.75,95% CI:0.35-1.59,P =.45). About complication rate, there's no statistical significant difference found in PCNL(OR=1.42, 95%CI:0.91-2.21,P=.12, I2=0%), RIRS (OR=0.74,95%CI:0.51-1.07,P = .11, I2=30%) and ESWL(OR=0.41,95% CI:0.16-1.09, P = .07,I2=70%). Both of PCNL and RIRS offer a longer operative time, the lower retreatment rate and auxiliary procedure rate while PCNL has the longest hospital stay and the highest SFR. However, ESWL is confirmed to have the lowest SFR, the higher retreatment rate and auxiliary procedure rate, but a shorter operative time and the shortest hospital stay. The overall complication rates among the three therapies are comparable.