Lower pole stones (LPSs) are common but less likely to pass spontaneously than other renal stones, often necessitating intervention. In 2015, a systematic review and meta-analysis comparing percutaneous nephrolithotomy (PCNL), flexible ureterorenoscopy (fURS), and extracorporeal shockwave lithotripsy (ESWL) was published. PCNL achieved the highest three-month stone-free rates (SFRs) but was most invasive; fURS outperformed ESWL, particularly for larger stones, while ESWL remained the least invasive option. However, the evidence base was limited, of low certainty, and lacked robust quality-of-life (QoL) and cost-effectiveness data. This year the review was updated to include randomised controlled trials (RCTs) published since 2015, identifying 24 RCTs (including three three-arm trials). Across seven studies comparing ESWL and FURS, meta-analysis showed higher SFRs with fURS (risk ratio [RR] 1.19, 95% CI 1.05–1.35; moderate certainty), although the effect was attenuated for stones ≤10mm. Retreatments and unplanned procedures were fewer after fURS, while ESWL had fewer complications. QoL outcomes remain inconclusive, with only two recent RCTs reporting data. Cost analyses suggested ESWL is more economical in the UK and China, but generalisability is uncertain. For fURS versus PCNL, nine RCTs showed marginally higher SFRs with PCNL (RR 1.07, 95% CI 1.01–1.12; moderate certainty). PCNL was associated with fewer retreatments, although recovery was quicker with fURS. One trial reported slightly better QoL with PCNL, but data remain sparse. Comparisons of PCNL versus ESWL consistently favoured PCNL in terms of SFRs and retreatments, though ESWL had fewer complications. Overall, although evidence has expanded since 2015, certainty remains low. fURS generally achieves better SFRs than ESWL, while PCNL offers the highest clearance rates at the cost of greater invasiveness. Differences in QoL appear minimal. Future studies should prioritise standardised outcome reporting, patient-reported measures, and economic analyses to better guide practice and policy.
