I am a lower pole calculus of 2 cm. My preferred treatment is:

Percutaneous nephrolothotomy

Why?

Lower pole study group (Albala, Clayman and et al, J Urol 2001):

122 pts, lower pole stone and symptoms, under 3cm, randomised to PCNL vs SWL, stratified by stone size

CLEARANCE RATES

LOWER Pole stone PCNL ESWL
1cm 100% 63%
1-2cm 92% 23% (but 56% by Lingman)

>2cm 85% 14%






SWL: stent for size >2.5 cm
PCNL: single stage procedure, used flexible endoscopy and fragmentation with laser, uss, lithoclast
Outcome: fragmentation to fragments less than 3mm
Clearance rate 11-20mm stones 23% vs 92% for SWL vs PCNL, 14% vs 100% for stones 21-30mm

No effect found from lower pole calyx anatomical factors
(cf Elbahnasy, where infundibulopelvic angle under 90°, length over 30mm and width <5mm all associated with poor clearance rates of stones using SWL)

Cost effectiveness to be stone free
Stones 11-19mm SWL 133% more than PCNL
Stones >20mm cost of SWL 411% greater than PCNL
No statistical difference in morbidity




Lower pole study group 2:
Ureteroscopy versus PCNL
1-2.5 cm lower pole stone
31% stone free in urs versus 76% for pcnl
Stone Ureteroscopy PCNL
1-2.5 31% 76%




Ureteroscopy versus ESWL for stone < 1cm (pearl, lower pole study 3 ) no diff between urs and eswl. (35% versus 50% statistically not significant) (Pearl Jurol 2005)


Stone Ureteroscopy ESWL
<1 cm 35% 50%





stones <10mm URS vs SWL, stones 11-25mm URS vs PCNL
• Why?
o Stone free rates 11-20mm 71%, >20mm 65% with URS (Grasso, 1999)
o All stones greater than 2cm clearance rate of 91% after second look procedure in pts with renal stones who were poor PCNL candidates (Grasso, J Urol 1998)