Efficacy and safety of the surgical treatments for lower calyceal stones: a systematic review and network meta-analysis.

Objective: Efficacy and safety of five common surgical treatments for lower calyceal (LC) stones were assessed for LC stones 20 mm or less.

Methods: A systematic literature search was conducted up to June 2020 using PubMed, EMBASE, and Cochrane Library. The study has been registered in PROSPERO, CRD42021228404. Randomized controlled trials evaluating the efficacy and safety of five common surgical treatments for LC stones were collected, including percutaneous nephrolithotomy (PCNL), mini-PCNL (MPCNL), ultramini-PCNL (UMPCNL), extracorporeal shock wave lithotripsy (ESWL), and retrograde intrarenal surgery (RIRS). Heterogeneity among studies was assessed by using global inconsistency and local inconsistency. Both pooled odds ratio, along with 95% credible interval (CI) and the surface under the cumulative ranking curve values were calculated to assess the outcomes, paired comparisons of efficacy and safety of five treatments.

Results: Nine peer-reviewed randomized controlled trials, comprising 1674 patients in recent 10 years, were included. Heterogeneity tests showed no statistical significance, and a consistency model was chosen, respectively. The order of surface under the cumulative ranking curve values for efficacy was as follows: PCNL (79.4), MPCNL (75.2), UMPCNL (66.3), RIRS (29), and eSWL (0). For safety: eSWL (84.2), UMPCNL (82.2), RIRS (52.9), MPCNL (16.6), and PCNL (14.1).

Conclusion: In the current study, all five treatments are both effective and safe. Many factors must be considered to choose surgical treatments for LC stones 20 mm or less; the results that we separate conventional PCNL into PCNL, MPCNL, and UMPCNL make the questions even more controversial. However, relative judgments are still needed to be used as reference data in clinical management. For efficacy, PCNL>MPCNL>UMPCNL>RIRS>ESWL, ESWL is statistically inferior to the other four treatments, respectively. RIRS is statistically inferior to PCNL and MPCNL, respectively. For safety, ESWL>UMPCNL>RIRS>MPCNL>PCNL, ESWL is statistically superior to RIRS, MPCNL, and PCNL, respectively. RIRS is statistically superior to PCNL. We cannot reach conclusions about which surgical treatment is the best choice for all patients with LC stones 20 mm or less; therefore, tailored treatments based on individual patients still demand more attention than ever before for both patients and urologists.