Percussion, diuresis, and inversion therapy can facilitate lower renal pole stone passage after extracorporeal shock wave lithotripsy and retrograde intrarenal surgery? A systematic review and meta-analysis of randomized controlled trials.

PURPOSE: Patients with lower pole stones (LPS) present a significant challenge for urologists because of the increased likelihood of residual fragments and recurrence following extracorporeal shockwave lithotripsy (ESWL) and retrograde intrarenal surgery (RIRS). Although percussion, diuresis, and inversion (PDI) therapy has demonstrated potential for enhancing the stone-free rate (SFR) in these patients, its application remains a topic of debate. Consequently, our objective was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate SFR outcomes when comparing PDI therapy with observation in patients with LPS. MATERIALS AND METHODS: A systematic search was performed using PubMed, Embase, and Cochrane Library. We excluded conference abstracts, non-RCT trials, and studies that used the Lithecbole device. The main outcome was SFR, which was defined per study as no visible stone or residual fragments ≤ 2-4 mm. Risk of bias was assessed using the Cochrane RoB-2 tool and statistical analysis was performed using Review Manager 5.4.1 (Cochrane Collaboration). RESULTS: Five RCTs comprising a total of 394 patients with LPS were included in this meta-analysis. Of these, 208 (52.7%) underwent PDI therapy; within the PDI group, 60 (28.8%) underwent RIRS and 148 (71.1%) underwent ESWL. The follow-up period ranged from 2 weeks to 3 months. Three studies reported the mean infundibular-pelvic angle and infundibular length; there was no significant difference between PDI and control (25.9 vs. 24.8 mm; p = 0.83) and (69.1 vs. 69.9 degrees; p = 0.20), respectively. The meta-analysis revealed a statistically significant difference in SFR (OR 3.81; 95% CI 2.40, 6.06; p < 0.00001; I²=0%; Fig. 2). Furthermore, there was no significant difference in the overall complication rate between groups (OR 0.36; 95% CI 0.04, 3.56; p = 0.38; I²=0%; Fig. 3). No study reported complications of Clavien-Dindo grade III or higher. CONCLUSIONS: In conclusion, PDI therapy after ESWL or RIRS was associated with a higher short-term SFR in patients with LPS compared with observation. These findings suggest a potential benefit of PDI as an adjunctive strategy for patients with LPS.