Table 1.

Optimal management of LPS in 2016. Comparison of advantages and disadvantages of the various treatment options for lower pole stones. As there is a lack of good quality data comparing Mini-, Ultramini-, and Micro-PNL versus other treatment methods for lower pole stones, these have not been included as separate entities

Treatment Method	Advantages	Disadvantages	Indications
SWL	Non-invasive Few risks and low morbidity Short procedural time Can be done in an Outpatient setting with minimal anaesthetic required	Poor stone free rate for lower pole stones Poor efficacy with stones >1000HU Contraindicated in patients with coagulopathy, large stones, and patients who are pregnant or obese High set-up cost	First line treatment option for lower pole stones <10 mm where no unfavourable factors1 are present
SWL + Adjuvant Therapy2	As above, except stone free rates are higher	As above	As above. The use of adjuvant therapy adds little to no extra cost but is shown to improve stone free rates. Adjuvant therapy is therefore recommended where possible
RIRS	Minimally invasive Minimal hospital stay required High stone free rates Suitable for all stone compositions Morbidity comparable to SWL	Limited visualization Small size of fragment required for removal Reliance on high-cost disposable instrumentation	First line treatment option for lower pole stones <20 mm Indicated where SWL has failed. Second line treatment for stones >20 mm
PNL	Highest stone free rates Suitable for all types of stones and in all locations; Variable (usually short) procedural time Mini-, ultramini-, and micro-PNL with smaller tract sizes can help to minimise morbidity	Invasive Morbidity higher than other treatment options Significant blood loss (in some cases) Longer hospitalisation Serious complications such as urosepsis, pneumothorax and colonic injury are possible; Contra-indicated in patients with bleeding diatheses	Indicated for stones >15 mm. Further research is required to determine the use of mini-, ultramini- and micro-PNL for stones 10-20 mm

¹shockwave-resistant stones, acute infundibulopelvic angle, long lower pole calyx, narrow infundibulum

²inversion, percussion, diuresis