Management options for lower pole renal calculi

PURPOSE OF REVIEW: The optimal treatment of lower pole renal calculi is controversial. Shock wave lithotripsy, ureteroscopy and percutaneous nephrostolithotomy all constitute viable therapeutic options in select patients. RECENT FINDINGS: Lower pole stones smaller than 1 cm in diameter can be managed with observation, shock wave lithotripsy or ureteroscopy. Patients electing expectant management should be counseled regarding the potential for stone-related symptom progression and need for future intervention. Shock wave lithotripsy and ureteroscopy have similar stone-free rates, although shock wave lithotripsy may be preferable due to more favorable secondary outcomes. Lower pole stones 1-2 cm in diameter are best managed with percutaneous nephrostolithotomy, although ureteroscopy is an option in select patients, particularly those not considered candidates for percutaneous nephrostolithotomy. Finally, patients with lower pole stones larger than 2 cm are best served with percutaneous nephrostolithotomy, as the morbidity in experienced hands is low and stone-free rates are unequivocally higher than those of other treatment modalities. SUMMARY: A variety of factors, including patient body habitus, local renal anatomy, cost and patient preference, must be taken into consideration when determining the optimal treatment modality for lower pole renal calculi.