Relocating lower pole stones during retrograde intrarenal surgery improves stone-free rate

Lower pole renal stones are more difficult to clear during retrograde intrarenal surgery (RIRS) due to anatomical constraints. This meta-analysis aimed to evaluate whether relocating these stones to a more accessible calyx before lithotripsy improves surgical outcomes. A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, and Web of Science were searched up to July 2025. Included studies were randomized controlled trials comparing stone relocation versus in situ lithotripsy during RIRS in adult patients with unilateral lower pole renal stones ≤2 cm. Primary outcomes included stone-free rate, operative time, and complication rates. Three RCTs involving 282 patients (140 relocation and 142 in situ) were analyzed. Relocation significantly improved stone-free rate (RR = 1.17; 95% CI, 1.05-1.29; P = 0.003), with low heterogeneity ( I ² = 25%). Operative time was slightly longer with relocation (mean difference = 4.55 min), but not statistically significant ( P = 0.10). Complication rates were comparable (RR = 1.48; P = 0.25). All included studies were assessed as having low risk of bias based on the Cochrane Risk of Bias 2.0 tool. Relocating lower pole stones during RIRS appears to improve stone clearance without increasing operative time or complications, and seems safe and effective, although the results should be interpreted cautiously due to the limited sample size.