An Updated Systematic Review, Meta-analysis, and Trial Sequential Analysis of Endoscopic Combined Intrarenal Surgery (ECIRS) versus Percutaneous Nephrolithotomy (PCNL) for Upper Urinary Tract Calculi
In brief
Combined endoscopic surgery raises stone-free rates 40% and halves major complications
In a meta-analysis of 18 studies (946 ECIRS vs 1226 PCNL patients), ECIRS achieved a markedly higher stone-free rate-about 40% fewer residual fragments-and cut major (Clavien-Dindo at least 3) complications roughly in half. Hospital stay was also about one-day shorter, suggesting lower morbidity, but the evidence is largely observational and awaits confirmation in randomized trials.
- Journal
- European urology open science (Q1)
- Published
- 7 September 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Bruno D Terada, Artur S Almeida, Felipe G A Gonçalves, Leonardo O D da Silva, Breno C Porto, Rodrigo A S Sardenberg, et al.
- PMID
- 42750827
- DOI
- 10.1016/j.euros.2026.07.005
Why clinicians should know about it
- Picked for Urology (paper of the day, 18 September 2026): ECIRS vs PCNL outcomes for upper urinary tract stones
Abstract
CONTEXT: Percutaneous nephrolithotomy (PCNL) remains the gold standard for large intrarenal stones. However, endoscopic combined intrarenal surgery (ECIRS) has emerged as an alternative, offering simultaneous antegrade and retrograde access with enhanced intrarenal visualization. This systematic review and meta-analysis evaluates the comparative outcomes of ECIRS and PCNL, with the aim of synthesizing available evidence on stone-free rates (SFRs), complications, and perioperative variables. OBJECTIVE: This systematic review and meta-analysis evaluates the comparative outcomes of ECIRS and PCNL, with the aim of synthesizing available evidence on stone-free rates (SFRs), complications, and perioperative variables. EVIDENCE ACQUISITION: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic review was conducted across MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library for studies comparing ECIRS with PCNL for the treatment of upper urinary tract calculi in adult patients. The primary endpoint was SFR; secondary outcomes included length of hospital stay (LOS) and postoperative complications. Statistical analysis was conducted using R version 4.6.0 software. EVIDENCE SYNTHESIS: Eighteen studies met inclusion criteria, encompassing 946 patients treated with ECIRS and 1226 with PCNL. Meta-analysis revealed that ECIRS was associated with a lower risk of residual fragments-that is, higher SFR-(risk ratio [RR] = 0.41; 95% confidence interval [CI]: 0.33 to 0.52; p < 0.001). Postoperative fever (RR = 0.79; 95% CI: 0.56-1.11; p = 0.2) and urosepsis (RR = 0.66; 95% CI: 0.30-1.45; p = 0.3) were not statistically significantly different between groups. Major complications (Clavien-Dindo grade ≥3) occurred less frequently with ECIRS (RR = 0.51; 95% CI: 0.30 to 0.87; p = 0.01), and postoperative LOS was also shorter in the ECIRS group (mean difference = -1.30 d; 95% CI: -2.10 to -0.51; p = 0.001). CONCLUSIONS: The available evidence suggests that ECIRS is associated with better SFRs and fewer major complications compared with PCNL, though these findings are primarily driven by observational data and should be interpreted with caution. These results are consistent with ECIRS being a potentially effective, lower-morbidity option in selected patients, though confirmation in high-quality randomized trials is warranted.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.