Economic Evaluation of Surgical Management for Urolithiasis: A Systematic Review of Comparative Cost Analyses from EAU endourology

Why clinicians should know about it

• Picked for Urology (top studies of the week, 1 November 2026): Comparative cost-effectiveness of stone procedures

Abstract

CONTEXT: Urolithiasis is a growing burden on health care systems. Extracorporeal shock wave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PCNL) are the main interventional options; however, their comparative cost-effectiveness is not fully established. OBJECTIVE: We aimed to systematically review comparative research assessing the economic outcomes of these treatment modalities. EVIDENCE ACQUISITION: A systematic search of PubMed/MEDLINE, Scopus, and Web of Science was performed for studies published between January 2010 and December 2025 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO: CRD420261303193). Eligible studies included cost analyses, cost-minimization, cost-effectiveness, cost-utility, and cost-benefit analyses comparing ESWL, RIRS, and/or PCNL. Risk-of-bias assessment used the Bias in Economic Evaluation checklist. All costs were adjusted for 2% annual inflation and converted to 2026 US dollars. EVIDENCE SYNTHESIS: Of the 1861 records identified, 18 studies met inclusion criteria: ESWL versus RIRS (n = 9), ESWL versus PCNL (n = 2), RIRS versus PCNL (n = 4), and three-way comparisons (n = 3). Six studies assessed cost-effectiveness, six assessed cost-utility, and six were cost analyses. In ESWL versus RIRS comparisons, randomized trials reported approximately US $1251 lower costs for ESWL at 6 mo with small quality-adjusted life year (QALY) losses (-0.018 to -0.021), whereas long-term claim data showed higher 7-yr cumulative costs for ESWL (US $4647) compared with RIRS (US $4273). In ESWL versus PCNL studies, ESWL had lower per-patient costs (US $647-747 vs US $1307-1478) despite higher initial stone-free rates with PCNL. In RIRS versus PCNL evaluations, UK trials reported mean 12-mo costs of US $7722 for RIRS and US $6654 for PCNL, with PCNL showing an 87% probability of cost-effectiveness at US $29 152/QALY. Studies showed substantial heterogeneity in time horizons (2 wk to 7 yr), perspectives, and costing methods; only one-third performed probabilistic sensitivity analyses. CONCLUSIONS: Comparative economic value among stone treatments is highly context-dependent: ESWL tends to be less costly in the short term (<12 mo), whereas RIRS may offer better long-term value for smaller stones through lower retreatment rates, and PCNL appears more cost-effective for larger stones in some settings. However, substantial study heterogeneity and methodological limitations restrict the generalizability of these findings. PATIENT SUMMARY: We reviewed studies comparing the costs of the three main treatments for kidney stones: extracorporeal shock wave lithotripsy, ureteroscopy (ie, retrograde intrarenal surgery), and percutaneous nephrolithotomy. We found that shock wave therapy costs less upfront but often requires repeat procedures, whereas ureteroscopy offers better long-term value for smaller stones, and percutaneous nephrolithotomy is most cost-effective for larger stones. More rigorous and longer-term studies are needed before firm recommendations can be made for all patients.

Abstract as published, via PubMed.