Is endoscopic combined intrarenal surgery ready for primetime in endourology? Outcomes from a systematic review and meta-analysis

Abstract

Introduction: We aimed to review the outcomes of endoscopic combined intrarenal surgery (ECIRS) as compared to conventional percutaneous nephrolithotomy (PCNL) for kidney stones.

Material and methods: We performed a systematic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We included all studies comparing ECIRS and conventional PCNL. Surgical time, hemoglobin drop, and postoperative stay were pooled using the inverse variance of the mean difference (MD) with a random effect, 95% confidence intervals (CI), and p-values. Complications, stone-free rate, and retreatment were assessed using Cochran-Mantel-Haenszel method with random effect model and expressed as odds ratio (OR), 95% CI, and p-values.

Results: A total of 17 studies were included. Surgical time and mean postoperative length did not significantly differ between the groups (MD -8.39 minutes 95%CI -21.30, 4.53, p = 0.20; 5.09 days 95%CI -19.51, 29.69, p = 0.69). Mean hemoglobin drop was significantly lower in the ECIRS group (MD -0.56 g/dl 95%CI -1.08, -0.05, p = 0.03), while blood transfusion rate did not differ between the two groups (OR 0.88 95%CI 0.64, 1.23, p = 0.15). While the incidence of postoperative sepsis did not differ between the two groups (OR 0.52 95% CI 0.17, 1.59, p = 0.25), the incidence of postoperative fever was lower in the ECIRS group but the difference was not significant (OR 0.61 95%CI 0.35, 1.06, p = 0.08). The stone-free rate was significantly higher in the PCNL group (OR 2.52 95%CI 1.64, 3.90, p <0.0001) and the retreatment rate was lower in the ECIRS group (OR 0.34 95%CI 0.14, 0.87, p = 0.002).

Conclusions: ECIRS showed shorter operative time, lower complication rate, and retreatment compared to PCNL. Conventional PCNL showed a higher stone-free rate.

Keywords: endoscopic combined intrarenal surgery; kidney stone; percutaneous nephrolithotomy; retrograde intrarenal surgery.

Figure 1

PRISMA flow diagram of the study.

Figure 2

Meta-analysis of surgical time and length of stay in studies comparing ECIRS vs conventional PCNL. ECIRS – endoscopic combined intrarenal surgery; PCNL – percutaneous nephrolithotomy

Figure 3

Meta-analysis of bleeding in studies comparing ECIRS vs conventional PCNL. ECIRS – endoscopic combined intrarenal surgery; PCNL – percutaneous nephrolithotomy

Figure 4

Meta-analysis of infection complications in studies comparing ECIRS vs conventional PCNL. ECIRS – endoscopic combined intrarenal surgery; PCNL – percutaneous nephrolithotomy

Figure 5

Meta-analysis of stone-free rate and retreatment rate in studies comparing ECIRS vs conventional PCNL. ECIRS – endoscopic combined intrarenal surgery; PCNL – percutaneous nephrolithotomy

Figure 6

Risk of bias in non-randomized controlled trials (ROBINS-I). A) Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies; B) Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Figure 7

Risk of bias in randomized controlled trials (ROB-2). A) Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies; B) Risk of bias summary: review authors' judgements about each risk of bias item for each included study.