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

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.