Pleurectomy versus chemical pleurodesis for primary spontaneous pneumothorax: a systematic review and meta-analysis

Background The 2024 joint European guidelines could make no recommendation on pleurectomy versus chemical pleurodesis for preventing recurrence of primary spontaneous pneumothorax. We compared recurrence, postoperative complications and long-term harms after the two techniques. Methods We searched PubMed, Cochrane CENTRAL (including trial registry records), eLibrary.ru, CyberLeninka and Google Scholar on 3 October 2026 without date or language limits, and performed forward citation searching and reference-list checking. Direct or extractable comparisons of pleurectomy with chemical pleurodesis in primary spontaneous pneumothorax were eligible provided co-interventions on bullae were balanced; studies in which the balance could not be verified were analyzed separately. Risk ratios were pooled under a random-effects model (restricted maximum likelihood, Knapp–Hartung adjustment); complications were synthesized narratively. Risk of bias was assessed with ROBINS-I and certainty with GRADE, starting from high certainty. The review received no funding. Results Of 3074 records screened and 323 reports assessed in full text, eight non-randomized studies (ten reports) were included. In the primary analysis (five studies, 1082 patients or procedures; 26/428 recurrences after pleurectomy, 15/654 after chemical pleurodesis) the risk ratio was 1.42 (95% confidence interval 0.64–3.18; I² = 0%); sensitivity analyses on this set were not statistically significant, except fixed-effect models using the unstratified data of one study. Adding a multicenter cohort in which the balance of co-interventions could not be verified gave 1.94 (1.14–3.32). Complications showed no consistent difference between groups. In the multicenter cohort of uncertain eligibility, the only study to report long-term harms, chronic chest paresthesia was reported in 56% of patients after partial pleurectomy versus 6% after talc poudrage, and chronic chest pain in 18% versus 0.3%. Certainty of evidence was very low for every outcome. Conclusions The evidence is very uncertain whether pleurectomy and chemical pleurodesis differ in recurrence or postoperative complications. One cohort of uncertain eligibility reported far more chronic chest paresthesia and pain after partial pleurectomy than after talc poudrage — a signal that requires confirmation in independent comparative studies. These findings do not support a general preference for either technique. Systematic review registration PROSPERO CRD420261387101. Registration The review protocol was registered in PROSPERO (CRD420261387101; submitted 13 May 2026, registered 14 May 2026) after pilot work, so registration was not fully prospective. The timing of registration and all deviations from the registered information are reported in the Methods and in Additional file 1. The review is not a clinical trial and no trial registration applies.