Endoscopic Combined Intrarenal Surgery <i>Vs</i> Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis

Introduction: Endoscopic combined intrarenal surgery (ECIRS) has emerged as a significant advancement in the management of patients with a high stone burden or large, complex stones. This technique has been reported to improve the stone-free rate (SFR) while reducing complications commonly associated with percutaneous nephrolithotomy (PCNL). However, most available evidence comes from single-center studies with relatively small cohorts. We conducted a systematic review and meta-analysis to compare perioperative outcomes between the two procedures. Methods: A systematic search of PubMed, Embase, and Scopus databases was conducted to identify both randomized and nonrandomized studies comparing ECIRS and PCNL. Primary outcomes included SFR after a single session, need for ancillary treatments, and major complications (Clavien–Dindo grade ≥3). Secondary outcomes were transfusion rates, operative time, and hospital stay. Random-effects models were applied when heterogeneity was high ( I 2 &gt; 50%). Results were expressed as odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs). Results: Fifteen studies (12 retrospective and 3 randomized) involving 1988 patients were included. A significantly higher SFR (OR 3.02, 95% CI: 2.40–3.80; p &lt; 0.001) and a lower need for ancillary procedures (OR 0.20, 95% CI: 0.13–0.31; p &lt; 0.001) were observed with ECIRS. Similarly, a lower rate of major complications (OR 0.58, 95% CI: 0.34–0.97; p = 0.03) and transfusions (OR 0.49, 95% CI: 0.28–0.88; p = 0.01) also favored ECIRS. Operative time (MD −9.25 minutes, 95% CI: −16.82 to −1.67; p = 0.01) and hospital stay (MD −1.61 days, 95% CI: −2.54 to −0.69; p = 0.0006) were significantly longer in the PCNL group. Conclusions: ECIRS achieved higher single-session SFRs without increasing major complications or transfusion rates. This technique may also reduce operative time and hospital stay, particularly when performed by experienced endourologists. Given that most included studies were retrospective, further randomized trials are required to strengthen the evidence base and better define the clinical role of ECIRS.