Safety and effectiveness of retrograde intrarenal surgery versus percutaneous nephrolithotomy in older patients: a systematic review and meta-analysis by the EAU-YAU urolithiasis and EAU endourology sections

BACKGROUND: The comparative efficacy and safety of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) have been extensively evaluated in the general adult population; however, evidence specifically focused on older patients remains limited. Given the underrepresentation of older individuals in comparative studies and the lack of age-specific meta-analytic data, we conducted a systematic review and meta-analysis to evaluate and compare the efficacy and safety of RIRS versus PCNL in the geriatric population. METHODS: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Comparative studies evaluating outcomes of RIRS and PCNL in older patients were identified through comprehensive searches of PubMed/MEDLINE, Embase, Web of Science, and the Cochrane Library up to January 2026. Primary outcomes included overall, minor, and major complications, as well as stone-free rate (SFR). Subgroup analyses were performed according to the age thresholds used to define the geriatric population (≥ 60 and ≥ 65 years). RESULTS: Eight studies including 849 older patients (419 RIRS, 430 PCNL) were analysed. PCNL was associated with a significantly higher final SFR (OR 0.63, 95% CI: 0.43-0.93; p = 0.02). RIRS was associated with lower odds of overall complications (OR 0.54, 95% CI: 0.37-0.80; p = 0.002), minor complications (OR 0.65, 95% CI: 0.43-0.98; p = 0.04), major complications (OR 0.30, 95% CI: 0.12-0.74; p = 0.008), and blood transfusion (OR 0.14, 95% CI: 0.04-0.49; p = 0.002). No significant differences were observed in postoperative fever or sepsis. Operative time did not differ significantly, whereas hospital stay was significantly shorter following RIRS (MD - 2.0 days, 95% CI: -2.6 to - 1.3; p < 0.001). CONCLUSIONS: In older adults, PCNL was associated with higher stone clearance rates, whereas RIRS showed a more favourable safety profile and shorter hospitalisation. Treatment selection should balance efficacy against perioperative morbidity.