Is Nonpapillary Puncture a Feasible Alternative to Papillary Access in Percutaneous Nephrolithotomy? A Systematic Review and Meta-Analysis

Purpose: Percutaneous nephrolithotomy (PCNL) is the gold standard for treating large and complex renal calculi, but puncture path selection (papillary vs nonpapillary) remains a critical debate because of bleeding risk concerns. This systematic review and meta-analysis aimed to compare the safety and efficacy of nonpapillary vs papillary access in PCNL. Methods: A comprehensive literature search was conducted in the PubMed, Embase, Web of Science, Wanfang, and China National Knowledge Infrastructure databases from inception to December 2025, supplemented by an unpublished dataset from our team’s ongoing clinical study. Eligible studies were comparative trials reporting postoperative hemoglobin drop, complication rate, stone-free rate (SFR), or operative time. Quality assessment was performed using the Cochrane Risk of Bias Tool 2.0 and the Newcastle–Ottawa Scale, with statistical analysis conducted in Stata 17.0. Results: A total of nine studies involving 1229 patients (787 in the papillary group and 442 in the nonpapillary group) were included. No significant differences were observed between nonpapillary and papillary access in terms of postoperative hemoglobin drop (mean difference [MD] = 0.159, 95% confidence interval [CI] = −0.365 to 0.683, p = 0.5519), overall complication rate (risk ratio [RR] = 0.949, 95% CI = 0.701 to 1.286, p = 0.7371), blood transfusion rate (RR = 0.835, 95% CI = 0.483–1.443, p = 0.5174), or SFR (RR = 0.970, 95% CI = 0.909–1.035, p = 0.3527). Although no significant overall difference in operative time was found (MD = −1.852, 95% CI = −6.745 to 3.040, p = 0.4580), subgroup analysis of prospective studies revealed that nonpapillary access was associated with a significantly shorter operative time (MD = −6.608, 95% CI = −11.573 to −1.643, p = 0.0091). Conclusion: Nonpapillary access is a safe and effective alternative to papillary access for PCNL, with comparable bleeding risk, complication rate, and SFR, and potential efficiency benefits in standardized settings. Urologists can flexibly select the puncture path based on clinical scenarios, with Doppler ultrasound preferred for avoiding vascular-rich regions. Future large-scale randomized controlled trials with standardized protocols and studies on artificial intelligence-assisted fused-image-guided puncture are warranted to further optimize PCNL access strategies.