Endoscopic Combined Intrarenal Surgery (ECIRS) Versus Percutaneous Nephrolithotomy (PCNL) for Large and Complex Renal Stone: A Systematic Review and Meta-Analysis

Background Managing complex and large renal stone with percutaneous nephrolithotomy (PCNL) is difficult due to the likelihood of residual stone and multiple access. Endoscopic combined intrarenal surgery (ECIRS) is introduced as an improvement to the procedure to manage stones in one session. The objective of this systematic review and meta-analysis is to compare the efficacy and safety between ECIRS and PCNL for treating large and complex renal stone. Materials and Methods We conducted a systematic review in the Embase, Scopus, and MEDLINE databases based on the 2020 Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guideline. Eligible studies comprised both randomized and non-randomized studies comparing ECIRS and PCNL. Results A total of five non-randomized studies and one randomized controlled trial (RCT) were included. The analysis was divided into two subgroups based on the PCNL type, a conventional PCNL (cPCNL) and a mini-PCNL (mPCNL). The one-step stone-free rate (SFR) of ECIRS were significantly higher compared to both the cPCNL (OR 5.14, 95%CI 2.54 - 10.4; p < 0.001) and mPCNL (OR 4.27, 95% CI 2.57 - 7.1, p < 0.001). There were no significant differences in mean operative time (MOT) and hemoglobin drop between both groups (p>0.05). The use of auxiliary procedures was significantly higher in both PCNL groups compared to the ECIRS group (OR 0.19, 95% CI 0.13 - 0.30, p < 0.001). The overall complication rate of ECIRS was lower compared to PCNL (OR 0.43, 95% CI 0.21 - 0.85, p = 0.02), especially urosepsis, in which the incidence was lower compared to cPCNL (OR: 0.14, 95% CI 0.02-0.78, p=0.02), but not mPCNL (p>0.05). Conclusion ECIRS is an effective and safe treatment particularly for large and complex nephrolithiasis, with significantly higher one-step SFR, lower necessity for auxiliary procedures, and a lower complication rate compared to PCNL.