Retrograde intrarenal surgery versus miniaturized percutaneous nephrolithotomy for renal calculi: a grade-assessed meta-analysis of randomized controlled trials with trial sequential analysis

Clinical Snapshot

Key Findings

• P Value: p < 0.001

• Effect Size: RR 0.92 favoring mPCNL

• Primary Outcome: Single session stone-free rate significantly higher with mPCNL

• Nnt Or Sensitivity: For every 12.5 patients treated with mPCNL instead of RIRS, one additional patient achieves single-session stone clearance

• Confidence Interval: 95% CI: 0.88-0.96

Clinical Application

Both techniques widely available in Australian tertiary urology centers with appropriate expertise Relevant to Australian urological practice; both procedures covered under Medicare with appropriate item numbers; aligns with Urological Society of Australia and New Zealand guidelines for stone management Patients with 1-3cm renal stones suitable for minimally invasive intervention

Abstract

BACKGROUND: The optimal management of medium-sized (1-3 cm) renal stones remains a clinical dilemma, with retrograde intrarenal surgery (RIRS) and miniaturized percutaneous nephrolithotomy (mPCNL) serving as competing minimally invasive options. To overcome the selection bias inherent in previous meta-analyses that included observational data, we aimed to compare the efficacy and safety of both techniques by exclusively analyzing randomized controlled trials (RCTs). METHODS: A systematic literature search of five databases was conducted up to February 2026. Only RCTs comparing RIRS and mPCNL were included. The primary outcomes were the single session stone-free rate (SFR) and overall complication rate. Secondary outcomes included stone clearance-related outcomes, operative performance outcomes, and recovery-related outcomes. Data were pooled using a random-effects model, and trial sequential analysis (TSA) was applied. RESULTS: Thirty RCTs encompassing 4173 patients were included. mPCNL demonstrated a significantly higher single-session SFR compared to RIRS (R.R: 0.92, 95% C.I: 0.88-0.96, p < 0.001). RIRS showed a trend toward a lower overall complication rate although the difference did not reach statistical significance (RR = 0.79, 95% CI: 0.63-1.01; p = 0.057), reduced blood transfusion requirements, smaller hemoglobin drops, and shorter hospitalization times. However, RIRS required significantly more postoperative auxiliary procedures. Operative times and high-grade Clavien-Dindo III-V complication rates were comparable between both techniques. TSA confirmed that the cumulative evidence for single-session SFR was sufficient and conclusive, whereas TSA findings for overall complication rate should be interpreted cautiously. CONCLUSIONS: mPCNL achieves significantly higher SFR than RIRS in the management of 1-3 cm renal calculi. However, RIRS was associated with lower bleeding-related morbidity and shorter hospitalization, although no statistically significant difference was observed in the overall complication rate. Therefore, the choice between RIRS and mPCNL should be individualized, balancing maximal SFR against procedural invasiveness according to patient characteristics and stone complexity.

References

1. 1.Alharran, A. M., Albloushi, M. H., Ali, A. M., Aldousari, A. H., Gadelmawla, A. F., Taleb, A. H., & Alaradi, H. (2026). Retrograde intrarenal surgery versus miniaturized percutaneous nephrolithotomy for renal calculi: A grade-assessed meta-analysis of randomized controlled trials with trial sequential analysis. World Journal of Urology. https://doi.org/10.1016/j.juro.2007.11.076