Efficacy and safety of different guidance methods in percutaneous nephrolithotomy: a network meta-analysis

Precisely establishing puncture access is crucial for successful percutaneous nephrolithotomy (PCNL). This study compared the efficacy and safety of different puncture guidance methods in PCNL.

A search was conducted in Web of Science, PubMed, Embase, and Cochrane Library up to 8 March 2025 for randomized controlled trials (RCTs) comparing five guidance methods (fluoroscopy, ultrasound (US), fluoroscopy + US, contrast-enhanced US (CEUS), and CT 3D image reconstruction) in PCNL. Complications, operation time, stone clearance rate, length of stay, first puncture success rate, and hemoglobin loss were compared by network meta-analyses. We assessed the risk of bias using the Risk of Bias 2 (RoB 2) tool, and assessed the certainty of evidence using the Confidence in Network Meta-Analysis (CINeMA).

Twenty-seven RCTs (n = 3223) were included. CT 3D image reconstruction [RR 1.07, 95% CrI (1.01, 1.14)] and CEUS [RR 1.09, 95% CrI (1.00, 1.20)] had higher stone clearance rates than US. CT 3D image reconstruction [RR 0.33, 95% CrI (0.21, 0.52)] and CEUS [RR 0.46, 95% CrI (0.26, 0.79)] had lower complication rates than fluoroscopy. CT 3D image reconstruction had shorter operation time than US [SMD -0.63, 95% CrI (-0.96, - 0.30)] and fluoroscopy [SMD -0.56, 95% CrI (-0.94, - 0.16)]. CT 3D image reconstruction [SMD -0.77, 95% CrI (-1.24, - 0.30)] and CEUS [SMD -1.23, 95% CrI (-1.72, - 0.76)] had less hemoglobin loss than fluoroscopy. No significant differences were present in the first puncture success rate and length of stay among these interventions (P>0.05).

CT 3D image reconstruction and CEUS, as guidance methods in PCNL, are superior in safety and efficacy, but further RCTs are required.