Flexible Ureteroscopy Versus Minipercutaneous Nephrolithotomy for 2 to 4 cm Renal Stones: A Systematic Review and...

As the global prevalence of urolithiasis rises, selecting the optimal surgical intervention for large renal stones remains critical. Although percutaneous nephrolithotomy (PCNL) is the standard for stones more than 2 cm, the choice between flexible ureteroscopy (FURS) and mini-PCNL (mPCNL) for these burdens is debated. This systematic review and meta-analysis compares the efficacy and safety of FURS versus mPCNL for kidney stones measuring 2 to 4 cm.

Following the Preferred Reporting Items of Systematic Reviews and Meta-Analysis guidelines, a comprehensive search of electronic databases identified randomized controlled trials and observational studies comparing FURS and mPCNL in adults with large renal stones of 2 to 4 cm. Primary outcomes included operative time, length of hospital stay, blood loss, hemoglobin drop, stone-free rate (SFR), and overall complication rates.

A total of 20 studies involving 2326 patients were included. The pooled analysis revealed no statistical significance in the overall SFR across groups between FURS and mPCNL (mean difference [MD] = 0.98, 95% confidence interval [CI] [0.95; 1.01], p < 0.1330). Conversely, FURS demonstrated a superior safety profile, with significantly shorter hospital stays (MD = -57.10, 95% CI [-84.10; -30.11], p < 0.0001), reduced hemoglobin drop (MD = -0.75, 95% CI [-1.42; -0.07], p = 0.03), and lower blood transfusion rates (risk difference [RD] -0.02, 95% CI [-0.03; -0.01], p = 0.0013). FURS was associated with a statistically significant decrease in the overall complication incidence rates (risk ratio = 0.52, 95% CI [0.41; 0.65], p < 0.0001).

FURS is a highly effective and safer alternative to mPCNL for managing 2 to 4 cm kidney stones. Although FURS and mPCNL offer close efficacy, FURS significantly minimizes surgical morbidity and hospitalization. The integration of advanced suctioning and laser technologies further positions FURS as a competitive primary treatment for large stone burdens.