Suction ureteroscopy matched mini-PCNL for larger renal stones

Design

Systematic review and meta-analysis (3 randomised trials, 7 cohorts)

Population

2,347 adults with large upper-tract stones, predominantly 2-to-3 cm

Primary outcome

Stone-free rate and perioperative outcomes

Effect

Stone-free odds ratio 0.90 (0.70 to 1.17); fewer complications and shorter stay with suction ureteroscopy

Guidelines still recommend percutaneous nephrolithotomy as first-line for renal stones larger than 2 cm, but flexible ureteroscopy has advanced with high-power lasers and suction access sheaths. This meta-analysis of 10 studies and 2,347 patients compared suction-assisted flexible ureteroscopy with mini-percutaneous nephrolithotomy, mostly for 2-to-3 cm stones.

Stone-free rates were comparable — odds ratio 0.90 (95% CI 0.70 to 1.17) across all sizes and 0.80 (0.60 to 1.08) for stones of 2 cm or more — with similar need for ancillary procedures. Suction ureteroscopy had significantly fewer overall complications, less haemoglobin decline and transfusion, and shorter hospital stay, while mini-percutaneous nephrolithotomy had shorter operative times for the larger stones. Urosepsis was low and similar.

This supports suction-assisted ureteroscopy as a viable primary option for selected 2-to-3 cm stones, not only as a fallback, trading a longer operation for a lower-morbidity, shorter-stay procedure. The evidence is mostly from Asian centres and partly non-randomised, so patient selection and local expertise still guide the choice.

• Meta-analysis of 10 studies (three randomised trials), 2,347 patients, mostly 2-to-3 cm stones.
• Stone-free rates were comparable (odds ratio 0.90, 95% CI 0.70 to 1.17; 0.80 for stones 2 cm or more).
• Suction ureteroscopy had fewer complications, less bleeding and transfusion, and shorter stays.
• Mini-percutaneous nephrolithotomy had shorter operative times for larger stones.
• Consider suction ureteroscopy as a primary option for selected 2-to-3 cm stones, not only a fallback.

Why it matters

It challenges the guideline default of percutaneous surgery for stones over 2 cm, offering a lower-morbidity route where expertise allows.

Don't overread it

Mostly retrospective and Asian-centre data; it supports suction ureteroscopy in selected patients rather than overturning percutaneous nephrolithotomy as standard.

The statistics, in plain English

Stone-free odds ratios near 1.0 with intervals crossing 1.0 mean no meaningful difference in clearance; the safety and stay advantages are the discriminating findings, though mostly non-randomised Asian data temper the certainty.

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