ECIRS triples stone-free odds versus PCNL in large kidney stones, meta-analysis finds

Photo by Trust "Tru" Katsande / Unsplash

Journal of endourology Published June 1, 2026 Medically reviewed June 1, 2026 Study authors: Calvillo-Ramirez Alejandro, Pauchard Felipe, Anceno Alec, Del Rio-Martinez Christopher J, Acevedo-Ro… PubMed ↗ DOI ↗ By Dr. Lars van Dijk, PhD · Surgical, Procedural & Diagnostic

Key Takeaway

Consider ECIRS over PCNL for large kidney stones to improve stone-free rates and reduce complications.

This systematic review and meta-analysis compared endoscopic combined intrarenal surgery (ECIRS) with percutaneous nephrolithotomy (PCNL) in patients with a high stone burden or large, complex kidney stones. The analysis included 1988 patients across multiple studies.

ECIRS was associated with a significantly higher stone-free rate after a single session (OR 3.02, 95% CI: 2.40-3.80, p < 0.001) and a lower need for ancillary procedures (OR 0.20, 95% CI: 0.13-0.31, p < 0.001). Major complications (Clavien-Dindo grade ≥3) were also lower with ECIRS (OR 0.58, 95% CI: 0.34-0.97, p = 0.03), as were transfusion rates (OR 0.49, 95% CI: 0.28-0.88, p = 0.01). Operative time was shorter with ECIRS by a mean difference of -9.25 minutes (95% CI: -16.82 to -1.67, p = 0.01), and hospital stay was shorter by -1.61 days (95% CI: -2.54 to -0.69, p = 0.0006).

The authors note that most included studies were retrospective and came from single-center settings with relatively small cohorts, which limits the strength of the evidence. No data on follow-up duration or funding were reported.

For clinicians, ECIRS may offer advantages in stone clearance and perioperative outcomes for patients with complex stones, particularly when performed by experienced endourologists. However, the retrospective nature of the evidence warrants cautious interpretation.

Study Details

Study typeMeta analysis

Sample sizen = 1,988

EvidenceLevel 1

PublishedJun 2026

PMID42021727

View Original Abstract ↓

INTRODUCTION: Endoscopic combined intrarenal surgery (ECIRS) has emerged as a significant advancement in the management of patients with a high stone burden or large, complex stones. This technique has been reported to improve the stone-free rate (SFR) while reducing complications commonly associated with percutaneous nephrolithotomy (PCNL). However, most available evidence comes from single-center studies with relatively small cohorts. We conducted a systematic review and meta-analysis to compare perioperative outcomes between the two procedures. METHODS: A systematic search of PubMed, Embase, and Scopus databases was conducted to identify both randomized and nonrandomized studies comparing ECIRS and PCNL. Primary outcomes included SFR after a single session, need for ancillary treatments, and major complications (Clavien-Dindo grade ≥3). Secondary outcomes were transfusion rates, operative time, and hospital stay. Random-effects models were applied when heterogeneity was high ( > 50%). Results were expressed as odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs). RESULTS: Fifteen studies (12 retrospective and 3 randomized) involving 1988 patients were included. A significantly higher SFR (OR 3.02, 95% CI: 2.40-3.80; < 0.001) and a lower need for ancillary procedures (OR 0.20, 95% CI: 0.13-0.31; < 0.001) were observed with ECIRS. Similarly, a lower rate of major complications (OR 0.58, 95% CI: 0.34-0.97; = 0.03) and transfusions (OR 0.49, 95% CI: 0.28-0.88; = 0.01) also favored ECIRS. Operative time (MD -9.25 minutes, 95% CI: -16.82 to -1.67; = 0.01) and hospital stay (MD -1.61 days, 95% CI: -2.54 to -0.69; = 0.0006) were significantly longer in the PCNL group. CONCLUSIONS: ECIRS achieved higher single-session SFRs without increasing major complications or transfusion rates. This technique may also reduce operative time and hospital stay, particularly when performed by experienced endourologists. Given that most included studies were retrospective, further randomized trials are required to strengthen the evidence base and better define the clinical role of ECIRS.