Fluoroless ultrasound-guided techniques lower complications in percutaneous nephrolithotomy with equivalent stone-free rates

BACKGROUND: Endourologic procedures for ureteral/renal stones traditionally rely on fluoroscopic guidance. The necessity of fluoroscopy for safe and effective stone treatment remains controversial. OBJECTIVE: To perform a systematic review and meta-analysis to evaluate intraoperative, perioperative, and postoperative outcomes of fluoroless fluoroscopy-guided endourologic procedures for kidney and/or ureteral stones. MATERIALS AND METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, we searched PubMed, Cochrane Central Register, and Scopus on 13 November 2025. Inclusion criterion comprised randomized trials comparing fluoroless with fluoroscopy-guided ureteroscopy (URS) or percutaneous nephrolithotripsy (PCNL). Binary outcomes were assessed using the Cochran-Mantel-Haenszel Method with the random effect model and reported as odds ratio (OR), 95% confidence interval (CI), and p-values. Continuous variables were pooled using the inverse variance of the mean difference with a random effect. Statistical significance was set at < 0.05. EVIDENCE SYNTHESIS: Eighteen randomized studies were included: 7 URS studies (1119 patients) and 11 PCNL studies (1370 patients). For PCNL, fluoroless ultrasound-guided techniques demonstrated superior safety with significantly lower overall complications (OR 0.57, 95% CI 0.42-0.78, = 0.0004), minor complication- (OR 0.60, 95% CI 0.41-0.86, = 0.006), and major complication- rates (OR 0.52, 95% CI 0.30-0.88, = 0.02) compared with fluoroscopy-guided approaches. Stone-free rates (SFRs) were equivalent between groups (OR 1.03, 95% CI 0.77-1.38, = 0.83). For URS, fluoroless approaches showed comparable overall complications (OR 1.08, 95% CI 0.81-1.45, = 0.60), major complications, SFR (OR 0.89, 95% CI 0.65-1.19, = 0.47), and reintervention rates. Flexible fluoroless URS demonstrated fewer minor complications (OR 2.09, 95% CI 1.43-3.06, < 0.0001). Mean surgical time increased minimally for fluoroless URS (1.60 minutes, = 0.03). CONCLUSIONS: Fluoroless ultrasound-guided PCNL demonstrates superior safety with maintained efficacy compared with fluoroscopy-guided techniques. Fluoroless URS shows equivalent safety and efficacy with minimal operative time differences. These findings support transitioning from fluoroscopy-dependent to fluoroscopy-optional endourology, aligning with radiation safety principles while maintaining optimal patient outcomes.