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Systematic review and meta-analysis comparing fluoroless ureteroscopy and conventional ureteroscopy in the management of ureteral and renal stones.

CONTEXT
Stone recurrence is frequent in stone formers, and repeated diagnostic and therapeutic procedures in recurrent stone formers place patients and urologists at a significant risk of radiation-related effects.


OBJECTIVE
To assess the efficacy and safety of fluoroless ureteroscopy (URS) compared with conventional URS in the management of ureteral and renal stones.


EVIDENCE ACQUISITION
A systematic review was performed in accordance with the PRISMA statement. Studies providing data on the stone-free rate (SFR), secondary procedures, operative time, and complication rate for fluoroless URS and conventional URS were included. An overall analysis and a subgroup analysis based on the stone target (ureteral stones, renal stones, or a combination thereof) were performed.


EVIDENCE SYNTHESIS
A total of 23 studies were included, recruiting 4029 patients. Pooled data showed that in comparison with conventional URS, fluoroless URS exhibited a similar SFR (OR: 0.99; 95% CI: 0.92-1.06; p=0.709), without significant differences in overall intraoperative complication rate (OR: 0.73; 95% CI: 0.33-1.63; p=0.446), overall postoperative complication rate (OR: 0.98; 95% CI: 0.59-1.63; p=0.949), major postoperative complication rate (Clavien ≥3) (OR: 0.46; 95% CI: 0.14-1.53; p=0.205), operative time (SMD: 0.07; 95% CI: -0.15-0.29; p=0.537), hospital stay (SMD: -0.12; 95% CI: -0.26-0.02; p=0.084), or secondary procedures (OR: 1.20; 95% CI: 0.58-2.49; p=0.616). Subgroup analysis revealed no differences in outcomes according to the stone target. We also identified a rate of conversion to the conventional technique of 5% (95% CI: 3%-7%).


CONCLUSION
The available data suggest that for the treatment of ureteral and renal stones, fluoroless URS offers a similar SFR to that provided by the conventional technique without any increase in complication rate, operative time, hospital stay, or secondary procedures. Critical review of the dogmatic routine use of fluoroscopy during URS may be warranted.