How Do Combined Percutaneous Nephrolithotomy and Retrograde Intrarenal Surgery Impact Stone-Free Rates, Surgical Complications, and Patient Recovery Time in Advanced Kidney Stone Cases? : A Systematic Review and Metaanalysist Studies

Abstract

Introduction: The management of large (>2 cm) and complex kidney stones poses a significant urological challenge. While percutaneous nephrolithotomy (PCNL) is the standard treatment, it carries risks and may require multiple access tracts, increasing morbidity. Combined approaches, such as PCNL with retrograde intrarenal surgery (RIRS), have emerged as a promising strategy to improve outcomes. This systematic review and meta-analysis evaluates the impact of combined surgical techniques on stone-free rates, surgical complications, and patient recovery time for advanced kidney stone disease. Methods: Adhering to PRISMA guidelines, a systematic search was conducted across PubMed, Semantic Scholar, Springer, and Google Scholar. Inclusion criteria targeted studies comparing combined PCNL and RIRS with other modalities in adult patients with large or complex stones. Following screening and data extraction, 21 studies were included for qualitative synthesis and meta-analysis. Results: The meta-analysis revealed that combined approaches resulted in significantly higher stone-free rates (Hazard Ratio [HR]: 0.80, 95% CI: 0.75-0.85) , shorter operating times (HR: 0.72, 95% CI: 0.59-0.86) , shorter hospital stays (HR: 0.68, 95% CI: 0.62-0.75) , faster recovery times (HR: 0.63, 95% CI: 0.57-0.7) , and a lower frequency of complications (HR: 0.25, 95% CI: 0.11-0.59). No statistically significant difference was found for blood loss. Significant heterogeneity was detected across all outcomes (I² > 96%). Conclusion: The evidence strongly suggests that for large and complex kidney stones, combined surgical approaches offer superior efficacy and safety compared to monotherapy. These techniques lead to higher stone-free rates, fewer complications, and faster patient recovery. However, the conclusions are limited by substantial heterogeneity across the included studies. Future high-quality, large-scale randomized controlled trials with standardized protocols are imperative to validate these findings and refine treatment guidelines.