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 (fURS) compared with conventional ureteroscopy (cURS) in the management of ureteral and renal stones. Evidence Acquisition: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies providing data on the stone-free rate (SFR), secondary procedures, operative time (OT), and complication rate for fURS and cURS 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 cURS, fURS exhibited a similar SFR (odds ratio [OR]: 0.99; 95% confidence interval [CI]: 0.92 to 1.06; p = 0.709), without significant differences in overall intraoperative complication rate (OR: 0.73; 95% CI: 0.33 to 1.63; p = 0.446), overall postoperative complication rate (OR: 0.98; 95% CI: 0.59 to 1.63; p = 0.949), major postoperative complication rate (Clavien ≥3; OR: 0.46; 95% CI: 0.14 to 1.53; p = 0.205), OT (standardized mean difference [SMD]: 0.07; 95% CI: -0.15 to 0.29; p = 0.537), hospital stay (SMD: -0.12; 95% CI: -0.26 to 0.02; p = 0.084), or secondary procedures (OR: 1.20; 95% CI: 0.58 to 2.49; p = 0.616). The 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% to 7%). Conclusions: The available data suggest that for the treatment of ureteral and renal stones, fURS offers a similar SFR to that provided by the cURS without any increase in complication rate, OT, hospital stay, or secondary procedures. Critical review of the dogmatic routine use of fluoroscopy during ureteroscopy may be warranted.