Nephrolithiasis is a very prevalent disease affecting 10 to 15% of people worldwide (1). For the past decades, the incidence of nephrolithiasis has been increasing even further. This is mainly attributed to dietary changes (like high salt intake), surging incidence of metabolic syndrome or obesity, and climate change where higher mean temperatures has made dehydration a more common occurrence (2, 3). Moreover, the recurrence of stone disease is also very common. Up to 50% of patients, who were initially newly diagnosed with urolithiasis, will experience at least one episode of recurrence within five years(4). Global studies have confirmed the rising prevalence of urolithiasis without sparing anyone and equally affecting both low- and high-income regions (5, 6), which further highlights the growing burden of urolithiasis on healthcare systems worldwide.

Although some kidney stones remain asymptomatic, many patients present with acute flank pain, hematuria, urinary tract infections, or urinary obstruction, often necessitating intervention. In certain cases, untreated stones may result in chronic kidney damage or infection-related complications (7). Management options range from watchful waiting to minimally invasive interventions like ureteroscopy or more invasive options like percutaneous procedures, depending on the clinical presentation, stone anatomy and patient-specific factors.

The primary treatment modalities include ESWL, URS (including both flexible and rigid modalities) and PCNL. The choice of treatment depends on stone size, location, burden, composition, renal anatomy, comorbidities, and patient’s preference (8). Guidelines have been developed by the EAU to help guide the choice of intervention (7). Many studies have shown that URS and PCNL generally achieve higher SFRs than ESWL, particularly for larger or lower-pole stones (9–11). Flexible URS outperformed ESWL for 5–20 mm stones (10), and mini-PCNL matched standard PCN, but with less morbidity (12). All of these and many other findings highlight the importance of tailoring treatment to stone parameters and patient centered factors rather than relying on a single preferred modality.

Beyond clinical success, the economic dimension of stone management has gained increasing importance as healthcare systems look for cost-effective and sustainable care. Analysing Markov models that compare ESWL, URS, and PCNL, have demonstrated that while PCNL provides the highest SFR, URS often represents the most cost-effective option for intermediate stone sizes when quality-adjusted life years (QALYs) are taken into consideration(13–15). Studies have revealed wide variability, with direct procedural costs ranging from $249–$48,937 for URS, $177–$10,185 for ESWL, and $165–$101,510 for PCNL, depending on health system context and complication rates (16). The UK-based PUrE Trial 1 demonstrated that for lower-pole stones ≤ 10 mm, flexible URS achieved a higher stone-free rate than ESWL (72% vs 36%). Despite its lower stone clearance, ESWL was more cost-effective. (17). These findings highlight the importance of balancing clinical efficacy with economic and patient-centered considerations in treatment selection.

Beyond clinical and economic measures, quality of life (QoL) has gained increasing recognition as a critical dimension of outcome assessment. Traditional instruments such as the SF-36, disease-specific measures like the Urinary Stones Intervention Quality of Life (USIQoL) questionnaire and QALYs have captured significant post-treatment improvements but also highlight persistent impacts of stone disease on physical and psychosocial well-being (16, 18–20). PROMIS-based analyses demonstrate that patients with recurrent stones experience sustained impairments in pain interference and physical function domains, while even stone-free individuals may continue to report anxiety or lifestyle restrictions related to recurrence risk (21, 22). QoL studies following ESWL, URS, and PCNL consistently suggest that minimally invasive approaches, especially URS, are associated with faster recovery, lower postoperative discomfort, and earlier return to daily activities (23, 24).

In addition to patient-reported quality of life, objective outcomes play a crucial role in determining postoperative recovery and overall well-being. These include length of hospital stay, blood transfusion rate, auxiliary or secondary procedure rate, retreatment rate, and post-procedure complication rate, all of which significantly influence recovery time, morbidity, healthcare costs, and patient satisfaction. Meta-analyses comparing ESWL, URS, and PCNL have shown that ESWL has higher retreatment and auxiliary procedure rates, while PCNL generally carries higher transfusion and complication risks but achieves superior SFRs (10, 25). Similarly, URS tends to offer a favorable balance of shorter hospital stay and lower complication rates with acceptable efficacy (26). Large observational datasets confirm that modality choice affects re-intervention rates and sick-leave duration, which indirectly impacts patients’ physical recovery and quality of life(14). Therefore, combining patient-reported and objective recovery measures provides a more comprehensive understanding of treatment outcomes.

Taken together, the current literature highlights the importance of a multidimensional evaluation of kidney stone management outcomes. Focusing solely on SFR overlooks other crucial aspects of care like clinical, economic, and patient-centered outcomes.

This systematic review aims to compare stone-free rate, treatment cost, and quality-of-life outcomes of ESWL, URS and PCNL (including miniaturized variants). By integrating clinical effectiveness with economic and patient perspectives, this review seeks to support evidence-based practice and optimize healthcare resource allocation in endourology.

The review is structured according to the PICO framework, aiming at adult patients (≥ 18 years) who are diagnosed solemnly with kidney stones. The treatment modalities of interest are ESWL, URS, and PCNL. The studies sought had to compare at least two of these modalities. The primary outcomes included SFR, treatment cost, clinical outcomes and QoL scores.

Literature search was performed across PubMed, Embase, Scopus, and the Cochrane Library. The search included MeSH terms like “kidney stones,” “urolithiasis,” “stone-free rate,” “cost,” “economic evaluation,” “quality of life,” “clinical outcomes” and the treatment modalities “ESWL, URS, PCNL”. Boolean operators like “AND,” “OR” were used to optimize search sensitivity and specificity. Only publications, written in or translated to, English language from 2010 and onwards, comparing at least two of the above mentioned treatment modalities, and including randomized controlled trials (RCTs), cohort studies, and systematic reviews were selected.

Inclusion criteria comprised studies as mentioned above and reporting at least two of the primary outcomes (SFR, cost, clinical outcomes, QoL scores). Only renal calculi were included; however, no differentiation was made based on stone size or anatomical location within the kidney. Exclusion criteria included studies limited to pediatric populations, non-comparative designs, case reports, conference abstracts, expert opinions, and articles not published in English.

Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) was used as a study selection and data extraction tool. Two reviewers independently screened titles and abstracts, and performed full-text assessment for eligibility. Any discrepancies were resolved through discussion until a final consensus was reached on the set of included studies.

The risk of bias for each included study was collated and summarized descriptively, focusing on key methodological domains such as study design, sample size, and reporting transparency. No formal risk-of-bias assessment tools were applied.

A quantitative meta-analysis was conducted using R software (version 4.x; R Foundation for Statistical Computing, Vienna, Austria) within RStudio to compare stone-free rates (SFR) among ESWL, URS, and PCNL. Only SFR measured at 3 months post-procedure was considered, as this was the most frequently reported outcome across studies. Study-level data were cleaned and standardized using the readxl, dplyr, janitor, and tidyr packages to ensure consistent variable naming and formatting. Pairwise meta-analyses were performed using the Mantel–Haenszel method, with risk ratio (RR) as the effect measure. Both fixed- and random-effects (DerSimonian–Laird) models were estimated, with the random-effects model reported as primary. Heterogeneity was assessed using the Cochran Q test and τ² statistics, and studies with invalid or incomplete data, as well as systematic reviews, were excluded. Forest plots were generated to display individual and pooled RRs with 95% confidence intervals, including corresponding event counts and sample sizes.

In order to clearly illustrate the cost-related outcomes of each treatment modality using heterogeneous study designs, albatross plots were constructed. The benefit of the albatros plots is that they provide a visual synthesis of effect estimates, sample sizes, and statistical significance of cost difference at once and neutalizing the discrepancies in the study design of the studies used. Conventional meta-analysis was not feasible due to the lack of standard deviations and confidence intervals in many studies, which would have excluded most available data and weakened the significance of our systematic review. For each study, cost ratios were calculated by dividing the cost of each intervention by the cost of the most expensive procedure, setting the ratio of the last to 1. This approach standardized costs by minimizing variability due to currency, inflation, study year, country-specific pricing, and hospital-level cost differences.For studies reporting effect estimates with associated p-values, point size was scaled by − log₁₀(p), so larger points reflected stronger statistical evidence. The x-axis displayed effect estimates (mean cost ratios), while the y-axis reflected study sample size. Hence, larger trials were positioned higher in the plot. Each treatment modality was color-coded, and study identifiers were included to facilitate cross-referencing. This hybrid approach accommodated both p-value- and interval-based evidence, maximizing data inclusion and providing a simplified comprehensive overview of the literature in one figure. All analyses and visualizations were performed in R (version 4.5.1) using the ggplot2 and ggrepel packages.

QOL Analysis:

Various approaches and techniques of meta-analysis were used to evaluate patient-reported quality of life (QoL) and post-procedural recovery outcomes among URS, ESWL, and PCNL. The main challenge was to incorporate all the various QoL validated questionnaires, including general health instruments (e.g., SF-36, EQ-5D) and procedure-specific items, with pain intensity scores like (VAS) used to capture postoperative discomfort. Hospital stay duration, retreatment rates, auxiliary procedures, transfusions, and complication rates were included as objective outcomes influencing QoL and recovery.

For continuous outcomes such as hospital stay and patient-reported QoL, means and standard deviations were extracted. With the help of the statistics software R (version 4), pairwise meta-analyses were performed using Hedges’ g standardized mean differences (SMDs) and forest plots were generated.

Using the same statistics software, binary outcome variables such as retreatment, auxiliary procedures, transfusions, and complications were studied by calculating risk ratios (RRs) using the Mantel–Haenszel random-effects model. Forest plots were created to display study-level and pooled estimates with 95% confidence intervals, ensuring all study labels and numerical data were clearly visible. Notably, transfusion data for ESWL were excluded since there were no studies which reported transfusions in this group.

Manuscript Writing and Review Process:

The text was independently reviewed and edited by three of the authors, each providing their own revisions and suggestions. All adjustments were then carefully integrated to produce a cohesive and refined final version.

AI was used to help correct grammatical errors, rephrase sentences, and reformat the text for improved readability and visual appeal. It also assisted in phrasing procedural steps and coding for statistical data analysis. No text was entirely generated by AI; it served only as a supportive tool for technical corrections and adjustments, not for creating original content or information.

EndNote was used to manage and format all references accurately throughout the manuscript.

Stone Free Rate:

Forest plots showing pooled risk ratios (RR) with 95% confidence intervals comparing stone-free rates among extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL). Only studies reporting SFR at 3 months post-procedure were included. Random-effects (DerSimonian–Laird) models were applied for pairwise comparisons: (1) URS vs ESWL — favoring URS; (2) PCNL vs URS — favoring PCNL; and (3) ESWL vs PCNL — favoring PCNL.

A total of twenty-eight randomized controlled trials (RCTs) and two cohort studies were included in the SFR meta-analysis. Studies were excluded if key numerical data were unavailable (Deem et al., 2011)(29) or if SFR was reported at time points other than three months (Dutta et al., 2023; Elal et al., 2024)(27, 56). Additionally, Pietropaolo et al. was excluded because outcomes were presented as intervals rather than means or p-values(48).

The meta-analysis demonstrated significant differences in stone-free rates among the three treatment modalities. URS achieved a 28% higher SFR compared with ESWL (pooled RR = 1.28, 95% CI 1.09–1.51, p = 0.0027), while PCNL showed a 13% higher SFR compared with URS (pooled RR = 1.13, 95% CI 1.07–1.19, p < 0.0001). In contrast, ESWL was associated with a 19% lower SFR relative to PCNL (pooled RR = 0.81, 95% CI 0.72–0.91, p = 0.0003).

Collectively, these findings confirm a clear hierarchy in treatment efficacy: PCNL provides the highest stone-free rates, followed by URS, with ESWL demonstrating the lowest effectiveness. These results align with existing literature emphasizing the superior clearance of PCNL in managing larger or more complex stones, while URS offers a balance of efficacy and minimally invasive recovery.

Cost:

A total of nine randomized controlled trials (RCTs) and seven cohort studies were included in the cost analysis. Patel (2021)(63), Schulz (2022)(28), Konnopka (2022)(14), and Johnston (2023)(64) were excluded from the albatross plot due to their exceptionally large sample sizes relative to the other studies, for the sake of clarity and visual appeal of the plot. The excluded studies were discussed separately below.

Among these excluded studies, Schulz (2022) reported cost ratios of 0.61, 0.69, and 1.00 for URS, ESWL, and PCNL, respectively (p = 0.001; n = 164,203), indicating URS as the least costly and PCNL as the most expensive(28). Similarly, Konnopka (2022) found cost ratios of 0.49 (URS), 0.57 (ESWL), and 1.00 (PCNL) (p = 0.001; n = 54,609), confirming the same trend(14). Johnston (2023) reported that URS was 22% less costly than PCNL (ratio 0.78, p = 0.01; n = 125,316)(64). Moreover, Patel (2021) also found that URS was cheaper than ESWL (ratio 0.85, p = 0.01; n = 3,809) further confirming the above findings.(63).

Across the included studies, URS and ESWL had the largest sample sizes, while PCNL was evaluated less frequently. PCNL studies consistently clustered near a cost ratio of 1.0, reflecting its relatively higher expense. URS generally demonstrated intermediate cost values, and ESWL clustered predominantly below 0.75, suggesting lower overall costs. These findings align with prior systematic reviews (Srisubat et al., 2014; Nedbal et al., 2025), with the exception of Geraghty (2018), which reported URS as less costly than ESWL (ratio 0.77)(9, 11, 16).

Quality of Life and Clinical Outcomes:

Forest plots presenting pooled standardized mean differences (SMD) with 95% confidence intervals comparing hospital stay duration among extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL). Random-effects (DerSimonian–Laird) models were used for pairwise comparisons. The results demonstrate: (1) ESWL vs URS — favoring ESWL (shorter hospital stay), (2) ESWL vs PCNL — favoring ESWL, and (3) URS vs PCNL — favoring URS

Systematic reviews were excluded from this analysis to ensure inclusion of only primary comparative data. Kandemir (2017) was excluded due to incomplete reporting (35).

As expected, ESWL was associated with the shortest hospital stay, consistent with its outpatient, same-day procedural nature, whereas PCNL typically required at least one overnight admission. The meta-analysis revealed statistically significant differences in mean hospital stay across treatment modalities. Compared with URS, ESWL demonstrated a markedly shorter stay with a standardized mean difference (SMD) of − 4.78 (95% CI − 6.04 to − 3.52, p < 0.0001). Similarly, ESWL was significantly shorter than PCNL, with an SMD of − 4.84 (95% CI − 6.35 to − 3.34, p < 0.001). The comparison between URS and PCNL also favored URS, with an SMD of − 1.92 (95% CI − 2.70 to − 1.13, p < 0.0001), indicating a shorter hospital stay for URS.

These findings are consistent with previously published evidence. Geraghty et al. (2018) reported a mean hospital stay of 1.2 days for ESWL compared with 3.1 days for URS(11). Söderberg et al. (2023) observed a mean of 1.81 days for PCNL versus 1.04 days for URS (p = 0.05)(54), while Srisubat et al. (2014) documented 2.5 days for PCNL compared with 0 days for ESWL (p = 0.001)(9).

All in all, these results confirm a positive correlation between hospital stay duration and procedural invasiveness, with ESWL having the shortest stay, URS an intermediate duration, and PCNL the longest. All of which are in agreement with the results of the largest cohort included in our study by Schulz et al. (28)

Kandemir (2017) was excluded from this analysis due to lack of data access(35), and Pietropaolo (2020) was excluded as it was a systematic review(48). A meta-analysis was performed to evaluate the risk of blood transfusion among URS, PCNL, and ESWL. Forest plots including ESWL were excluded, as no study reported transfusion events in patients undergoing ESWL.

The pooled analysis demonstrated that PCNL was associated with a significantly higher risk of blood transfusion compared with URS (pooled RR = 1.13, 95% CI 1.07–1.19, p < 0.0001). The estimated transfusion rates were approximately 12.7% for PCNL and 0% for URS.

These findings are consistent with the known differences in the invasive nature of each procedure with the PCNL involving greater parenchymal disruption and hence a greater potential for bleeding.

Combined forest plots presenting pooled risk ratios (RR) with 95% confidence intervals comparing auxiliary or secondary treatment rates among extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL). A random-effects (DerSimonian–Laird) model was applied for analysis. The results demonstrate: (1) URS vs ESWL — favoring URS (lower rate of secondary treatment), (2) PCNL vs URS — favoring PCNL, and (3) ESWL vs PCNL — favoring PCNL.

Combined forest plots presenting pooled risk ratios (RR) with 95% confidence intervals comparing retreatment rates among extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL). A random-effects (DerSimonian–Laird) model was applied for analysis. The results demonstrate: (1) URS vs ESWL — favoring URS (lower retreatment rate), (2) PCNL vs URS — favoring PCNL, and (3) ESWL vs PCNL — favoring PCNL.

Systematic reviews were excluded from this analysis to ensure inclusion of only primary comparative data.

In regards to auxiliary procedure rate, Dutta (2023) was excluded due to insufficient data availability(27), while Pietropaolo (2020) did not demonstrate any statistically significant differences in auxiliary procedure rates among URS, ESWL, and PCNL(48). In contrast, Söderberg et al. (2023) reported an auxiliary procedure rate of 1% for URS, which was lower than 3% for PCNL (p = 0.05)(54).

The pooled results showed that the likelihood of requiring an auxiliary procedure was higher with ESWL compared with URS (RR = 0.37 for URS vs ESWL, 95% CI 0.27–0.51, p < 0.0001), suggesting that ESWL patients were more likely to need additional interventions. Similarly, ESWL showed a higher risk compared with PCNL (RR = 3.61 for ESWL vs PCNL, 95% CI 2.46–5.28, p < 0.0001). When comparing PCNL and URS, the risk of auxiliary procedures was slightly lower with PCNL (RR = 0.60, 95% CI 0.36–0.997, p = 0.049).

Regarding the analysis of the retreatment rate, Deem (2011) was excluded from this analysis due to incomplete data(29), and Geraghty et al. (2018), being a systematic review, was also excluded. As per Geraghty ea at. (2018) no statistically significant differences were demonstrated in the retreatment rates between ESWL and URS(11). However, our pooled meta-analysis results revealed notable differences in retreatment rates across treatment modalities. When comparing URS and ESWL, the pooled risk ratio (RR) was 0.23 (95% CI 0.12–0.44, p < 0.0001), indicating that patients treated with ESWL had a significantly higher likelihood of requiring retreatment compared with those undergoing URS. In the PCNL versus URS comparison, the pooled RR was 1.54 (95% CI 1.49–1.59, p < 0.0001), suggesting that retreatment occurred slightly more frequently after PCNL than URS, though both rates remained low. The ESWL versus PCNL comparison yielded an RR of 9.31 (95% CI 3.46–25.06, p < 0.0001), confirming that ESWL had the highest retreatment rates among all treatment modalities.

Overall, ESWL showed the highest rates of auxiliary procedures and retreatment. On the other hand, URS demonstrated the lowest rates for both outcomes, while PCNL showed intermediate results, being more effective than ESWL but slightly more likely to require additional intervention than URS. It should be noted, however, that PCNL is typically reserved for patients with larger stone burdens, which may account for its higher re-intervention rates compared with URS.

Combined forest plots presenting pooled risk ratios (RR) with 95% confidence intervals comparing complication rates among extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL). A random-effects (DerSimonian–Laird) model was applied for analysis. The results demonstrate: (1) URS vs ESWL — no statistically significant difference in complication rates, (2) PCNL vs URS — favoring URS (lower complication rate), and (3) ESWL vs PCNL — favoring ESWL (lower complication rate).

Several studies were excluded from the quantitative analysis to ensure inclusion of only primary comparative data. Geraghty et al. (2018) and Pietropaolo et al. (2020) were excluded as systematic reviews; the former reported no statistically significant difference in complication rates between ESWL and URS (p = 0.29), while the latter found ESWL to have the highest complication rate (9%), followed by PCNL (6.6%) and URS (2%)(11, 48). Söderberg et al. (2023) was also excluded as a systematic review, noting slightly higher complication rates for URS (3.1%) compared with PCNL (2.7%)(54). Kandemir (2017) was excluded due to incomplete data(35).

The pooled meta-analysis comparing complication rates across treatment modalities demonstrated that URS and ESWL showed no significant difference in overall complication rates (RR = 1.01, 95% CI 0.59–1.72, p = 0.983), indicating similar safety profiles between these minimally invasive procedures. In contrast, PCNL was associated with a significantly higher complication rate compared with URS (RR = 1.42, 95% CI 1.04–1.95, p = 0.0289), and also higher than ESWL (RR = 2.56, 95% CI 1.69–3.84, p < 0.0001).

Overall, these findings indicate that while ESWL and URS offer comparable safety outcomes, PCNL carries a significantly greater risk of complications, consistent with its more invasive surgical nature.

Deem (2011) was excluded from the analysis due to incomplete data(29). Additionally, several studies (Atis 2021; Gadelmoula 2019; Jain 2021; Kassem 2025; Wymer 2021) were excluded because of missing or inaccessible standard deviation (SD) values, which prevented calculation of standardized mean differences (Hedges’ g) necessary for data homogenization and meta-analysis(13, 20, 37, 49, 58).

In the random-effects network meta-analysis, URS versus PCNL demonstrated a Hedges’ g of 0.68 (95% CI − 0.22 to 1.57), and ESWL versus URS showed a Hedges’ g of − 0.86 (95% CI − 1.76 to 0.14). In both comparisons, the confidence intervals crossed zero, indicating no statistically significant differences in postoperative quality-of-life outcomes between the treatment modalities.

No ESWL–PCNL network comparison was generated, as available data did not allow for direct or indirect linkage between these two interventions. Although a trend toward better QoL was observed with URS, these differences were not statistically significant and warrant further validation in larger, high-quality comparative studies.

A descriptive bias assessment was performed across all included studies to evaluate methodological quality and potential threats to internal validity. Four domains were assessed: selection bias, performance bias, reporting bias, and conflict of interest. Results were summarized using a traffic-light plot, providing a visual overview of the distribution and severity of bias across studies.

Overall, randomized controlled trials demonstrated a generally low risk of selection bias. However, performance bias was frequently present, given the practical impossibility of double blinding in surgical interventions. Reporting bias was also evident in several studies that lacked statistical parameters like standard deviations or confidence intervals.

Cohort studies exhibited a moderate-to-high risk of selection and reporting bias due to variability in inclusion criteria, follow-up duration, and outcome reporting. Conflict of interest bias was generally low, though a few studies disclosed funding or affiliations with device manufacturers.

Importantly, most studies demonstrated unclear risk across at least one bias domain, largely due to incomplete reporting or insufficient methodological detail.

SFR analysis confirmed that PCNL achieves the highest clearance rates, followed by URS, with ESWL showing the lowest efficacy. These results reflect procedural capability, with PCNL reserved for larger or more complex stones, while URS and ESWL remain appropriate for smaller calculi or when minimally invasive management is preferred(8, 12).

Economic assessment revealed that ESWL was generally the least costly modality, followed by URS, while PCNL incurred the highest overall expense, consistent with its greater procedural complexity and hospital resource use. Analyses of hospital stay, and transfusion risk further underscored the procedural gradient in invasiveness; ESWL was predominantly an outpatient procedure, URS offered an intermediate recovery profile, and PCNL required longer hospitalization and required a higher transfusion risk.

When examining auxiliary and retreatment rates, ESWL demonstrated the greatest need for additional or repeat interventions, while URS had the lowest rates. PCNL achieved high single-session efficacy but required occasional secondary intervention, reflecting its superior stone clearance capacity. Complication analysis showed comparable safety profiles between ESWL and URS, whereas PCNL entailed a significantly higher risk of complications, consistent with its more invasive nature. No significant differences were observed in quality-of-life (QoL) outcomes among the modalities. Although URS, when comparing it against each of ESWL and PCNL, showed a nonsignificant trend toward better QoL. Data variability and inconsistent reporting highlight the need for standardized patient-reported outcome measures in future research.

Several limitations must be acknowledged. This review did not account for stone size or volume, burden, or anatomical position (upper, mid, or lower pole), which are known to influence treatment outcomes. Although most included studies focused on single renal stones, variability in stone characteristics remains a potential confounder. In addition, the reporting of SFR outcomes was heterogeneous across studies, with varying definitions, imaging modalities, and follow-up intervals used to determine stone clearance. These inconsistencies limit the comparability and reliability of pooled SFR estimates. Furthermore, while many studies utilized flexible URS, others employed rigid URS, and this distinction was not consistently reported or analyzed. Similarly, some studies assessed mini-PCNL, whereas others evaluated standard PCNL, which may have diluted contrasts in procedural outcomes. Additionally, limited access to full datasets in some studies restricted our ability to extract complete numerical information, further contributing to variability across analyses. These methodological and reporting inconsistencies underscore the need for more standardized comparative data in future research and uniform definitions in future research. Overall, these findings indicate that treatment selection should be individualized based on stone characteristics, patient comorbidities, and patient’s preferences and clinical priorities. PCNL remains the most effective but most invasive option; URS provides a favorable balance of efficacy, safety, and recovery; and ESWL offers the least invasive and most cost-effective approach, although with higher retreatment needs. Notably, the emergence of miniaturized PCNL (mini-PCNL) and suction use in URS may alter this landscape by potentially reducing morbidity and hospital stay while maintaining high stone-free rates(13,66).

Integrating clinical, economic, and patient-centered outcomes underscores the importance of personalized, evidence-based decision-making in endourology. Future studies should emphasize standardized reporting of SFR, cost-effectiveness, quality-of-life measures, and procedural variations to make future systematic reviews more effective in creating new treatment algorithms to optimize patient outcomes in kidney stone disease.