Endourologic procedures for ureteral/renal stones traditionally rely on fluoroscopic guidance. The necessity of fluoroscopy for safe and effective stone treatment remains controversial.
To perform a systematic review and meta-analysis to evaluate intraoperative, perioperative, and postoperative outcomes of fluoroless vs fluoroscopy-guided endourologic procedures for kidney and/or ureteral stones.
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, we searched PubMed, Cochrane Central Register, and Scopus on 13th 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 p < 0.05.
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, p = 0.0004), minor complication- (OR 0.60, 95% CI 0.41-0.86, p = 0.006), and major complication- rates (OR 0.52, 95% CI 0.30-0.88, p = 0.02) compared with fluoroscopy-guided approaches. Stone-free rates (SFRs) were equivalent between groups (OR 1.03, 95% CI 0.77-1.38, p = 0.83). For URS, fluoroless approaches showed comparable overall complications (OR 1.08, 95% CI 0.81-1.45, p = 0.60), major complications, SFR (OR 0.89, 95% CI 0.65-1.19, p = 0.47), and reintervention rates. Flexible fluoroless URS demonstrated fewer minor complications (OR 2.09, 95% CI 1.43-3.06, p < 0.0001). Mean surgical time increased minimally for fluoroless URS (1.60 minutes, p = 0.03).
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.
Journal of endourology. 2026 Mar 09 [Epub ahead of print]
Daniele Castellani, Federico Falsetti, Luca Spinozzi, Vineet Gauhar, Steffi Kar-Kei Yuen, Luca Orecchia, Giacomo Maria Pirola, Pankaj N Maheshwari, Horacio Sanguinetti, Scott Quarrier, Hsiang Ying Lee, Brett A Johnson, Khurshid R Ghani, Carlo Giulioni
Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy., Urology Unit, Villa Igea Private Hospital, Ancona, Italy., Department of Urology, Ng Teng Fong General Hospital, Singapore, Singapore., Department of Surgery, S.H. Ho Urology Centre, Chinese University of Hong Kong, Hong Kong, China., Urology Unit, Azienda Ospedaliero-Universitaria Policlinico Tor Vergata, Rome, Italy., Urology Unit, San Giuseppe Hospital, IRCCS Multimedica, Multimedica Group, Milan, Italy., FUTURE Collaborative Team of the Endourological Society.