ECIRS versus PCNL for renal stone management. A meta-analysis of 3 studies with over 300 patients found that ECIRS had a shorter mean operative time and higher stone-free rate compared to PCNL, but similar length of hospital stay. A randomized controlled trial assessed 67 patients and found ECIRS had a shorter operative time and higher stone-free rate. Risk of bias was low. The analysis concluded ECIRS is more efficacious than PCNL for renal stones.

1. Endoscopic Combined Intrarenal Surgery versus
Percutaneous Nephrolithotomy for Renal
Stones Management: A Meta-analysis
Eko Indra Pradono, MD
Faculty of Medicine, Universitas Indonesia / H. Adam Malik Hospital, Medan, Indonesia
Presented at :
4-6th April Grand Hyatt, Singapore

2. REFERENCES
INTRODUCTION
• ECIRS
• Novel way to approach renal cavities antero-retrogradely to remove renal stones 
combining PCNL and fURS
• Useful in managing patient with large stones, special cases (regardless of age and body
habitus)
• Provides benefits  minimizing radiation exposure & risk of haemorrhage
• PCNL
• Gold standard for renal stones management
• Unfortunately the residual remains high
INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION
AIM OF THE STUDY
Compare efficacy and safety of ECIRS and PCNL in renal stones management regarding mean operative
time, final stone free rate, and length of stay

3. REFERENCES
METHODS
• Conducted according to PRISMA guidelines
• PICO
P  patients with renal stones
I  endoscopic combined intrarenal surgery (ECIRS)
C  percutaneous nephrolithotomy (PCNL)
O  mean operative time, final stone free-rate, length of hospital stay
• A systematic literature search was conducted in October 2018 using Medline
(PubMed), Google Scholar, Science Direct, and Cochrane.
INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION

4. REFERENCES
• Database, search strategy, and number of articles retrieved
INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION
Database Search strategy Hits
MEDLINE
(PubMed)
(((endoscopic combined intrarenal surgery [All Fields]) OR ECIRS [All Fields]))) AND (((PCN [All Fields])) OR PCNL [All Fields])) OR
percutaneous nephrolithotomy [All Fields])) AND (stone-free rate [All Fields]) AND (mean operative time [All Fields]) AND (length of
hospital stay [All Fields])
9
Google Scholar
"endoscopic combined intrarenal surgery"; "percutaneous nephrolithotomy"; "stone-free rate"; "operative time"'; "length of
hospital stay"
9
Science Direct endoscopic combined intrarenal surgery; percutaneous nephrolithotomy; stone-free rate; operative time; length of hospital stay 4
Cochrane
((endoscopic combined intrarenal surgery [All text]) AND (percutaneous nephrolithotomy [All text]) AND (stone-free rate [All text])
AND (operative time [All text]) AND (length of hospital stay [All text]))
1
• Study selection
• Full-text potential article was independently assessed by 3 reviewers (EIP, FP, DD).
• Duplication was also screened manually  abstract examination based on predetermined inclusion
and exclusion criteria.
• Exclusion criteria:
• Only discussed about one arm; review or meta-analysis; duplicated data; comments, editorials, letters, case reports,
congress reports; animal experiments; and non-English articles.

5. REFERENCESINTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION
• Data extraction and quality assessment
• Cross-reference was conducted to ensure the studies which were not found in computerized search.
• Randomized clinical trial (RCT)  Modified Jadad score, cohort studies  Newcastle-Ottawa Scale
(NOS)
• Criteria for studies
• Type of source outcomes: mean operative time, final stone-free rate, length of hospital stay
• Data collection and statistical analysis
• Selected studies were appraised based on the Oxford Center of Evidence-based Medicine
Worksheet for therapy and analyzed by Review Manager 5.3.
• Mean operative time and length of hospital stay were estimated using MD & 95% CI
• Stone-free rate was estimated using OR and 95% CI.
• P-value <0.005 was considered statistically significant.
• Heterogeneity was evaluated using Cochrane Q statistic & I2 statistic.

6. REFERENCES
RESULTS
• Literature search
• Total 23 publications at initial; 10
studies were excluded due to
duplication.
• Moreover, 7 were excluded during title
and abstract screening.
• 6 studies underwent full-text appraisal,
but only 3 studies were considered for
further qualitative and quantitative
analysis.
INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION
Cochrane
1
PubMed
9
Google
Scholar
9
Science Direct
4
Filtering doubles
13
Screening title abstract*
6
Full text and abstract are assessed for availability and eligibility*
3 studies included in qualitative synthesis
Percutaneous
nephrolithotomy
OR PCN OR PCNL
Stone-
free rate
OR SFR
Length of
hospital
stay
A
N
D
Endoscopic
combined intrarenal
surgery OR ECIRS
Exclusion ciriteria:
- Children patients
- Only discuss
ECIRS or PCNL
Exclusion criteria:
- Non-English
studies
- Descriptive studies
- Non comparative
studies
Search period: October 2018
*All decisions were made by discussions of 3 reviewers
3 studies included in quantitative synthesis
IdentificationScreeningEligibilityIncluded
A
N
D
Operative
time OR
operative
duration
A
N
D
A
N
D

7. REFERENCESINTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION
• Study characteristics
• 3 studies were further analyzed.
• 1 study was prospective RCT (assessed using modified Jadad and scored 8 over 8), 2 studies
were prospective cohort (assessed with NOS)
Author(s) Year Study design
Number of patients Mean operative time Stone-free rate Length of hospital stay (days)
ECIRS PCNL ECIRS PCNL ECIRS PCNL ECIRS PCNL
Hamamoto
et al
2014 Retrospective
cohort
60 82 120.5 ± 6.7 134.1 ± 7.8 86.7% 61.1% 7.0 ± 0.6 12.9 ± 1.4
Zelvys et al 2014 Cohort
prospective
22 182 98.54 ± 26 85.27 ± 22.5 94.2% 90.3% 5.4 ± 1.7 5.2 ± 0.9
Wen at al 2016 Randomized
controlled
trial
33 34 105.33 ± 30.28 83.58 ± 24.37 96.97%
(32/33)
91.18%
(31/34)
9.66 ± 2.31 10.12 ± 2.11

8. REFERENCESINTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION
• Risk of bias summary
• Most of aspects are good in the risk of bias assessment.
• The study conducted by Wen et al recruited 67 patients and they were randomly assigned to two
groups: ECIRS and PCNL group.
• This study did not only select RCT study because there were only few studies comparing ECIRS and
PCNL in the terms of mean operative time, stone-free rate, and length of hospital stay.

9. REFERENCESINTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION
Meta-analysis result
• MEAN OPERATIVE TIME
• FINAL STONE-FREE RATE

10. REFERENCESINTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION
Meta-analysis result
• LENGTH OF HOSPITAL STAY

11. REFERENCES
CONCLUSION
ECIRS is more efficacious compared to PCNL in renal stones
management evaluated from mean operative time, stone-free rate, and
length of hospital stay.
INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION

12. REFERENCES
1. Ping H, Zhang JH, Wang MS, Xing NZ. Endoscopic combined intrarenal surgery for the treatment of postpercutaneous nephrolithotomy residual
stones. CMJ. 2016;129(23):2885-7.
2. Manikandan R, Mittal JK, Dorairajan LN, Mishra AK, Sreerag KS, et al. Endoscopic combined intrarenal surgery for simultaneous renal and ureteric
stones: a retrospective study. J Endourol. doi: 10.1089/end.2016.0329.
3. Hamamoto S, Yasui T, Okada A, Taguchi K, Kawai N, et al. Endoscopic combined intrarenal surgery for large calculi: simultaneous use of flexible
ureteroscopy and mini-percutaneous nephrolithotomy overcomes the disadvantageous of percutaneous nephrolithotomy monotherapy. J
Endourol. 2014;28(1):23-33.
4. Zelvys A, Cekauskas A, Jankevicius F. Role of combined intrarenal surgery (ECIRS) in management of large/complex kidney stones. Eur Urol Suppl
2014; 13(2): e1192.
5. Wen J, Xu G, Du C, Wang B. Minimally invasive percutaneous nephrolithotomy versus endoscopic combined intrarenal surgery with flexible
ureteroscope for partial staghorn calculi: a randomised controlled trial. Int J Surg. 2016;28:22-27.
6. De La Rosette JJ, Tsakiris P, Ferrandino MN, et al. Beyond prone position in percutaneous nephrolithotomy: a comprehensive review. Eur Rol.
2008;54:1262-9.
7. Yamashita S, Kohjimoto Y, Iba A, Kikkawa K, Hara I. Stone size is a predictor for residual stone and multiple procedures of endoscopic combined
intrarenal surgery. Scand J Urol Nephrol. 2017;51(2):159-164.
8. Ritter M, Krombach P, Michel MS. Percutaneous stone removal. Eur Urol Suppl. 2011;10:433-9.
INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

13. THANK YOU
INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES