Cost and Effectiveness of Flexible Ureteroscopy Versus Shockwave Lithotripsy for Urolithiasis: A Systematic Review and Meta-analysis by the European Association of Urology Endourology Section

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BACKGROUND AND OBJECTIVE: We conducted a systematic review and meta-analysis to compare the cost and effectiveness of flexible ureteroscopy (URS) and shockwave lithotripsy (SWL) in the management of urolithiasis. Given the widespread use of both modalities, comparison of their stone-free rates (SFRs), retreatment rates, complications, costs, and hospital length of stay (LOS) can provide valuable insights for optimizing treatment strategies. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with searches of the PubMed, Cochrane, and Google Scholar databases for relevant studies. The inclusion criteria were comparative studies analysing costs and clinical outcomes of SWL and URS for urolithiasis management. The meta-analysis included 22 studies involving 146 845 patients, of whom 81 772 (55.7%) underwent SWL and 65 073 (44.3%) underwent URS. Statistical analyses were performed using R. Random-effects or fixed-effect models were applied, depending on study heterogeneity. Subgroup analyses by stone size and location were also conducted. KEY FINDINGS AND LIMITATIONS: URS had a significantly higher SFR (82.2% vs 64.4%; p < 0.001) and a significantly lower retreatment rate (10.6% vs 29.4%; p < 0.001) in comparison to SWL. There were no significant differences between URS and SWL in the overall complication rate (22.6% vs 22.5%), the mean procedural cost ($2546.20 ± $1297.30 vs $2830.40 ± $1652.10), or mean LOS (2.8 d for both). Subgroup analyses confirmed similar trends across stone size and location categories. CONCLUSIONS AND CLINICAL IMPLICATIONS: While direct procedural costs were only slightly lower for URS, this modality had superior efficacy, with higher SFR and lower retreatment rates, suggesting it is a more cost-effective option in the long term. These findings support preference for URS for urolithiasis treatment when considering both clinical and economic outcomes.

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