Evaluation of outcomes in kidney stone management: Stone-free rate vs Cost vs Quality of life – A systematic review from EAU Endourology

Background: Nephrolithiasis is a prevalent and highly recurrent pathology that affects up to 15% of the global population. The three main treatment modalities of nephrolithiasis are extracorporeal shock wave lithotripsy (ESWL) , ureteroscopy (URS) , and percutaneous nephrolithotomy (PCNL) , however they differ in efficacy, invasiveness, and cost. Although stone-free rate (SFR) remains the traditional measure of success, a comprehensive evaluation should integrate economic and patient-centered outcomes. Objective: To compare stone-free rate (SFR), cost, and quality-of-life (QoL) outcomes for patients undergoing ESWL, URS, and PCNL. Methods: A systematic review was conducted following the PICO framework. We identified comparative studies involving adult patients (≥ 18 years) with renal stones using PubMed, Embase, Scopus, and Cochrane Library. The primary outcomes included SFR, treatment cost, clinical outcomes and QoL scores. Quantitative and qualitative meta-analyses were performed in R software. Results: Forty six studies were included in this systematic review. PCNL achieved the highest SFR , followed by URS , and ESWL demonstrated the lowest (RR = 1.13 for PCNL vs URS, p  < 0.0001). Moreover, ESWL was the cheapest, while PCNL was the most expensive. Hospital stay and transfusion rates increased proportionally with procedural invasiveness. URS had the lowest complication and retreatment rates , while ESWL and PCNL had the highest retreatment rates and complication rates respectively. No statistically significant differences were found in QoL outcomes among the treatment modalities. Conclusions: PCNL remains the most effective but most invasive treatment, URS offers a balanced compromise of efficacy, safety, and cost, while ESWL is the least invasive and most economical option but carries the highest risk of retreatment. Future studies should standardize reporting of SFR, cost-effectiveness, quality-of-life measures, and procedural variations.