Nedbal C. et al., 2025: 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.

Carlotta Nedbal 1, Robert Geraghty 2, Pietro Tramanzoli 3, Dario Sessa 4, Vineet Gauhar 5, Andrea Benedetto Galosi 6, Andrea Gregori 7, Bhaskar K Somani 8
Eur Urol Focus. 2025 Jul 8:S2405-4569(25)00173-7. doi: 10.1016/j.euf.2025.06.004 FREE ARTICLE

Abstract

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.

Comment Peter Alken

The authors know their business and have recently published on the topic (1).
I wouldn't recommend this review-soup (2), however.


The oldest 168 ingredients originate from the Netherlands and were added 27 years ago. 78.301 come from Germany. 3,519 case data were generated in nine prospective studies; The recipe is a mixture from 12 countries. The cost per patient vary between 267 to 16.900 $ for SWL and 621,95 to 10.000 $ for URS.
I believe the combination was only made palatable through statistical processing.
In addition, there are some flaws. I could not trace in the original publication (3) referred to, the 93% complication rate of SWL in Table 2 of the present paper. The paper could have got more care, to avoid mistakes like: 45.773+32.528 = 164.203 in Table 1.

1 Nedbal C, Tramanzoli P, Castellani D, Gauhar V, Gregori A, Somani B. Cost-effectiveness and health economics for ureteral and kidney stone disease: a systematic review of literature. Curr Opin Urol. 2025 Jul 1;35(4):368-376. doi: 10.1097/MOU.0000000000001216. Epub 2024 Aug 19. PMID: 39162117.
2 Nedbal C, Geraghty R, Tramanzoli P, Sessa D, Gauhar V, Galosi AB, Gregori A, Somani BK. 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. Eur Urol Focus. 2025 Jul 8:S2405-4569(25)00173-7. doi: 10.1016/j.euf.2025.06.004. Epub ahead of print. P MID: 40634171.
3 Salem HK. A prospective randomized study comparing shock wave lithotripsy and semirigid ureteroscopy for the management of proximal ureteral calculi. Urology 2009;74:1216–21. https://doi.org/10.1016/j.urology.2009.06.076.

Peter Alken