Laser versus pneumatic lithotripsy in adult patients undergoing semirigid ureteroscopy: A systematic review, meta-analysis, and trial sequential analysis

Abstract

BACKGROUND: Ureteral calculi are a common cause of acute urologic morbidity, and semirigid ureteroscopy is a standard treatment when spontaneous passage fails. The relative effectiveness and safety of laser lithotripsy (LL) versus pneumatic lithotripsy (PL) remain clinically important questions. OBJECTIVES: To compare LL (Holmium:YAG or Thulium fiber) with PL for ureteral stones in adults undergoing semirigid ureteroscopy, focusing on early stone-free rate (SFR) and key perioperative outcomes. METHODS: We searched PubMed, Scopus, CENTRAL, and Google Scholar from inception to 4 September 2025 for randomized controlled trials (RCTs). Eligible studies included adults (⩾18 years) undergoing semirigid ureteroscopy comparing LL with PL. The primary outcome was early SFR (1-4 weeks). Secondary outcomes included operative and lithotripsy times, stone migration, complications, hospital stay, DJ stenting, auxiliary procedures, and late SFR (>4 weeks). Meta-analyses used fixed- or random-effects models as appropriate. Trial Sequential Analysis (TSA), Egger's test, Begg-Mazumdar, and trim-and-fill assessed robustness and publication bias. Certainty of evidence was evaluated using GRADE. The review was registered in PROSPERO (CRD420251207635). RESULTS: = 2791) were included. LL significantly improved early SFR (OR 2.02; 95% CI 1.59-2.58) and late SFR, reduced stone migration, postoperative fever, overall complications, DJ stenting, and auxiliary procedures. Operative time and procedure-related injuries were similar, while lithotripsy time was longer for LL. TSA confirmed conclusive evidence for early SFR. No substantial publication bias was detected. GRADE rated evidence as high for early SFR and stenting. CONCLUSIONS: LL provides superior stone clearance and better overall clinical outcomes than PL, with comparable operative safety. It should be considered the preferred intracorporeal modality during semirigid ureteroscopy for ureteral stones.