Antegrade versus retrograde ureteroscopy for large proximal ureteric stones: a meta-analysis.

OBJECTIVES: To perform a meta-analysis comparing the outcome of antegrade versus retrograde ureteroscopy for the management of large proximal ureteric stones. METHODS: A systematic review and meta-analysis of randomized controlled trials was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, with registration in PROSPERO (CRD420251085029). Randomized controlled trials comparing antegrade and retrograde ureteroscopy for proximal ureteric stones ≥10 mm were included. The primary outcome was stone-free rate. Secondary outcomes included auxiliary procedure rates, operative time, length of hospital stay, postoperative haematuria, postoperative fever, and ureteral strictures. Data were analysed using Review Manager V5.4, and the quality of the evidence was assessed using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) tool. RESULTS: A total of 14 trials including 1432 patients were analysed. Retrograde ureteroscopy achieved lower stone-free rates than antegrade ureteroscopy (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.20-0.44) and required more auxiliary procedures (OR 5.83; 95% CI 3.86-8.82). Antegrade ureteroscopy was associated with longer hospital stay (mean difference [MD] 1.29 days, 95% CI 1.24-1.35) and longer operative time (MD 12.03 min, 95% CI 11.34-12.72). Postoperative haematuria was less frequent with retrograde ureteroscopy (OR 0.40; 95% CI 0.25-0.64), whereas postoperative fever (OR 0.93; 95% CI 0.60-1.42) and ureteral strictures (OR 3.70; 95% CI 0.76-18.07) did not differ significantly between approaches. The certainty of evidence ranged from moderate to very low, mainly due to the risk of bias and heterogeneity. CONCLUSIONS: For large proximal ureteric stones, antegrade ureteroscopy offers superior stone clearance and fewer auxiliary procedures than retrograde ureteroscopy, at the cost of longer operative time, longer hospital stay, and higher haematuria rates. These findings support antegrade ureteroscopy when definitive single-stage stone clearance is the primary treatment goal.