Hybrid endoscopic-robotic approaches for complex upper urinary tract disorders: a systematic review and single-arm meta-analysis

Abstract

Complex upper urinary-tract disorders (CUUTD) pose challenges owing to multifactorial etiology. Evidence on hybrid endoscopic-robotic approaches (HERA) remains limited. We evaluated the efficacy, safety, and outcomes of HERA for CUUTD across adult and pediatric populations. We performed a PRISMA-compliant systematic review and single-arm meta-analysis of pooled proportions (Freeman–Tukey transformation) registered in PROSPERO (CRD420251022229). PubMed, Scopus, Web of Science databases were searched for English full-texts only (last searched: June 22, 2025). Inclusion criteria were: randomized controlled trials (RCTs) and non-randomized studies using HERA for CUUTD. Exclusion criteria were: isolated pathologies, single-modality, non-English, and insufficient data. Populations were grouped as adult, pediatric, or mixed. The independent dual review and risk of bias (RoB) assessment used Joanna Briggs Institute checklists. Heterogeneity (I2) and publication bias (Egger’s test) were evaluated. Fourteen retrospective studies (2005–2023) from international centers (n = 95: 26 adults, 44 pediatric, and 25 mixed populations; low bias) were included. In the absence of comparator arms, our findings represent descriptive pooled estimates of efficacy and safety. Pooled stone-free rate was 90.3% (95% CI 82.9–95.8%; I2 = 75.8%%) and was higher in adults (100%) than in pediatrics (81.8%; p = 0.0082). Obstruction resolution was 100%; although no intraoperative complications were observed, postoperative complications were noted in 11.6% cases, mostly Clavien–Dindo II–IIIa. The reoperation rate was 9.6%, mean operative time was 185.2 min, and the mean hospital stay was 3.5 days. Stone recurrence and obstruction recurrence were noted in 4.2% and 0% cases, respectively. In selected patients and experienced centers, HERA may achieve high SFR and obstruction resolution with acceptable morbidity; however, the overall strength of evidence is low, heterogeneity is substantial, and publication bias was detected. Findings are preliminary and hypothesis-generating. Rigorous prospective comparative studies with standardized outcome definitions and follow-up are needed before drawing firm practice-changing conclusions.