Endoscopic dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction: A systematic review and pooled analysis of powered vs. non-powered technique

Purpose: Endoscopic dacryocystorhinostomy (eDCR) has become the standard surgical treatment for primary acquired nasolacrimal duct obstruction (PANDO), demonstrating safety and success rates comparable to external DCR. However, surgical failure remains a concern, often related to aberrant mucosal healing, synechiae formation, and ostium restenosis. The optimal surgical approach, particularly regarding powered versus non-powered techniques and the role of adjunctive treatments such as silicone stents and mucosal flaps, remains debated. Methods: A systematic review and pooled analysis were conducted in accordance with PRISMA guidelines. The protocol was registered on PROSPERO (CRD420251014988). PubMed, Scopus, and Web of Science were searched through March 2025. Eligible studies included adults with PANDO undergoing primary eDCR, with detailed reporting of technique, outcomes, and at least 50 cases. Data were extracted and stratified by surgical approach (powered vs. non-powered) and adjunctive treatments (stenting, mucosal flaps). Results: A total of 107 studies comprising 17,415 DCRs were included. Overall surgical success was 87.5%, with no significant difference between powered (87.7%) and non-powered (87.6%) approaches (OR 0.95, 95% CI 0.87-1.05, p = 0.316). Laser-assisted DCR was associated with significantly lower success (OR 0.80, p = 0.001). Mucosal flap preservation improved outcomes, while silicone stenting showed no consistent benefit. Non-powered techniques were associated with shorter operative times. Conclusions: Powered and non-powered eDCR techniques demonstrate comparable efficacy in managing PANDO. Non-powered approaches, particularly with mucosal flap preservation, may offer practical advantages, reduced morbidity, and shorter operative times, supporting their role as a valuable alternative in clinical practice.