Enhanced Outcomes with Suction-Assisted Retrograde Intrarenal Stone Surgery for Urolithiasis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND

We aimed to evaluate the efficacy, safety, and cost-effectiveness of suction-assisted retrograde intrarenal surgery (SA-RIRS) compared with conventional retrograde intrarenal surgery (RIRS) and to compare outcomes between suction catheters and suction sheaths in the management of upper urinary tract stones ≤30 mm.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed, Embase, Cochrane Library, and Web of Science were searched to September 2025. Eligible RCTs compared SA-RIRS (catheter or sheath) with conventional RIRS in adults. Primary outcomes were stone-free rate (SFR), total complications, and operative time; secondary outcomes included hospital stay, reoperation rate, stone retropulsion, basket use, and laser time. Risk of bias (RoB) was assessed using the Cochrane RoB 2.0, and evidence certainty was rated with the Grading of Recommendations, Assessment, Development, and Evaluation.

RESULTS

Six RCTs involving 843 patients (SA-RIRS: 420; conventional RIRS: 423) were included. SA-RIRS significantly improved SFR (odds ratio [OR] = 4.00, 95% confidence interval [CI]: [2.92, 5.48], p < 0.001) and reduced total complications (OR = 0.40, 95% CI: [0.17, 0.97]), stone retropulsion (OR = 0.26, p = 0.03), and basket use (OR = 0.01, p < 0.001). Subgroup analysis demonstrated that both suction sheaths (OR = 4.46) and suction catheters (OR = 2.64) significantly improved SFR compared with conventional RIRS, with sheaths showing greater complication reduction (OR = 0.27 vs 0.77). No significant differences were observed in operative time, hospital stay, or reoperation rate. Evidence certainty was high for all outcomes.

CONCLUSIONS

SA-RIRS provides superior stone clearance and safety compared with conventional RIRS. Although sheath-based systems offer the highest SFRs and complication reductions, suction catheters also significantly improve clearance and remain a cost-effective option for impacted ureteral stones. Findings support integrating SA-RIRS into routine endourological practice, with device selection guided by stone location and resource availability.Trial Registration PROSPERO:CRD420251149743.