The evolution of retrograde intrarenal surgery: a comprehensive meta-analysis of suction-assisted versus conventional techniques against mini-PCNL for 2-3 cm renal stones.

OBJECTIVE

To evaluate the technological evolution of Retrograde Intrarenal Surgery (RIRS) by comprehensively comparing real-world and randomized outcomes of suction-assisted (SA-fURS) and conventional (C-fURS) techniques against Mini-Percutaneous Nephrolithotomy (mPCNL) for 2-3 cm renal stones.

METHODS

A systematic search was performed in PubMed, Embase, Web of Science, Cochrane Library, and Scopus up to September 1, 2025. Randomized controlled trials (RCTs) and observational studies were included. Primary outcomes were immediate and final stone-free rates (SFR). Secondary outcomes included complications, operative time, and hospital stay. The certainty of evidence was assessed using the GRADE approach.

RESULTS

Eighteen studies (4 RCTs, 14 non-RCTs) involving 3,832 patients were included. mPCNL provided higher immediate SFR (OR 0.41, low certainty). However, low-certainty evidence suggests the difference in final SFR between SA-fURS and mPCNL did not reach statistical significance (OR 0.77, P = 0.11), whereas C-fURS remained significantly inferior. RIRS demonstrated a superior safety profile with significantly lower risks of hemorrhage (OR 0.40, moderate certainty) and blood transfusion (OR 0.17, moderate certainty), and a shorter hospital stay (MD -2.26 days, very low certainty), despite longer operative times (MD 8.81 min, Very Low Certainty).

CONCLUSION

While mPCNL provides superior immediate clearance, low-certainty evidence indicates no statistically significant difference in final stone-free rates between SA-fURS and mPCNL. Furthermore, SA-fURS demonstrates a favorable safety profile and faster recovery. Crucially, C-fURS remains significantly inferior in efficacy. These comprehensive findings validate recent randomized trials in a broader clinical context, establishing SA-fURS as a highly effective, minimally invasive alternative to mPCNL, whereas C-fURS should be considered a suboptimal choice for this stone burden.