Abstract
OBJECTIVE: To systematically evaluate the effectiveness and safety of suction-assisted sheaths (SAS) compared to traditional access sheaths (TAS) in minimally invasive percutaneous nephrolithotomy (MPCNL) for renal calculi-addressing key limitations of MPCNL such as compromised irrigation outflow, intraoperative elevation of intrarenal pressure (IRP), and the associated risk of infectious complications. METHODS: This PRISMA-compliant meta-analysis (PROSPERO-registered) included 10 randomized controlled trials (RCTs; n = 1,540) identified through comprehensive searches of PubMed, Embase, Web of Science, and the Cochrane Library from database inception to May 2025. Pooled outcomes were calculated using random- or fixed-effects models, with subgroup analyses based on lithotripsy modality (laser vs. non-laser) and stone type (staghorn vs. non-staghorn). Study quality was assessed using the Cochrane Risk of Bias Tool, and evidence certainty was graded via GRADE. RESULTS: Compared to TAS, the use of SAS was associated with a significantly higher immediate stone-free rate (SFR; OR 2.29, 95% CI 1.76-3.00) and 3-month SFR (OR 2.72, 95% CI 1.42-5.22), with a greater benefit observed in non-staghorn stones. SAS was also associated with a mean reduction in intrarenal pressure (IRP) of 8.25 mmHg (95% CI - 9.44 to - 7.06), with a more pronounced effect in non-laser procedures. A significant reduction in operative time was observed (MD -13.86 min, 95% CI - 26.43 to - 1.30), although this finding should be interpreted with caution due to substantial heterogeneity (I² = 98%). Regarding safety, SAS was associated with lower rates of postoperative fever (OR 0.40), transfusion (OR 0.43), second surgeries (OR 0.63), and auxiliary procedures (OR 0.38). No significant differences were found for UTI, hospitalization duration, or hemoglobin loss. CONCLUSIONS: This meta-analysis suggests that the use of a suction-assisted sheath in MPCNL is associated with higher stone-free rates, shorter operative times, reduced intrarenal pressure, and a lower incidence of certain postoperative complications, including fever and transfusion requirements. The findings indicate a favorable safety and efficacy profile, suggesting that SAS is a valuable modification for optimizing procedural outcomes.