Comparison of Flexible and Navigable Suction Ureteral Access Sheath Versus Conventional Ureteric Access Sheath in RIRS: A Systematic Review and Meta-Analysis

Abstract

Objective: To evaluate the efficacy and safety of flexible and navigable suction ureteral access sheath (FANS) versus conventional ureteric access sheath (C-UAS) in Retrograde Intrarenal Surgery (RIRS) for renal stone disease through meta-analysis and trial sequential analysis (TSA). The FANS technology has emerged as a potential solution, incorporating active suction mechanisms to enhance stone clearance and visualization.

Methods: PubMed, EMBASE, Cochrane, and Scopus were searched from 2000 to June 2025 for randomized controlled trials (RCTs) and prospective studies comparing FANS vs. C-UAS in adult RIRS. The primary outcome was stone-free rates at various time points; secondary outcomes included complications, operative, and recovery parameters. The risk of bias was assessed, and random-effects meta-analyses with subgroup, meta-regression, TSA, and Bayesian modeling were performed.

Results: Fifteen studies comprising 11 RCTs and 4 observational studies with 3030 participants were included. Flexible and navigable suction ureteral access sheath achieved a significantly higher immediate stone-free rate (79.1% vs. 54.5%; Relative Risk (RR): 1.47, 95% CI: 1.23-1.7; P < .001). Significant heterogeneity was noted (I2 = 89.3%). The absolute risk difference was 24.6% (number needed to treat = 6). Stone-free rates favored FANS at 30 days (93.5% vs. 82.7%; RR = 1.13) and 3 months (96.2% vs. 88.4%; RR = 1.09), both statistically significant. Flexible and navigable suction ureteral access sheath reduced overall complications by 52% (9.7% vs. 20.2%). Benefits were greatest for stones >20 mm (RR = 2.14), density ≥1000 HU (RR = 1.94), and non-pre-stented patients (RR = 1.37). Trial sequential analysis (3030 patients; 106.4% information size) confirmed FANS superiority. Machine learning prediction of stone-free success showed high accuracy (Area Under the ROC Curve [AUC] = 0.89).

Conclusion: Flexible and navigable suction ureteral access sheath shows clear superiority, improving immediate stone-free rates by 47% with notable safety benefits, TSA confirms evidence sufficiency.

Cite this article as: Mittal A, Subramanyam AD, Panwar VK, Malhotra K, et al. Comparison of flexible and navigable suction ureteral access sheath versus conventional ureteric access sheath in RIRS: A systematic review and meta-analysis. Urol Res Pract. 2026, 52, 0119, doi:10.5152/tud.2026.25119.