Network meta-analysis of clinical efficacy and safety of flexible ureteroscopic holmium laser lithotripsy combined with tip-flexible suction ureteral access sheath for kidney stones.

BACKGROUND: The tip-flexible suction ureteral access sheath is an innovative device designed to reduce intrarenal pressure and improve stone clearance during flexible ureteroscopy. This network meta-analysis compared its efficacy and safety with traditional ureteral access sheath (T-UAS)-assisted flexible ureteroscopy, mini-percutaneous nephrolithotomy (mini-PCNL), and extracorporeal shock wave lithotripsy (ESWL) for 1-3 cm kidney stones. METHODS: PubMed, Web of Science, and Cochrane CENTRAL were searched up to December 2025. We included 18 studies (7 RCTs, 3 prospective, 8 retrospective) with a total of 4,987 patients across all study arms. The primary outcome was 1-month stone-free rate (SFR). A frequentist random-effects network meta-analysis was performed. RESULTS: For SFR, SUCRA values were: suction sheath 0.84, mini-PCNL 0.76, traditional UAS 0.31, ESWL 0.07. Suction sheath significantly reduced overall complications (RR=0.35, 95% CI: 0.24-0.50) and postoperative fever (RR=0.35, 95% CI: 0.23-0.52) versus traditional UAS. Operative time did not differ between suction sheath and traditional UAS (MD=-0.31 min, 95% CI: -10.64 to 11.25). Intraoperative blood loss was lower with suction sheath than with PCNL/mPCNL (MD=-3.43 g/L, 95% CI: -5.59 to -1.27). Heterogeneity was low for SFR and complications but high for operative time (I2=98.1%). meta-regression did not identify significant sources, and sensitivity analyses confirmed robustness. CONCLUSIONS: The tip-flexible suction ureteral access sheath provides a favorable balance of efficacy and safety for 1-3 cm kidney stones, with SFR comparable to mini-PCNL but with significantly fewer complications and less trauma. It may be preferred for stones ≤2 cm and an alternative for 2-3 cm stones in patients unfit for percutaneous surgery.