Optimizing RIRS in Complex Renal Anatomy: A Comparative Study of Tip-Flexible Suction Versus Conventional Ureteral Access Sheath

Background/Objectives: Managing kidney stones in patients with congenital renal anomalies—such as horse-shoe kidney or ectopic kidney—presents unique challenges for endourologists. In these anatomically complex cases, standard ureteral access can be difficult, and pressure management becomes critical. Suction-assisted ureteral access sheaths have emerged as a promising solution, but clinical data in this population remain limited. This study evaluates whether using a tip-flexible suction UAS improves outcomes in retrograde intrarenal surgery compared to conventional access. Methods: We retrospectively reviewed 67 patients with confirmed renal anomalies and stones sized 2–4 cm who underwent RIRS at two academic centers between October 2022 and December 2024. Patients were grouped based on the type of UAS used: suction-assisted (TFS-UAS) or conventional (T-UAS). Surgical and postoperative outcomes, including stone-free rate (SFR), complication profile, operative time, and hospital stay, were compared. Results: The TFS-UAS group showed a higher 30-day SFR (94.3%) compared to the convention-al group (81.3%), although the difference was not statistically significant. Operative time was longer with TFS-UAS (p < 0.001), but this was offset by a shorter hospital stay (p = 0.003). No major differences were seen in complication rates. Conclusions: Using a suction-assisted UAS in RIRS for patients with congenital renal anomalies ap-pears to offer meaningful clinical benefits—most notably better fragment clearance and quicker recovery. While the technique may increase operative time, the trade-off seems justified, particularly in anatomically challenging cases.