Retrograde intrarenal surgery with flexible and navigable suction access sheaths vs mini‐percutaneous nephrolithotomy for large upper urinary tract stones: a systematic review and meta‐analysis

Objective To conduct a meta‐analysis comparing the efficacy and perioperative outcomes of contemporary flexible and navigable suction access sheath‐assisted retrograde intrarenal surgery (FANS‐RIRS) against percutaneous nephrolithotomy (PCNL) for the management of large upper urinary tract stones, as despite technological advances in RIRS such as high‐powered lasers and FANS that have substantially enhanced its performance, current guidelines continue to recommend PCNL as first‐line treatment for renal stones >2cm. Methods MEDLINE, Embase, and the Cochrane Library were searched for studies performing direct comparisons of FANS‐RIRS against PCNL in adult patients until September 2025. Primary outcomes included stone‐free rates (SFRs) and need for ancillary procedures. Secondary outcomes included operative time, length of postoperative hospitalisation, and postoperative complications. Results A total of 10 studies (three randomised control trials, seven retrospective cohort studies) comprising 2347 patients were included; preoperative stone sizes were predominantly 2–3 cm. All PCNL procedures in the studies included were performed as mini‐PCNL. The SFRs for FANS‐RIRS were comparable with mini‐PCNL across all stone sizes (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.70–1.17) and stones ≥2 cm (OR 0.80, 95% CI 0.60–1.08), with low heterogeneity. Ancillary procedures rates were similar (OR 1.22, 95% CI 0.61–2.44). FANS‐RIRS was associated with significantly fewer overall complications, specifically smaller haemoglobin decline, need for transfusion, and shorter hospital stay. However, mini‐PCNL demonstrated shorter operative times for stones ≥2 cm. Urosepsis rates were low and similar between both groups. Limitations include predominance of Asian studies, variability of practice, and inclusion of non‐randomised studies. Conclusions Contemporary FANS‐RIRS achieves SFRs comparable to mini‐PCNL even for 2–3 cm stones, while offering superior safety profiles and shorter hospitalisation; this supports FANS‐RIRS as a viable primary treatment in selected patients.