Intrarenal Pressure Monitoring and Control Strategies Using Suction in Flexible Ureteroscopy: An EAU Endourology Systematic Review of Technologies and Clinical Outcomes

PURPOSE: Intrarenal pressure (IRP) is a key physiological parameter during retrograde intrarenal surgery (RIRS), and elevated IRP has been linked to postoperative infectious and renal complications. Multiple technologies have been developed to monitor and control IRP during RIRS. We aimed to systematically evaluate pressure-monitoring and pressure-control technologies used during RIRS, including suction irrigation pressure autoregulating systems (SIPS), pressure-monitoring systems, and flexible and navigable suction ureteral access sheaths (FANS), with a primary focus on their IRP control performance and a descriptive assessment of reported perioperative outcomes. METHODS: This systematic review was conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO (CRD420261298652). MEDLINE, Web of Science, and Scopus were searched on November 1, 2025. Randomized and non-randomized studies evaluating pressure-sensing, suction-assisted, or SIPS-based technologies during RIRS were included. Primary outcomes were intraoperative IRP metrics. Secondary outcomes included fever, sepsis, stone-free rate (SFR), operative time, and secondary intervention. Risk of bias was assessed using RoB 2, ROBINS-I, and the JBI Critical Appraisal Checklist for Case Series, as appropriate, and certainty of evidence was evaluated using GRADE. RESULTS: We included 11 studies comprising 786 patients for clinical analysis. Across studies, reported IRP profiles varied by pressure-monitoring or pressure-control technology and procedural protocol. Studies evaluating active pressure-control systems reported low intraoperative IRP, whereas pressure-monitoring studies showed substantial variability in IRP during conventional ureteroscopy. Studies evaluating pressure-monitoring FANS reported controlled IRP profiles alongside higher irrigation flow rates and, in some comparisons, shorter operative times. Use of an 11/13F ureteral access sheath, compared with a 13/15F sheath, was associated with a higher likelihood of elevated intraoperative IRP (≥30 mmHg) (OR: 12.5). Across individual studies, reported postoperative fever rates ranged from 0% to 5%, sepsis rates from 0% to 3%, and stone-free rates for stones ≤2 cm from 87.5% to 95.8%; these outcomes were assessed descriptively. Heterogeneity in study design and pressure-reporting methods precluded meta-analysis. CONCLUSION: Available studies suggest that pressure-monitoring and pressure-control technologies may improve intrarenal pressure management during RIRS. However, current evidence is limited by methodological heterogeneity and the predominance of non-randomized studies. Large multicenter randomized trials with standardized pressure metrics and clinically meaningful endpoints are required to determine whether improved IRP control translates into better perioperative outcomes.