Retrograde intrarenal surgery with or without ureteral access sheath: a systematic review and meta-analysis of randomized controlled trials

Introduction: The ureteral access sheath (UAS) is a medical device that enables repeated entrance into the ureter and collecting system during retrograde intrarenal surgery (RIRS). Its impact on stone-free rates, ureteral injuries, operative time, and postoperative complica-tions remains controversial. Therefore, we performed a systematic review and meta-analy-sis comparing RIRS with versus without UAS for urolithiasis management.Purpose: To compare outcomes from retrograde intrarenal surgery (RIRS) for stone extrac-tion with or without ureteral access sheath (UAS); evaluating stone-free rate (SFR), ureteral injuries, operative time, and postoperative complications.Materials and Methods: We systematically searched PubMed, Embase, and Cochrane Li-brary in June 2024 for randomized controlled trials (RCTs) evaluating the eff icacy and safety outcomes of UAS use in RIRS for urolithiasis treatment. Articles published between 2014 and 2024 were included. Pooled risk ratios (RRs) and mean diff erences (MDs) were calculated for binary and continuous outcomes, respectively.Results: Five RCTs comprising 466 procedures were included. Of these, 246 (52.7%) utilized UAS. The follow-up ranged from 1 week to 1 month. UAS reduced the incidence of postopera-tive fever (RR 0.49; 95% confidence interval [CI] 0.29-0.84; p=0.009), and postoperative in-fection (RR 0.50; 95% CI 0.30-0.83; p=0.008). There were no significant diff erences between groups in terms of SFR (RR 1.05; 95% CI 0.99-1.11; p=0.10), ureteral injuries (RR 1.29; 95% CI 0.95-1.75; p=0.11), operative time (MD 3.56 minutes; 95% CI -4.15 to 11.27 minutes; p=0.36), or length of stay (MD 0.32 days; 95% CI -0.42 to 1.07 days; p=0.40).Conclusion: UAS leads to a lower rate of post-operative fever and infection. However, UAS did not significantly reduce or increase the SFR or the rate of ureteral injuries during RIRS for patients with urolithiasis. The use of UAS should be considered to decrease the risk of infec-tious complications, particularly in those who may be at higher risk for such complications.