Background <p>As a safe approach to the upper urinary tract, flexible ureteroscopic lithotripsy (fURL) is a widely accepted treatment for nephrolithiasis. Sometimes, this technique can rely on the natural expulsion of stones, increasing the risk of infections and stone recurrence. To mitigate these issues, some studies tried to use a suctioning ureteral access sheath (S-UAS).</p> Methods <p>A systematic review was conducted across multiple databases for trials comparing S-UAS with traditional (T-UAS) in retrograde intrarenal surgery (RIRS). The primary endpoint was the stone-free rate (SFR), while adverse effects, operative time, fever rate, and hospital stay were analyzed as secondary outcomes.</p> Results <p>We retrieved 8 articles, encompassing a total of 2,255 patients, with 978 in the S-UAS group and 1,247 in the T-UAS group. Our analysis revealed a higher SFR in the S-UAS group after 1&#xa0;day, and also at later time points (one or three months) (OR 3.79; 95% CI 1.70–8.46; <i>p</i> = 0.001; <i>I</i>² = 89.2%) and (OR 1.98; 95% CI 1.52–2.59; <i>p &lt;</i> 0.001; <i>I</i>² = 0%), respectively. Regarding surgical complications, we observed a lower incidence in the S-UAS group (OR 0.37; 95% CI 0.26–0.51; <i>p &lt;</i> 0.001; <i>I</i>² = 0%), as well as a reduced fever rate (OR 0.34; 95% CI 0.24–0.48; <i>p &lt;</i> 0.001; <i>I</i>² = 0%) and a shorter length of hospital stay (MD -0.11; 95% CI -0.16 to -0.05; <i>p &lt;</i> 0.001; <i>I</i>² = 39.6%). No differences were found in the operative time between both approaches (MD -2.49; 95% CI -7.62–2.65; <i>p &lt;</i> 0.343; <i>I</i>² = 88.3%).</p> Conclusion <p>Our study suggests that using S-UAS in RIRS may enhance the SFR, and also reduce both complications and hospital stay.</p> Trial registration <p>This systematic-review and meta-analysis was prospectively registered on PROSPERO under protocol CRD42024543084.</p>