Influence of sheath size on suction mini‐PCNL outcomes: An observational study from the EAU endourology section and the global suction in mini‐PCNL collaborative study group

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Abstract Objective We aim to evaluate the association between sheath size and outcomes in suction mini‐percutaneous nephrolithotomy (SM‐PCNL). Materials and Methods A prospective, multicentre study enrolled 1534 patients undergoing SM‐PCNL from March to November 2024 across 30 centres. Patients were stratified into three groups: Group 1 (14–15 Fr, n = 780), Group 2 (16–18 Fr, n = 388), and Group 3 (20–22 Fr, n = 366). Primary outcome was 30‐day stone‐free rate (SFR) determined by non‐contrast CT. Secondary outcomes included complications, operative times and hospital stay. Results Group 3 achieved the highest zero residual fragment rate (92.6%) compared to Groups 2 (80.7%) and 1 (79.5%) ( p < 0.001). Operative times were shortest in Group 3 (36 min) and longest in Group 2 (65 min). Larger sheaths were associated with significantly higher overall complication rates: Group 1 (7.6%), Group 2 (14.4%) and Group 3 (14.8%) ( p < 0.001). Transfusion requirements increased with sheath size: 0% (Group 1), 1.5% (Group 2) and 3.3% (Group 3). Group 3 had exclusive pleural injuries requiring chest tubes (2.7%) and highest pelvicalyceal perforation rates (4.1% vs 1.3% in Group 2, 0% in Group 1). Larger sheath (16/18 Fr: OR 1.82; 21/22 Fr: OR 4.14) and single step dilation (OR 3.84) were associated with higher odds of zero residual fragments. Sheath size 21/22 Fr (OR 2.12) and increasing Guys stone score (score 2: OR 1.94; score 3: OR 3.51; score 4: OR 2.63 95% CI) were factors significantly associated with higher odds of overall complications. Conclusions Sheath selection in SM‐PCNL requires balancing efficacy against safety. Larger sheaths (20–22 Fr) optimize stone clearance but increase complications. Smaller sheaths (14–15 Fr) offer superior safety for simple cases. Intermediate sizes (16–18 Fr) may represent an optimal compromise for moderately complex stones.

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