State universities are increasingly being transformed from institutions with traditional teaching and research responsibilities to have a third, societal role in sustainable regional and economic development. In doing so, universities support knowledge spillovers to improve sustainable entrepreneurial ecosystems that benefit economic revitalization or further development of regions. At the same time they promote stakeholder involvement in crucial governance processes at the regional level. Based on a comparative case study design building on three cases in Germany, our research analyses these interdependencies focussing on university-linked support programmes for sustainable entrepreneurship and the effects on sustainable regional development. Our findings provide a nuanced view clarifying the different roles universities have, how knowledge spillovers are created, and what outputs, outcomes, and effects are realized at the regional level and beyond. Specifically, we demonstrate that depending on the regional context, different configurations, pathways, and intervention points of universities may equally improve sustainable entrepreneurial ecosystems.