Suction sheaths in kidney stone surgery

Suction in kidney stone surgery

For years, surgeons have treated kidney stones like in tiny "snow globe" environements —they break the kidney stones with lasers, but the resulting "dust" and debris cloud the view, making it hard to ensure every last bit is gone.

There has been a significant shift in kidney stone surgery over the last few years with the introduction of suction sheaths in both Flexible Ureteroscopy (fURS) and Percutaneous Nephrolithotomy (PCNL) procedures. Unlike traditional rigid tubes, these sheaths allow the surgeon to break a kidney stone into tiny dust pieces with a high-power laser and then "vacuum" the stone dust directly out of the kidney.

1. Why Suction is a "Game-Changer"

Standard stone surgery often suffers from a "snow-globe effect," where stone dust clouds the surgeon's view. Suction sheath technology solves this problem by using active suction to:

• Improve Visibility: It continuously removes blood and stone "snow" so the surgeon can see the target clearly.

• Lower Kidney Pressure: During surgery, saline is pumped into the kidney to see. If pressure gets too high, it can push bacteria into the blood (pyelovenous backflow). Suction keeps this pressure at safer, lower levels.

• Reduce Infection: Studies show that patients treated with suction sheaths have a 69% lower risk of postoperative fever compared to those using traditional sheaths.

2. Flexible Ureteroscopy (fURS): The Vacuum Highway

The use of Flexible and Navigable Suction (FANS) access sheaths represents a paradigm shift in retrograde intrarenal surgery.

Clinical Outcomes and Evidence

• Superior Stone-Free Rates (SFR): A 2025 meta-analysis found that patients treated with FANS were four times more likely to be completely stone-free on the first day after surgery compared to traditional sheaths.

• Lasing Strategies: Research shows that "Dusting" (turning stones into fine powder) results in higher 100% stone-free rates (69.4%) compared to "Popcorning" (53.9%).

• Laser Type Matters: The use of advanced Thulium Fiber Lasers (TFL) or pulsed Thulium:YAG lasers is the strongest predictor of achieving a zero-fragment result, even more so than the lasing technique itself.

• Scope Choice: While both reusable and single-use scopes are safe, using single-use scopes in combination with smaller (10/12 Fr) suction sheaths provides the highest odds of 100% stone clearance.

3. PCNL

Percutaneous Nephrolithotomy (PCNL) is typically used for larger or more complex stones. The advent of suction sheaths has been particularly impactful for the "mini-PCNL" technique.

The Pressure Problem

Because the "tunnels" in Mini-PCNL are so small, the water pressure inside the kidney can spike much faster than in traditional surgery. This is where the suction sheath becomes a literal lifesaver.

• A Strong Recommendation: The 2025 American Urological Association (AUA) guidelines provide a formal "Conditional Recommendation" for using suction sheaths in Mini-PCNL.

• Better Results: Suction efficiently clears large fragments, which helps improve stone-free rates and reduces the need for a second "cleanup" surgery later.

• Tailored Safety: While Mini-PCNL can sometimes take longer than standard surgery, suction makes the process more efficient and safer by regulating internal pressure.

Conclusion

Suction sheath technology represents a meaningful evolution in endoscopic stone management. By enabling active fragment retrieval while maintaining stable intrarenal pressures, it addresses the two most persistent challenges in urology: residual fragments and infectious complications.

Mr Ivo Dukic is one of the UK's premier complex stone surgeons and top kidney stone specialists, offering world-class urological care in Birmingham. Recognised as the leading PCNL expert in the West Midlands, Mr Dukic delivers cutting-edge minimally invasive treatments, including:

• Mini-PCNL for optimal outcomes.

• Ultra-mini PCNL for reduced recovery times.

• Advanced endoscopic removal and complex renal stone surgery.

Mr Dukic combines years of specialist experience with the latest innovations, such as suction sheaths and LASER technology in both mini PCNL and flexible ureterorenoscopy, to provide superior treatment outcomes.

You can schedule an appointment with him for expert, bespoke advice through his Top Doctors profile or book an appointment through Harborne Hospital, HCA Healthcare, the Priory Hospital, Edgbaston, Circle Health Group or Droitwich Spa, Circle Health.