Should we choose suction mini-percutaneous nephrolithotomy or flexible ureteroscopy with flexible and navigable suction ureteral access sheath in patients aged 65 years and above? An International Alliance of Urolithiasis and European Association of Urology Section of Endourology collaboration

Introduction: Flexible ureteroscopy (FURS) using the flexible and navigable suction ureteral access sheath (FANS) is a novel technique for treatment of kidney stones. We aimed to compare outcomes of FURS with FANS in the sitting vs standing position. Patients and Methods: We analyzed adult patients from 21 centers who underwent FURS with FANS, divided according to whether the surgeon operated in a sitting or standing position. Baseline demographics, operative parameters, and 30-day outcomes were compared. Multivariable logistic regression was used to identify potential predictive factors for zero residual fragments (ZRF). Results: There were 457 patients in the sitting group and 247 patients in the standing group. In the sitting group, more patients had the surgical procedure under general anesthesia (p = 0.022). Disposable scopes were preferred in the standing group (p < 0.001). Median lasing and ureteroscopy time were significantly shorter in the siting group, but there was no difference in total surgical time (median 45 vs 46 minutes, p = 0.102). A larger but nonsignificant percentage of grade 1 access sheath insertion injuries were reported in the standing position. Multivariable logistic regression analysis showed that stone volume (odds ratio [OR]: 0.82, 95% confidence interval [CI]: 0.72-0.93, p = 0.003) and operative time (OR: 0.99, 95% CI 0.99-1.00, p = 0.002) but not surgeon position (OR: 1.04, 95% CI: 0.75-1.44, p = 0.82) were significant predictors of ZRF. Procedural safety was not compromised significantly. Conclusions: FURS with FANS is equally safe and effective in the sitting and standing positions. This study provides the impetus to improve FURS ergonomics, especially with the move toward its use in complex and large stones.

While research on the comparison between the Flexible and Navigable Suction Ureteral Access Sheath (FANS) and the traditional ureteral access sheath (TUAS) in flexible ureteroscopy for unilateral stones is scarce, this study aims to assess their performance during bilateral same-session flexible ureteroscopy, examining safety, efficacy, and perioperative outcomes. In total, 100 cases aged 23 to 65 with bilateral stones under 20 mm were randomized into two groups: one using the NUAS and the other the TUAS. Exclusion criteria encompassed pediatric cases, individuals with untreated coagulopathies, and those with stones in calyceal diverticula. A significant difference was observed in the distribution of stone-free rates (SFRs) between the groups, with the FANS group demonstrating a elevated grade A (absolute stone-free) rate and fewer grade C (2.1 to 4 mm residual stones) as opposed to the TUAS one (70% vs. 20%, and 6% vs. 48%, p < 0.001). Additionally, the operative time was significantly longer in the TUAS group (58.4 ± 14.53 min) as opposed to the FANS group (48.41 ± 13.9 min, p = 0.001). The infection rate was also significantly elevated in the TUAS group (16%) as opposed to the FANS group (4%, p = 0.046). In terms of intraoperative and postoperative adverse events, the groups were similar (p < 0.05). FANS emerges as a promising and safer approach for bilateral flexible ureteroscopy, offering superior SFRs, faster procedure times, and fewer infections when as opposed to the traditional TUAS approach.

Flexible and navigable suction ureteral access sheath (FANS) is a potential game changer in flexible ureteroscopy (FURS). The influence of sheath size on outcomes needs research. The primary aim was to analyze 30-day single stage stone free status (SFS), zero fragment rate (ZFR) and complications when using 10/12Fr sheaths vis a vis other sheath sizes. The global FANS research group published the 30-day outcomes in patients who underwent FANS and reasoned this can be a potential game changer. We included 295 patients from this anonymized dataset with division into two groups: Group 1 (Smaller sheath) - 10/12Fr FANS, and Group 2 (Larger sheath) - 11/13Fr or 12/14Fr sheaths. Stone volume was similar between both groups (median 1320 mm3, p = 0.88). Ureteroscopy and total operative time was longer in the smaller sheath group (35 vs. 32min, p = 0.02 and 50 vs. 45min, p = 0.001, respectively). While 30-day computed tomography SFS (100% stone free or single residual fragment ≤ 2mm) were not significantly different (96% vs. 95%, p > 0.99), ZFR (100% stone-free) was better with smaller sheaths (68% vs. 53%, p = 0.02). There was no difference in postoperative complication rates, and no sepsis in both groups. Urologists should consider individualizing appropriate sheath size in normal adult kidneys. Sheath size did not affect complication rates, risk of perioperative injury to the pelvicalyceal system or ureteric injury, but smaller FANS sheaths had similar high SFS. The ZFR with smaller sheaths was better, but this needs to be validated. These smaller sheath outcomes need to be balanced with longer ureteroscopy time, operative time, reach to the lower pole, ease of suction and visibility during lithotripsy. Large volume studies in different types of pelvicalyceal anatomy can determine if indeed smaller FANS is the best choice in FURS.

Flexible ureteroscopy (F-URS) with suction technology has become a minimally invasive surgery for the management of renal stones. While the Flexible and Navigable Suction Ureteral Access Sheath (FANS) and Direct In-Scope Suction (DISS) ureteroscopes individually have proven benefits and restrictions, there is no dedicated research if integrating both these technologies can complement the limitations of each to improve suction F-URS outcomes. This audit introduces the Flexible Integrated Retrograde Suction-Ureteroscopy Technique (FIRST) procedure, which integrates FANS with a DISS ureteroscope, and compares its outcomes against DISS combined with a conventional ureteral access sheath (C-UAS). This prospective audit enrolled 64 adult patients undergoing F-URS with a DISS ureteroscope between August 2024 and October 2025 at 2 institutions. Patients were allocated to DISS with FANS (Group 1, n = 37) or DISS with C-UAS (Group 2, n = 27) based on surgeon discretion and device availability. The primary outcome was 30-day stone-free rate (SFR) assessed by non-contrast CT scan (single fragment up to 2mm). Secondary outcomes included perioperative complications, renal function, and 3-month residual fragment rate, and the surgeon-reported ergonomics of procedures. Despite significantly greater stone burden in Group 1, the FIRST procedure achieved a superior 30-day SFR of 83.8% versus 70.4% in Group 2, with zero-residual-fragment status in 72.9% versus 48.1% of patients, respectively (p < 0.001). At three months, zero residual fragments were detected in all patients in Group 1 compared to 22.2% in Group 2 (p < 0.01), translating into zero reinterventions in Group 1. Surgeon-reported ergonomics, intraoperative visibility, and simultaneous DISS-laser manipulation were rated significantly superior in Group 1. Overall 30-day complication rates were comparable between groups (18.9% vs. 22.2%), with no high-grade (Clavien ≥ 3) complications and preserved renal function in either cohort. The FIRST procedure using this integrated suction technique can potentially give 100% SFR with significantly improved ergonomics with negligible complications. These findings support further investigation of the integrated FIRST procedure in routine and anatomically complex renal stone disease.

Recent guidelines highlight the significant role of sodium-glucose co-transporter-2 inhibitors (SGLT2is) in enhancing the overall condition of patients with heart failure with reduced ejection fraction (HFrEF), leading to their widespread use, but recent studies revealed an increased prevalence of urinary tract infections (UTIs) associated with this medication. The aim of the present study is to evaluate the risk of urosepsis after flexible ureteroscopy with flexible navigable vacuum assisted access sheath in patients diagnosed with renal stone disease who are using SGLT2i for HFrEF. This prospective comparative study included patients who were taking a SGLT2i (dapagliflozin 10 mg per day or empagliflozin 10 mg per day) for HFrEF and underwent flexible ureteroscopy in "Prof. Dr. Theodor Burghele" Clinical Hospital, Bucharest, Romania, between 01.01.2021 and 31.12.2024 for renal stone disease. All patients were completely assessed via imaging exam, complete blood count and urine analysis. The inclusion criteria were as follows: patients over 18 years old, established documented diagnosis of symptomatic HFrEF (Heart Failure New York Heart Association functional class II-IV), which has been present for at least two months and was optimally treated with pharmacological and/or device therapy, administration of SGLT2i, single-use flexible ureteroscopy, flexible and navigable vacuum-assisted ureteral access sheath (UAS) and the largest stone diameter less than 2 cm. The surgical technique met the same standard according to the recent recommendations of the International Alliance of Urolithiasis guideline on retrograde intrarenal surgery. Seventy-three patients who met the inclusion criteria were divided into two groups, according to previous SGLT2i administration, as follows: Group 1 (patients with SGLT2i) and Group 2 ( non-SGLT2i patients ). After analysing the demographic data, a slightly increased prevalence in female subjects was observed. There were no statistically different results regarding important pre-surgical data, such as mean stone dimension or density (HU), but there were preoperative differences regarding the prevalence of UTIs. After analyzing perioperative parameters such as mean previous JJ stented patients, mean surgical time and mean fluoroscopy time, the findings revealed no statistically significant differences. Regarding the main objective of the study, the present results revealed no differences in overall postoperative complications. There was a small number of postoperative urinary sepsis cases: three patients in Group 1 and two patients in Group 2. Although SGLT2i administration may even increase the risk of developing UTIs, this does not influence the postoperative complications outcome after flexible ureteroscopy for renal stone disease. High-standard equipment such as single-use devices and suction ureteral access sheaths has a safe profile regarding sepsis occurrence even in UTIs, facilitating drug administration.

Objective To evaluate the efficacy and complications of flexible ureteroscopy for the treatment of upper urinary tract calculi in children. Methods The clinical data of upper urinary tract calculi in 20 children including 16 male and 4 female, treated by using flexible ureteroscopy, were collected from January 2014 to May 2015 in the First Affiliated Hospital of Zhengzhou University.The mean age was 6.4 years(ranging from 2.7-15.0 years old). Among them, 6 cases had upper ureteral calculi and 14 cases had renal calculi.All the calculi was found unilaterally with on the left side in 12 cases and on the right side in 8 cases.Ipsilateral mild to moderate hydronephrosis were found in all of the cases.The mean stone size was 1.2 cm(ranging from 0.5-1.8 cm). All the cases were treated through retrograde flexible ureteroscopy holmium laser lithotripsy after the invalid conservative through conservative treatment.Double J tube was left routinely in the sick side 1 week before operation to expand the internal diameter of the ureter.A double J stent was left in place for 1 month after operation as a routine. Results The flexible ureteral access sheath failed to insert into the upper ureter in 2 cases because of the narrow ureter, then the flexible ureteroscopy was inserted into ureter through wire directly.The flexible ureteral access sheath was successfully inserted into the ureter for the others and flexible ureteroscopy were inserted through flexible sheath.The mean operative time was 38 min(ranging from 20-60 min). The patients were discharged from hospital after a mean of 4.5 days(ranging from 3-7 days). The rate of stone-free in one-stage was more than 90%.There were residual small stones in the lower calices of kidney in 2 cases.The perfusion liquid volume during the operation was 500 mL(ranging from 200-1 000 mL). There was no major perioperative complication, while transient macroscopic hematuria and fever were common complications after operation.The stone search was performed successfully in the whole 14 cases.NO residual stone could be found through ultrasound and kidney ureter bladder plain and Double-J stent was removed 1 month after operation. Conclusions Flexible ureteroscopy produces high stone-free rate and clinical safety for upper urinary calculi in children.However, the complications of flexible ureteroscopy lithotripsy cannot be ignored and sufficient preoperative preparation and careful perioperative safety control should be required. Key words: Upper urinary tract calculi; Flexible ureteroscopy; Complications; Child

DOSE A URETERAL ACCESS SHEATH FACILITATE URETEROSCOPY?

MP69-19 STONE SIZE ON ENDOSCOPIC VIEW AS A PREDICTOR OF SUCCESSFUL STONE RETRIEVAL DURING FLEXIBLE URETEROSCOPY

The treatment of impacted upper ureteral stones remains a significant challenge for urologists. Standard treatment protocols often favor Mini-Percutaneous Nephrolithotripsy (Mini-PCNL). It has been supposed to be associated with a higher stone clearance rate and a lower incidence of ureteral stricture compared to Flexible Ureteroscopy (FURS). Recently, FURS with flexible and navigable suction ureteral access sheath (FANS) has emerged as a promising alternative. The aim of this study was to compare the efficacy and safety of the FURS with FANS and Mini-PCNL for treating the impacted upper ureteral stones. A retrospective study of 80 patients treated with FURS with FANS (Group A, n = 43) or Mini-PCNL (Group B, n = 37) was conducted in our center (from June 2023 to August 2024). Primary outcomes included stone-free rate (SFR), hemoglobin drop, hospital stay, and complications (Clavien-Dindo classification) in 3 months. Both groups achieved comparable SFR (90.7% vs. 83.78%, P = 0.351). Group A had significantly lower hemoglobin drop (3.65 ± 8.39 vs. 7.89 ± 9.39 g/L, P = 0.036) and shorter hospital stays (1.79 ± 1.08 vs. 3.81 ± 1.37 days, P < 0.001). Complication rates were similar, but Group A had a higher rate of second-stage operation (18.6% vs. 8.1%, P = 0.174) and neither group required reoperation for ureteral stricture or rupture at 3 months post-surgery. FURS with FANS is a safe and effective alternative to Mini-PCNL for impacted upper ureteral stones larger than 10 mm, offering shorter recovery times and lower bleeding. However, its higher second-stage operation rate necessitates further investigation.

Basketing plays an important role during flexible ureteroscopy, but it can be time-consuming, especially when fragments are too large to pass through the ureteral access sheath. We aim to present the optimal on-screen, endoscopic stone size that predicts successful basketing through various access sheaths. A tipless basket, individually extended to 5mm from multiple ureteroscopes: (Flex-Xc, Karl Storz; Flex-X2s, Karl Storz; LithoVue, Boston Scientific; or URF-P6R, Olympus) and via differently sized access sheaths (10-12 Fr through 13-15 Fr), was used in retrieval attempts of various artificial stone sizes (2mm through 5mm). A relative endoscopic stone size was recorded as the stone's maximum diameter on endoscopic view compared to the total image diameter. Basketing of stones up to 2.5mm, yielding relative endoscopic stone sizes of 0.38 (Flex-Xc), 0.30 (Flex-X2s), 0.32 (LithoVue), and 0.34 (URF-P6R), was successful using all access sheaths. Only the 12-14 Fr and greater sheaths allowed for successful basketing of 3mm stones. Larger stones did not successfully pass through any of the access sheaths. Successful stone retrieval can be predicted by estimating the stone's size on screen, which is influenced by the type of flexible ureteroscope and access sheath. In our testing, stones of approximately one-third of the screen size passed successfully in all cases.

Use of suction in flexible ureteroscopy is increasing lately. The introduction of flexible and navigable suction access sheath (FANS) has shown improved stone free rate (SFR). However, its efficacy in lower pole stone (LPS) in terms of SFR and complications is yet to be studied. We collected data from 25 centers that included 394 adult patients undergoing ureteroscopy using FANS. Non contrast CT (NCCT) scan was done within first 30 days post operatively to access the SFR. Residual fragments were graded as A: 100% SFR; B: single fragment ≤ 2mm; C: single fragment 2.1-4mm; D: Single or multiple fragments > 4mm. Post operative complications were recorded. Out of 394 patients, non LPS (group1) comprised of 268 patients, rest 126 patients had LPS (group 2). Single stage zero fragment SFR was seen in 58.6% (group 1) vs. 54.8% (group 2) (P = 0.619). Single stage grade A + B SFR was achieved in 96.6% vs. 98.4% in groups 1 and 2 respectively. On multivariate analysis Thulium fiber laser use was significantly associated with higher odds of being grade A stone-free, while stone volume with lower odds. In LPS group only two patients needed reintervention. The highest grade of complication was Clavien 2, which was seen in 3.2% LPS group. Use of flexible and navigable suction ureteric access sheath for lower pole stones is effective and safe. The stone free rate of lower pole stones is comparable to non-lower pole locations with very low reintervention rate in both groups.

Objective: We aim to evaluate stone-free rate (SFR) and complications after flexible ureteroscopy (F-URS) for kidney stones, using a flexible and navigable suction ureteral access sheath (FANS), comparing thulium fiber laser (TFL) and high-power holmium:yttrium-aluminum-garnet laser (HPHL). Methods: Data from adults who underwent F-URS in 15 centers were prospectively analyzed (August 2023-January 2024). Exclusion criteria were ureteral stones, concomitant bilateral procedures, and renal abnormalities. One-to-one propensity score matching for age, gender, stone location, stone volume, and Hounsfield unit was performed. SFR was assessed using computed tomography scan within 30 days and defined as zero fragments. Data are presented as median (25th-75th quartiles). Multivariable logistic regression was performed to evaluate predictors of SFR. Results: Of included patients, HPHL was used in 114 patients and TFL in 181 patients. After matching, 96 patients from each group with similar baseline characteristics were included. There was no difference between the groups regarding the use of disposable scopes, lithotripsy mode, and ureteroscopy, lasing and total surgical time. There was no case of sepsis, and blood transfusion was necessary for only one patient in the HPHL group. The incidence of transient fever was similar (3.4% in HPHL vs 3.8% in TFL group). Postoperative day 1 loin pain did not differ significantly. Postoperative stay did not differ significantly [1 [0, 2] in HPHL vs 1 [0, 1] days in TFL group, p = 0.12]. Thirty-day SFR was similar (52.1% for HL vs 64.6% for TFL group, p = 0.11). At multivariable analysis, the use of TFL (odds ratio 1.95, 95% confidence interval 1.01-3.82) was significantly associated with higher odds of being stone-free. Conclusions: Both lasers are safe and efficacious and can be suitably used for F-URS with FANS with high SFR and minimal complications.

Durability of Flexible Ureteroscopes: A Randomized, Prospective Study

To evaluate outcomes after flexible ureteroscopy (F-URS) for renal stone(s) using a flexible and navigable suction ureteral access sheath (FANS-UAS) comparing Thulium fiber (TFL) vs pulsed Thulium:Yttrium aluminum garnet (p-Thulium:YAG) laser. Data from adults who had F-URS in 5 centers were prospectively collected (April 2023-January 2024). All patients had a preoperative and within 30days CT scan. Stone-free: grade A: zero fragments; grade B: single fragment ≤2mm; grade C: single fragment 2.1-4mm; grade D: single/multiple fragments >4 mm. One-to-one propensity score-matching for age, gender, prestenting, stone volume, stone location, and Hounsfield units was performed. Within 6months after surgery, an intravenous urography or CT urography scan was performed in all patients. Of 179 included patients, TFL was employed in 115 patients. After matching, 64 patients from each group with comparable baseline characteristics were included. Median lasing time was significantly longer in the TFL group (15.5 [10,23] minutes vs 13 [10,15] minutes, P=.02), while total surgical time did not differ. There was no case of blood transfusion and sepsis. Overall stone-free rate (SFR) was significantly different between the groups with a higher proportion of patients in p-Thu:YAG laser group undergoing reintervention for residual fragments (17.2% vs 3.1%). There was no case of new-onset hydronephrosis, ureteropelvic junction/ureteral stenosis, impaired urinary drainage, or altered pelvicalyceal anatomy at a median follow-up of 13weeks. F-URS using FANS-UAS showed negligible serious adverse events and good SFR using both lasers. p-Thu:YAG laser showed shorter lasing time, marginal better grade A+B SFR but higher reintervention rate for residual fragments.

Objective To systematically evaluate the necessity of presetting double-J stent before flexible ureteroscope lithotripsy. Methods Computer retrieved clinical studies on the effect of preoperative presetting double-J-catheter on flexible ureteroscope lithotripsy in PubMed, Cochrane Library, Embase, Scopus, Wan fang, CNKI and VIP databases were reviewed. The retrieval time was from the database construction to November 2018. All of the possible combinations of the following terms were used for the search: flexible ureteroscopic, preoperative, double J stent, and calculus. Two researchers independently conducted literature screening, quality evaluation and data extraction, and completed Meta analysis by using statistical software RevMan5.3. Results Thirty-two case-control trials and 14 randomized controlled trials were screened, with a total of 17 480 patients, including 6 211 patients in the experimental group and 11 269 patients in the control group. The results of meta-analysis showed that the experimental group was superior to the control group in term of the overall postoperative stone clearance rate (OR=1.69, 95%CI 1.37-2.08, P<0.05). In terms of postoperative kidney stone removal rate, the experimental group was superior to the control group (OR=1.67, 95%CI 1.41-1.99, P<0.05). In terms of the removal rate of ureteral calculi after surgery, there was no significant difference between the two groups (OR=1.71, 95%CI 0.91-3.20, P=0.10). The success rate of flexible ureteroscope access sheath implantation was higher in the experimental group (OR=5.77, 95%CI 3.32-10.31, P<0.05). The rate of passive usage balloon dilation in the control group was higher(OR=0.23, 95%CI 0.15-0.35, P<0.05). For the incidence of intraoperative complications, the experimental group was lower (OR=0.56, 95%CI 0.38-0.84, P=0.004). For the incidence of postoperative complications, the experimental group was also lower(OR=0.64, 95%CI 0.45-0.90, P=0.01). The operation time of the control group was longer(MD=-4.95, 95%CI -8.90--1.01, P=0.01). Conclusions Presetting double-J-catheter can improve the stone removal rate after flexible ureteroscope lithotripsy for the treatment of kidney stone, improve the success rate of flexible ureteroscope access sheath implantation, reduce the utilization rate of ureteral balloon dilator, reduce the incidence of intraoperative and postoperative complications, and shorten the operation time. Key words: Urinary calculus; Flexible ureteroscopic; Double J stent; Meta-analysis