The Role of Suction in Ureteroscopy: A Narrative Review

Kidney stone disease is a prevalent urological condition, affecting at least one in 10 individuals. The rising incidence of urolithiasis represents a significant burden on the National Health Service (NHS) and has driven major advances in endourology, including the use of flexible ureteroscopes (F-URS), high-efficiency laser fibres and techniques. Despite these advances, retrograde intrarenal surgery (RIRS) still has complications such as residual fragments and infection risk. Whilst suction technology has been utilised in percutaneous nephrolithotomy (PCNL) for over 25 years, its use in RIRS is new. This narrative review evaluates the safety and clinical efficacy of suction-assisted ureteroscopy (URS) in the management of kidney stones. A literature search was performed on PubMed and Google Scholar for studies published between January 2015 and October 2025, using the keywords 'suction', 'ureteroscopy', 'URS', 'F-URS', 'kidney stones', 'FANS,' 'flexible and navigation suction sheaths', 'suction urethral access sheaths', 'SUAS', 'direct-in-scope suction', 'DISS' and 'ureterorenoscopy'. Suction-assisted URS reduces intrarenal pressure and operative time and improves visibility. Suction urethral access sheaths (SUAS) enhance stone clearance rate (stone-free rate (SFR)) and reduce post-operative complications. Flexible and navigation suction sheaths (FANS) integrate a continuous suction mechanism with a flexible tip scope, further reducing post-operative fever and improving SFR. Direct in-scope suction (DISS) allows synchronous irrigation and suction via dual lumen designs, facilitating the efficient removal of larger stones. Despite encouraging outcomes, suction systems introduce additional procedural complexities. There remains a lack of standardised protocols and robust randomised controlled trials (RCTs) directly comparing different suction systems. Further multi-centre RCTs are warranted to establish best practice clinical guidelines for the safe and effective use of suction in modern endourology.