Utility and challenges of flexible and navigable suction ureteral access sheath (FANS) vs. suction mini-PCNL in...

Pediatric kidney stone disease presents unique challenges, necessitating minimally invasive techniques. Suction-assisted mini-percutaneous nephrolithotomy (SM-PCNL) is a well-established treatment, while flexible ureteroscopy using a flexible and navigable suction ureteral access sheath (FANS-UAS) is an emerging technique. Both integrate suction to improve stone clearance, reduce intrarenal pressure, and enhance visualization. However, comparative evidence in children remains limited.

This study hypothesized that FANS-UAS would demonstrate comparable stone-free rates (SFR) and perioperative outcomes to SM-PCNL in children with renal stones ≤2 cm, while potentially offering advantages in operative efficiency and patient recovery. We aimed to compare the perioperative outcomes and SFR of FANS-UAS versus SM-PCNL across multiple international centers.

A prospective, multicenter study analyzed 96 pediatric patients (50 FANS-UAS, 46 SM-PCNL) from eight centers. Inclusion criteria were age ≤16 years, normal renal anatomy, and stone burden ≤2 cm. Outcomes included SFR (assessed via 30-day non-contrast CT scan), operative time, complications, and hospital stay.

FANS-UAS demonstrated comparable SFR to SM-PCNL (66.0 % vs. 58.7 % for zero fragments) but with shorter operative times (42.5 vs. 82.5 min, p = 0.025) and hospital stays (2 vs. 3 days, p < 0.001). FANS-UAS was preferred for multiple stones (28 % vs. 0 %, p = 0.005). Complication rates were similar (12.0 % vs. 8.7 %, p = 0.845). Notably, all FANS-UAS patients required pre-stenting, and a lower body mass index (BMI) was associated with FANS-UAS selection (14.0 vs. 19.0 kg/m², p < 0.001).

FANS-UAS offers advantages in operative duration and utility for multiple stones, though it requires pre-stenting and careful sheath handling. SM-PCNL remains a reliable option with a strong safety record. Study limitations include its non-randomized design, small sample size, and short-term follow-up. The findings suggest that while stone burden is not the sole determinant, factors like BMI and the presence of multiple stones may influence the choice of approach.

FANS-UAS and SM-PCNL are both suitable for managing renal stones up to 2 cm in children. FANS-UAS offers benefits in operative efficiency and managing multiple stones. The choice of technique may be influenced by patient characteristics such as BMI, and ultimately, surgeon experience and comfort remain crucial for procedural success and complication rates.