CVAC 2.0 and Beyond: Aspiration-Driven Ureteroscopy

The rapid emergence of suction-enabled technologies has triggered a fundamental re-examination of how kidney stones are managed, how surgeons think about efficiency and safety, and how procedural decision-making is evolving in real time.

In part 3 of our 5-part series on suction technology, Karen L. Stern, MD, and Naeem Bhojani, MD, FRCSC, discuss the design and performance of the CVAC 2.0 aspiration scope, a system that differs markedly from both the flexible and navigable ureteric access sheath and direct in-scope suction (DISS) through its use of a separate irrigation channel and an internal suction channel. This dedicated inflow system, which includes multiple side-firing water jets, allows surgeons to maintain distension while selectively aspirating fragments up to approximately 2 mm. The separate channels prevent the system collapse seen with DISS and permit consistent irrigation even during active suction.

Stern and Bhojani outline the advantages of CVAC 2.0, particularly in cases involving larger stone burdens. Because the device can efficiently aspirate small fragments without repeated scope withdrawal, it reduces ergonomic strain and speeds up cases where dusting alone is insufficient. Surgeons report that CVAC 2.0 maintains effective performance regardless of stone volume—a contrast to sheath-based systems, where prolonged back-and-forth retrieval can become fatiguing. They also note that some surgeons modify their laser strategy during CVAC 2.0 cases, often favoring holmium platforms to generate fragments that fall into the optimal aspiratable size range.

However, the segment also addresses important limitations and safety considerations. Because the inflow channel is separate from the suction channel, a clog can occur without the immediate visual cues present in DISS systems. This introduces potential risk: irrigation can continue despite a lack of outflow, raising intrarenal pressure and possibly contributing to postoperative infection. Stern and Bhojani emphasize the need for continual audio and visual monitoring to detect changes in suction efficiency. Learning to identify these cues—particularly differences in sound during aspiration and subtle changes in calyceal collapse—is crucial for safe operation.

Other drawbacks involve the scope’s larger profile, reduced flexibility, and somewhat inferior image quality relative to modern disposable scopes. These features can make lower-pole access more challenging. Cost and reimbursement considerations are discussed as well, with the acknowledgment that current hospital-level reimbursement incentives may not be permanent and should not drive overuse.

Overall, this segment characterizes CVAC 2.0 as a powerful but nuanced tool whose benefits are most evident in large-volume cases. It excels when used thoughtfully, with careful attention to clog detection, laser technique, and ergonomic workflow.