How Suction Is Redefining Ureteroscopy and PCNL Practices

Is the advent of suction technology the harbinger of percutaneous nephrolithotomy (PCNL)’s demise? Perhaps not, but it nevertheless causing a sea change in the approach urologists take to treating stones.

In part 4 of our 5-part series on suction technology in kidney stone treatment, Karen L. Stern, MD, and Naeem Bhojani, MD, FRCSC, discuss how suction has become central to contemporary ureteroscopic practice and how its integration is reshaping surgical decision-making, treatment algorithms, and the perceived role of percutaneous procedures. Bhojani describes how suction is now incorporated into virtually every ureteroscopy he performs, noting that it has become difficult to justify procedures without it. The discussion then turns to the practical issue of access: when a sheath cannot be advanced, the surgeon adjusts by downsizing the sheath and scope, choosing between continuing with dusting alone or placing a stent and returning later. These decisions depend heavily on stone size and anatomic constraints, illustrating how suction has redefined what is considered an optimal or complete procedure.

The conversation then expands to the broader clinical implications of suction. Bhojani argues that suction-enabled ureteroscopy has reached a point where mini-PCNL is largely unnecessary for stones 3 cm and smaller, citing comparable clearance rates alongside fewer complications, better quality of life, and shorter hospitalization. Stern cautions that percutaneous approaches remain valuable, noting that suction has also improved mini-PCNL and shifted its indications upward. Both, however, agree the trend is unmistakable: technological progress is pushing ureteroscopy into territory previously dominated by percutaneous surgery.

Attention then turns to what is needed next. Stern and Bhojani identify fragment retrieval inefficiency as a remaining barrier, particularly the slow process of withdrawing the scope repeatedly to extract residual fragments. They describe newer automated irrigation systems that maintain consistent flow, communicate with the scope, regulate intrarenal pressure, and provide a “flush” mode that improves fragment mobilization. Although these systems are promising, cost and availability remain challenges.

The segment concludes with a forward-looking perspective: future platforms may integrate irrigation, suction, pressure control, temperature monitoring, and laser settings into a single automated system. Stern and Bhojani anticipate that artificial intelligence will eventually reduce cognitive burden, streamline decision-making, and create a tightly coordinated, closed-loop environment for safer, more efficient stone surgery.