How the SURE procedure boosts efficiency in treating stones

At the 2025 LUGPA Annual Meeting, urologist Matthew A. Love, MD, of The Urology Group in Ohio, presented a video on Steerable Ureteroscopic Renal Stone Evacuation (SURE), a novel approach to treating kidney stones using the CVAC device. This disposable, flexible ureteroscope integrates both stone fragmentation and suction, allowing surgeons to remove stone debris efficiently during the same procedure. According to Love, this technique enhances stone-free rates and reduces the need for repeat procedures.

Love highlighted the procedure’s efficiency compared with standard ureteroscopy, especially for large or complex stones distributed across multiple calyces. In some cases, SURE may even replace percutaneous nephrolithotomy (PCNL), offering a less invasive alternative with shorter operative times. The CVAC device has demonstrated utility for stones as small as 7 mm, providing flexibility across a range of stone sizes and improving operating room (OR) and ambulatory surgical center (ASC) efficiency.

From a safety perspective, the system’s internal fluid management helps regulate intrarenal temperature and pressure, potentially lowering infection risks. Love emphasized the importance of recognizing tactile and visual cues—such as changes in flow or sound—that indicate clogs or reduced performance. With experience, surgeons can minimize complications through proper scope handling and maintenance techniques.

According to Love, the ideal candidates for SURE are patients with 1 cm to 2 cm stones, where PCNL might otherwise be considered. It is also beneficial for those with contraindications to more invasive surgery, such as high body mass index (BMI) or anticoagulant use.

Love said he foresees broader applications of the CVAC device, including potential use for upper tract tumors, as aspiration and suction technologies continue to advance. He also noted the short learning curve and strong safety and efficacy data supporting the SURE approach.

Urology Times: You presented a video at this year's LUGPA Annual Meeting demonstrating Steerable Ureteroscopic Renal Stone Evacuation. Could you take us through what this procedure entails?

Love: SURE is a procedure that is typically done with the CVAC device, which is a disposable, flexible ureteroscope that allows you to treat larger stone burdens in the kidney and do it a little bit more efficiently. Essentially, it's an all-in-one scope that allows you to break up the stone fragments and vacuum them out at the same time to increase stone-free rates and decrease repeat procedures for patients in the future.

Urology Times: What have you observed in terms of stone-free rates or operative time compared to some of the other procedures for treating stones?

Love: As surgeons, we're all very efficiency minded, so it's how can we get this patient taken care of as quickly as possible, as efficiently as possible, and as safely as possible? From a safety standpoint, there are plenty of studies looking at that with the CVAC device. OR efficiency times, especially for larger, more complicated stones and stones in multiple calyces, ends up being a lot quicker than standard ureteroscopy as well. So it's a nice tool to have in our toolbelt as urologists for some of the more complex stones, sometimes even as a replacement for a PCNL procedure. Some of the data would suggest that you can use it on stones as small as 7 mm. So again, just further optimizing your OR time, allowing for more operating room and ASC efficiencies with using the scope.

Urology Times:Could you touch on some of the safety considerations with this technique?

Love: With the scope, there is an ability to kind of have an internal fluid management system. From a safety standpoint, assuming that you're paying attention to everything and operating the scope as it should, intrarenal temperatures, intrarenal pressures, and hypothetical sepsis risk should go down. The biggest concern is just being aware of those types of things where there may be a clog in the scope, there may not be enough fluid coming out, or there may be some sort of clog that prevents that scope from functioning how it should. So, paying attention to some of the tactile triggers, some of the sounds that the scope may be making, what you're seeing on the screen, good flow from right to left, that all kind of indicate a normal, functioning scope. There are multiple techniques that you can do in the operating room to make sure that you're de-clogging the scope or preventing further clogs. I think the more you have your hands on it, the more comfortable you get, and the lower likelihood of having any major complication.

Urology Times:What kind of cases or stone burdens are best suited for this approach?

Love: I think my wheelhouse kind of index patient is probably a 1 cm to 2 cm stone. Those really are optimized with the CVAC device, rather than going into a more invasive PCNL procedure for a stone that's right around that 2-cm mark. If I have a 8 mm or 9 mm renal pelvic stone, I think that case can be done very, very efficiently with a CVAC. I generally like those patients in that 1 cm to 2 cm range. In certain patients who can't have a PCNL for a variety of reasons—morbid obesity, really high BMI, can't come off of blood thinners—I think those patients also benefit from this compared with a standard ureteroscopy that may need to be staged - multiple procedures, multiple trips back to the operating room for that patient.

Urology Times:Where do you see the SURE procedure fitting into the treatment landscape?

Love: The more I use it, the more applications I see with it, potentially even taking care of upper tract tumors with this continuous flow that you get with the scope. I think the suction and aspiration technology space in urology has really taken off, and I see the CVAC device as the gold standard there.

Urology Times:What do you believe has been the biggest story in stone disease this year?

Love: I think it's been the aspiration suction technologies. There are multiple devices that are out on the market right now to really help improve those stone-free rates and do so in the least invasive way possible. Laser technology is getting better and better, but I really think it's the aspiration and suction technologies that have really taken off.

Urology Times: Is there anything you would like to add?

Love: I think if you haven't had a chance to get your hands on a scope, I think it's a really good opportunity to optimize outcomes for your patients. It's not a very steep learning curve. A lot of urologists are doing flexible ureteroscopy, so the learning curve is quite quick. I think [in terms of] optimizing outcomes, there are clear safety data, efficacy data, and again, being like-minded urologists who want to improve efficiencies and OR time optimization, I think it's another big win with that scope.