The Rise of Suction and an Overview of FANS

The landscape of endourology is undergoing one of the most significant periods of innovation since the advent of flexible ureteroscopy and modern laser systems. 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 this series, Karen L. Stern, MD, of Mayo Clinic in Phoenix, Arizona and Naeem Bhojani, MD, FRCSC, of the University of Montreal explore how these developments are reshaping daily practice.

In this opening segment, the discussion focuses on the rapid evolution of kidney stone surgery and how suction has transitioned from an aspirational idea to a core component of modern ureteroscopy. Stern and Bhojani note that within just the past few years, the field has experienced what they describe as an “explosion” of innovation, including major improvements in lasers, endoscopes, and pressure-monitoring tools. These developments have converged to make suction not only feasible but essential for managing increasingly complex stones.

They highlight how advances in laser technology—particularly the shift toward thulium fiber platforms—have enabled more efficient fragmentation and dust creation. At the same time, scopes have become slimmer and more capable, contributing to better access and visualization. The introduction of real-time intrarenal pressure monitoring has added another layer of safety, especially as suction systems have demonstrated consistently lower pressures during procedures.

Stern and Bhojani then turn to flexible and navigable suction ureteral access sheath (FANS), describing how FANS incorporates suction directly into the distal end of an access sheath, giving surgeons the ability to remove fragments efficiently while maintaining low intrarenal pressure. A major advantage is the flexible, atraumatic tip that can be navigated into specific calyces, enabling precise placement. FANS supports both passive and active suction: passive suction functions continuously, whereas active suction requires occluding a valve or port. This allows the surgeon to modulate suction intensity for stone retrieval, clearing dust, or lowering pressure.

They also discuss the practical challenges associated with learning FANS. New users must manage irrigation inflow, thumb-controlled suction ports, sheath positioning, and coordinated withdrawal of the scope to capture fragments. Irrigation inflow is emphasized as a critical factor—insufficient flow can prevent stones from exiting the kidney effectively. Although the learning curve is not extensive—often around 10 cases—mastery requires attention to ergonomics and efficient movement.