Suction Ureteral Access Sheaths During Flexible Ureteroscopy for Renal Stones: A Prospective Study and Cost Analysis

Background During flexible ureteroscopy (fURS), ureteral access sheaths (UASs) are used to protect the fURS scope and reduce intrarenal pressure. UASs with suction functionality are increasingly used during fURS, with purported benefits including faster stone clearance, the ability to treat larger stones, reduced intrarenal pressure (potentially decreasing infections), and cost savings due to less frequent use of expensive baskets. This single-center study aimed to compare outcomes of fURS cases using suction UASs (S-UASs) versus traditional UASs (T-UASs) and to assess potential cost savings. Methods Data were collected prospectively from the first 50 fURS cases performed for stone disease in adult patients using the ClearPetra S-UAS (August 2024 to February 2025) and compared with 50 fURS cases using T-UAS prior to the availability of S-UAS (April to July 2024). From August 2024, the choice of S-UAS, T-UAS, or no access sheath during fURS was at the discretion of the operating surgeon. Qualitative data were compared using Fisher's exact test or chi-squared test as appropriate. Quantitative data were compared using the Mann-Whitney U test. p-Values <0.05 were considered statistically significant. Costs used in the analysis were based on this single center's equipment prices. Results Baskets were used significantly less in the S-UAS group (p < 0.001), resulting in estimated cost savings of £115 per fURS, totaling £5,750 over 50 cases. There were no statistically significant differences between the S-UAS and T-UAS groups in rates of persistent stones on follow-up imaging at three and six months, reintervention, or complications (p > 0.05). Median operative time was longer in the S-UAS group, but this did not reach statistical significance (p = 0.099). The S-UAS group had higher rates of multiple stones, partial staghorn stones, stones larger than 2 cm, and bilateral fURS, as well as a lower rate of pre-stenting; however, none of these differences reached statistical significance (p > 0.05). Conclusions S-UAS usage during fURS for renal stones resulted in significantly less basket usage and associated cost savings. Rates of persistent fragments, reintervention, and complications were similar between the S-UAS and T-UAS groups. Operative time appeared longer in the S-UAS group, although this was not statistically significant. A large randomized controlled trial with a predefined follow-up imaging schedule, specifically evaluating whether S-UAS reduces reintervention rates compared with T-UAS following fURS, would be valuable to further investigate its effectiveness.