Technique, Feasibility, Utility, Limitations, and Future Perspectives of a New Technique of Applying Direct In-Scope Suction to Improve Outcomes of Retrograde Intrarenal Surgery for Stones

Retrograde intrarenal surgery (RIRS) is accepted as a primary modality for the management of renal stones up to 2 cm. The limitations of RIRS in larger volume stones include limited visualization due to the snow-globe effect and persistence of fragments that cannot be removed. We describe a new, simple, cost-effective modification that can be attached to any flexible ureteroscope which allows simultaneous/alternating suction and aspiration during/after laser lithotripsy using the scope as a conduit to remove the fragments or dust from the pelvicalyceal system called direct in-scope suction (DISS) technique. Between September 2020 and September 2021, 30 patients with kidney stones underwent RIRS with the DISS technique. They were compared with 28 patients who underwent RIRS with a 11Fr/13Fr suction ureteral access sheaths (SUASs) in the same period. RIRS and laser lithotripsy were carried out traditionally with a Holmium laser for the SUAS group or a thulium fiber laser for the DISS group. There was no difference in age, gender, and history of renal lithiasis between the two groups. Ten (40%) patients had multiple stones in the DISS groups, whilst there were no patients with multiple stones in the SUAS group. Median stone size was significantly higher in the DISS group [22.0 (18.0−28.8) vs. 13.0 (11.8−15.0) millimeters, p < 0.001]. Median surgical time was significantly longer in the DISS group [80.0 (60.0−100) minutes] as compared to the SUAS group [47.5 (41.5−60.3) minutes, p < 0.001]. Hospital stay was significantly shorter in the DISS group [1.00 (0.667−1.00) vs. 1.00 (1.00−2.00) days, p = 0.02]. Postoperative complications were minor, and there was no significant difference between the two groups. The incidence of residual fragments did not significantly differ between the two groups [10 (33.3%) in the DISS group vs. 10 (35.7%) in the SUAS group, p = 0.99] but 10 (33.3%) patients required a further RIRS for residual fragments in the DISS group, whilst only one (3.6%) patient in the SUAS group required a subsequent shock wave lithotripsy treatment. Our audit study highlighted that RIRS with DISS technique was feasible with an acceptable rate of retreatment as compared to RIRS with SUAS.