Does the existing evidence on flexible and navigable suction ureteral access sheath indicate a potential paradigm shift in the management of kidney and ureteral stones with flexible ureteroscopy? An overview from EAU endourology

PURPOSE OF REVIEW: This opinion article from the EAU Endourology Section critically summarizes the existing evidence on flexible and navigable suction ureteral access sheaths (FANS) to determine if they represent a paradigm shift in managing kidney and ureteral stones with flexible ureteroscopy (FURS). This scoping review aims to synthesize recent findings on FANS efficacy, safety, and potential to overcome limitations of conventional ureteral access sheath (C-UAS) and other modalities. RECENT FINDINGS: Current evidence demonstrates FANS significantly outperforms C-UAS. Key findings include substantially higher immediate and 30-day stone-free rates (SFR), including achievable zero-fragment status, even for stones >2 cm, multiple stones, lower pole stones, and in paediatric patients. FANS reduces infectious complications (e.g., postoperative fever and sepsis), improves intrarenal pressure control, minimizes radiation exposure risk, and shortens operative times. Studies show noninferiority to mini-PCNL for 2-3 cm stones, with advantages like better quality of life and reduced bleeding. FANS enables same-session bilateral procedures and may reduce the need for postoperative stenting. Surgeons report high satisfaction due to improved visualization, suction efficiency, and navigation. SUMMARY: The collective evidence from this review positions FANS as a transformative technology enabling a paradigm shift in FURS for both adults and children. By enhancing stone clearance, visualization, and efficiency while reducing infectious complications through superior IRP control and expanding applicability to complex cases, FANS overcomes key limitations of conventional approaches. As the technology evolves, FANS is established as essential for achieving optimal SFR in FURS, fundamentally changing urolithiasis management.