Отказ от уретрального доступа без шунта при флексоскопии показал более высокую эффективность и меньше осложнений

Flexible ureteroscopy (fURS) using direct in-scope suction (DISS) without a ureteral access sheath (UAS) was associated with high stone-free rates and fewer complications than DISS with UAS, according to findings published in World Journal of Urology. However, UAS was preferentially used for larger and more complex stones. “The use of a [UAS] during fURS has become widespread, as it facilitates repeated access to the collecting system, improves irrigation outflow and visualization, reduces intrarenal pressure, and enhances fragment evacuation,” the study authors wrote. “However, concerns remain regarding the potential risk of ureteric injury and the unclear impact of UAS on stone-free rates.” DISS provides integrated suction for fragment clearance and intrarenal pressure control, raising questions about whether UAS provides additional benefit when DISS is already used. The investigators conducted a prospective, multicenter study to evaluate the impact of UAS on perioperative outcomes in patients undergoing DISS-assisted fURS. The study analyzed data from an international registry of patients who underwent successful DISS-assisted fURS for renal or upper ureteral stones at 16 centers across 14 countries from May to December 2025. Patients underwent non-contrast computed tomography before and 30 days after treatment. Investigators defined complete stone clearance as no residual fragments. Overall stone-free status was defined as no residual fragments or a single residual fragment measuring greater than or equal to 2 mm. The analysis included 540 adult patients; 296 (54.8%) underwent DISS without UAS and 244 (45.2%) underwent DISS with UAS. Approximately 57% were men, and the median age was 55 years. Patients treated with UAS had greater stone complexity, with a larger median maximum stone diameter (12.0 vs 10.0 mm; P =.016), more frequent pre-stenting (57.0% vs 15.2%; P <.001), and a higher prevalence of multiple stones (24.6% vs 7.1%). Positive preoperative urine cultures were also more common in the UAS group (25.1% vs 10.8%; P <.001). Complete stone clearance rates at 30 days were similar without and with UAS (72.6% vs 70.0%), whereas overall stone-free rates were significantly higher without UAS (95.9% vs 88.9%; P =.011). Planned reintervention for residual stones did not differ significantly between groups. Operative time was shorter without UAS (39 vs 64 minutes; P <.001). Postoperative fever exceeding 38°C was less common without UAS (2.7% vs 11.5%; P <.001), as was all-cause readmission within 30 days (1.0% vs 7.0%; P =.001). Ureteral abrasion rates did not differ significantly between groups (1.7% vs 3.7%; P =.237). On multivariable analysis, UAS use was not independently associated with complete stone clearance (odds ratio [OR], 0.87; 95% CI, 0.50-1.54; P =.635). Greater stone volume was associated with lower odds of complete clearance (OR, 0.66; 95% CI, 0.49–0.89; P =.007). UAS use was independently associated with greater odds of complications (OR, 6.52; 95% CI, 3.51-12.41; P <.001) and pre-stenting (OR, 2.63; 95% CI, 1.44-4.90; P =.002). “From our study, surgeons favor DISS with UAS (conventional or FANS) in fURS for patients with larger stone burden, multiple locations, and those with more complex anatomy,” concluded the investigators. “Sheathless DISS strategy can minimize need for postoperative stenting without increasing readmissions or infective complications. These findings could help surgeons tailor DISS-based management.” Limitations of the study included its nonrandomized observational design, surgeon-directed selection of UAS, lack of direct intrarenal pressure measurements, heterogeneity in surgical technique across participating centers, exclusion of unsuccessful DISS procedures, potential residual confounding and selection bias, and limited longer-term imaging follow-up. There was no financial support listed for this study, and the authors reported no conflicts of interest. Please see the original reference for full disclosures. References: Fuligni D, Gauhar V, Pietropaolo A, et al. Real-world DISS practice combined with and without access sheath: insights from the global DISS dataset: a EAU endourology study. World J Urol. 2026;44:508. doi:10.1007/s00345-026-06607-7.