Flexible ureteroscopy with integrated suction, a useful innovation: a systematic review by the YAU and EAU endourology sections

PURPOSE OF REVIEW: Suction has been applied in retrograde intrarenal surgery (RIRS) in order to remove residual fragments (RF). The aim of this systematic review is to collect all applications of direct in-scope suction (DISS) in both clinical and experimental settings and compare DISS scopes with conventional scopes and suction ureteral access sheaths. RECENT FINDINGS: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines, an a priori systematic review protocol was developed and registered with PROSPERO. PubMed, Scopus and the Cochrane Library, were screened from 5 August 2025 and 18 studies met inclusion criteria. The stone-free rates (SFR) ranged from 39.5% to 100%, while the auxiliary procedures rates ranged from 0% to 33.3%. The intraoperative complication rates ranged from 0% to 58.6%. The Grade I-II complication rates (Clavien-Dindo Classification System), ranged from 0% to 36.7%, while the Grade III-IV ones ranged from 0% to 4.5%. Seven experimental studies were in vitro and two were ex vivo. SUMMARY: Our research showed that DISS is a feasible, safe and efficient approach for the ureteroscopic management of both renal and ureteral stones. DISS scopes can be efficiently used not only for dust or RF evacuation, but also for stone relocation and reduction of intrarenal pressure.