How to cite: Patel RM. Point/counterpoint debate: ureteroscopy sucks: DISS. Grand Rounds in Urology. November 2025. Accessed February 2026. https://grandroundsinurology.com/ureteroscopy-sucks-diss/
Summary
Roshan M. Patel, MS, MD, Assistant Professor of Urology, Director of Kidney Stone Center, University of California, Irvine, Irvine, California, argues that traditional ureteroscopy without suction is no longer optimal in modern stone surgery and that suction-integrated technologies significantly improve efficiency, stone clearance, and workflow. He presents a deliberately provocative case that ureteroscopy “sucks” when performed without aspiration, emphasizing that suction at the point of lithotripsy represents a necessary evolution in endourology.
Dr. Patel introduces two competing suction strategies. Direct in-scope suction (DISS) delivers suction through the ureteroscope working channel, enabling simultaneous laser lithotripsy, irrigation, and aspiration of dust and fragments at the source. Flexible and navigable suction sheaths (FANS) instead apply suction through a steerable ureteral access sheath, enabling evacuation of fragments through the sheath lumen.
Dr. Patel outlines the advantages of DISS, including immediate fragment removal during laser lithotripsy, reduced fragmentation time, and higher immediate stone clearance. Early in-vitro and clinical data demonstrate high aspiration rates and cleaner operative fields. Workflow benefits are emphasized, as DISS eliminates the need for a separate access sheath, improves maneuverability, reduces disposables, and shortens the learning curve through intuitive scope-based controls.
FANS are presented as a viable alternative with robust suction capacity, smaller sheath sizes, and lower per-case costs. However, drawbacks include increased mechanical complexity, a steeper learning curve related to sheath navigation, and potentially longer operative times.
Head-to-head prospective data are reviewed comparing DISS and FANS. In a study led by Dr. Humphreys, absolute stone volume reduction and relative stone clearance favored DISS, particularly in patients with larger stone burdens. Dr. Patel discusses institutional experience with DISS, showing improved margins per case, highlighting the economic pressures surrounding ureteroscopy and the appeal of technologies that improve efficiency without increasing payer reimbursement.
Dr. Patel argues that while both suction approaches represent progress, DISS currently offers the most intuitive, efficient, and effective method for improving ureteroscopic stone clearance. In the rapidly evolving landscape of stone surgery, he emphasizes that the most meaningful recent advancement is simple: suction.
About the 32nd Annual Perspectives in Urology: Point Counterpoint conference: Presented by Program Chair and Grand Rounds in Urology Editor-in-Chief E. David Crawford, MD, this conference brought together leading experts in urology, medical oncology, and radiation oncology to discuss and debate the latest topics in genitourinary cancers, primarily prostate cancer and bladder cancer. This interactive conference offered topical lectures, pro/con debates, interesting-case presentations, interactive panel discussions, and interactive audience and faculty networking.
ABOUT THE AUTHOR
Roshan M. Patel, MD, is an Assistant Professor of Urology, Chief of the Division of Urology, and the Director of the Kidney Stone Center at the University of California, Irvine. Dr. Patel specializes in kidney stones, kidney cancer, and robotic and laparoscopic surgeries. His clinical practice focuses on all aspects of minimally invasive urology procedures, including robotic, percutaneous, laparoscopic, ureteroscopic, and needle-ablative surgeries.
