Ureteroscopy “Sucks”: FANS is the Future

How to cite: Sheetz TJ. “Point/Counterpoint Debate: Ureteroscopy “Sucks”: FANS is the future.” Grand Rounds in Urology. November 13, 2025. Accessed Apr 2026. https://grandroundsinurology.com/ureteroscopy-sucks-fans-is-the-future/

Summary

Tyler J. Sheetz, MD, Assistant Professor of Urology, University of California, San Diego, San Diego, California, argues that flexible and navigable suction sheaths (FANS) represent the most versatile and efficient future for ureteroscopic stone surgery. He presents the case that FANS outperform direct in-scope suction approaches by offering superior versatility, visibility, reliability, and efficiency across a wider range of stone types and operative scenarios.

Dr. Sheetz opens with a brief historical overview of nephrolithiasis treatment, emphasizing that while stone fragmentation technologies have advanced dramatically, fragment evacuation remains a persistent challenge. Modern suction-assisted approaches are positioned as the next evolutionary step to address this problem.

FANS are defined as modified ureteral access sheaths with flexible, steerable tips and controlled suction ports that allow active evacuation of stone fragments. Multiple commercially available platforms are shown, and the operating room setup is reviewed, including wall suction, adjustable valves, and stone collection systems.

Dr. Sheetz reviews high-level clinical evidence supporting FANS. A recent meta-analysis including more than 1,800 patients demonstrated significantly higher stone-free rates at postoperative day one and at 30 days compared with traditional ureteroscopy, along with lower rates of postoperative fever. Operative time and hospital length of stay were not meaningfully increased.

The core of the debate centers on the contrast between FANS and direct in-scope suction (DISS) systems. Versatility is emphasized as a key advantage. With FANS, surgeons can dust or fragment stones depending on composition and response, whereas DISS systems require dusting to very small fragment sizes. This flexibility is particularly important given the heterogeneous nature of stone composition.

Visibility is highlighted as another advantage. The larger lumen of the access sheath allows continuous evacuation of dust, blood, and debris, maintaining a clear operative field. In contrast, DISS systems may produce reduced visualization when fragments accumulate, described as a “blizzard” effect.

Clogging and efficiency are also addressed. FANS allow rapid clearance of sheath obstructions under direct vision, whereas DISS systems may require multi-step unclogging protocols and raise concerns about elevated intrarenal pressure. For hard stones, FANS enable fragmentation into manageable pieces that are immediately evacuated, improving efficiency and reducing prolonged dusting times.

Dr. Sheetz argues that FANS offer a more adaptable and reliable solution for modern ureteroscopy and represent the most practical path forward for suction-assisted stone surgery.

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.