Efficacy and Safety of Flexible Ureteroscopy With Flexible Navigable Suction Ureteral Access Sheath Versus Mini-Percutaneous Nephrolithotomy With Vacuum-Assisted Access Sheath

In children, renal stones commonly result from congenital anatomical defects, metabolicabnormalities, or recurrent urinary tract infections. Consequently, urolithiasis is morefrequent in this age group and often requires more than one surgical intervention forcomplete management.Mini‐percutaneous nephrolithotomy (mini‐PCNL) and retrograde intrarenal surgery (RIRS)are both effective treatment modalities for renal calculi measuring up to 2.5 cm inpediatric patients, demonstrating similar efficacy and complication profiles .Currently, the majority of pediatric renal stones can be managed effectively using shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), or percutaneousnephrolithotomy (PCNL). Surgical interventions such as open, laparoscopic, or roboticsurgery are reserved for a minority of cases involving anatomical abnormalities. Asspontaneous passage of residual fragments occurs in only 20‐25% of cases, achievingcomplete stone clearance is essential to minimize the risk of recurrence and additionalinterventions.Technological advancements in endourological instrumentation have primarily aimed atminimizing procedure‐related morbidity, including blood loss, postoperative pain, andrenal injury. Consequently, miniaturized endoscopes and reduced‐caliber access tracts(11‐20 Fr) were developed, leading to the emergence of Mini‐PCNL techniques specificallyadapted for the management of large renal stones in pediatric patients.The use of retrograde surgical approaches has expanded the capability to treat largerrenal stones, despite often resulting in extended operative times. Due to its favorablesafety profile and reduced complication rates, RIRS has gained acceptance as a preferredoption for managing larger stones in pediatric patients.For stones larger than 20 mm, RIRS monotherapy is associated with lower stone‐free rate(SFR) compared to Mini‐PCNL. However, RIRS offers advantages including reduced radiationexposure, fewer complications, and shorter hospital stay.The Mini‐PCNL and RIRS provide comparable efficacy and complication rates in thetreatment of pediatric renal stones up to 2.5 cm. Furthermore, the study found that RIRSwas associated with significantly shorter hospital stays, reduced radiation exposure, anddecreased fluoroscopy time compared to Mini‐PCNL.Suction has been utilized in endourology for over 25 years, primarily in conjunction withultrasound and ballistic lithotripsy devices, and more recently through the use ofsuction sheaths during PCNL. Intraoperative suction has been introduced as an effectivemethod to remove residual fragments (RFs), thereby reducing the need for manualextraction with baskets.Suction has also been employed in RIRS, providing multiple advantages including improvedstone fragmentation and dusting, enhanced removal of debris and fragments, reduction ofintra‐renal temperature and pressure, as well as better intraoperative visualization.In a prospective multicenter trial, Gauhar et al. demonstrated that the flexible andnavigable suction ureteral access sheath (FANS‐UAS) is safe and effective for use inpediatric RIRS, yielding high stone‐free rates with low complication rates. This supportsits emerging role as a valuable innovation in pediatric endourological procedures.The initial experience using a semi‐closed‐circuit vacuum‐assisted mini‐percutaneousnephrolithotomy (Mini‐PCNL) system in pediatric patients, achieving an 80% stone‐freerate with no intraoperative complications and only minor postoperative events. Thistechnique, which integrates continuous irrigation inflow with suction‐controlled outflow,was found to be a safe and effective option for managing complex renal stones in childrenwhile maintaining acceptable operative times.