The global flexible and navigable suction ureteral access sheaths (FANS) survey on utility, practices and future needs in flexible ureteroscopy: a EAU Endourology, PEARLS and IAU collaboration

The landscape of flexible ureteroscopy (fURS) is evolving with the use of flexible and navigable suction ureteral access sheaths (FANS) as surgeons gain experience utilizing suction. Surveys offer a unique lens through which to evaluate the adoption, efficacy, and challenges associated with new endourology technology. As FANS become widespread, we aimed to capture real-world practice patterns of FANS utilization in fURS. A collaborative effort by the European Association of Urology (EAU), Progressive Endourological Association for Research and Leading Solutions (PEARLS) and International Alliance of Urolithiasis (IAU) lead to the design and dissemination of a 41-question survey via SurveyMonkey and social media from 19 April to 29 May 2025. Participation was voluntary. Descriptive statistics were applied to demographic details and categorical responses. A total of 680 participants had completed the questionnaire. The majority of respondents were endourology fellowship-trained consultants (71.8%) practicing in teaching hospitals. Overall, 91% of urologists used suction in fURS, with 28.7% having replaced all conventional sheaths with FANS. The most common indications included multiple renal stones, stones 1–2 cm in diameter, and bilateral stones. Key technical challenges included suction-induced pelvicalyceal system collapse (51.9%) and lower pole access (37.6%). Notably, 39.9% were unaware of their irrigation flow rates, and 28.1% did not know suction pressure settings. Low-power Holmium laser with a dusting-fragmentation-aspiration strategy was preferred. Future development priorities included defining irrigation/suction parameters (29.6%) and integrating pressure control mechanisms (25.9%). This survey highlights the rapid global adoption of FANS and its expanding role in complex stone management. Despite its perceived benefits in stone clearance and infection reduction, significant technical variability and knowledge gaps persist, underscoring the need for standardized protocols, structured training, and further technological innovation to optimize clinical implementation.