Direct in-scope suction (DISS) ureteroscopy: techniques, outcomes and future directions.

Objective: To provide an overview of direct in-scope suction (DISS) ureteroscopy, an emerging technology that integrates suction directly into the ureteroscope with the aim of enhancing stone clearance, improving visualisation, and reducing intrarenal pressure during ureteroscopic stone surgery.

Methods: We performed a narrative review of the current literature and incorporated insights from the authors' clinical experience using DISS ureteroscopy systems.

Results: Direct in-scope suction ureteroscopes are either single-channel or dual-channel. With single-channel ureteroscopes, irrigation must alternate with suction. A dual channel allows synchronous irrigation and suction. The suction can be applied continuously or intermittently (alternating with passive drainage). By actively managing intrarenal pressure, DISS may lower the risk of infectious complications and inadvertent laser injury. Unlike traditional ureteroscopy, some DISS systems may reduce the need for a ureteric access sheath (UAS). Early clinical data demonstrate that DISS offers stone-free rates comparable to standard ureteroscopy, with no increase in major complications. However, performance varies across devices, with trade-offs related to scope size, flexibility, suction power, and risk of clogging or collecting system collapse. Larger-calibre DISS ureteroscopes may face deflection limitations in tight calyces as well as the need for a UAS. Refinements in single-use platforms are addressing these challenges. DISS may be especially beneficial in patients with moderate-to-large stone burdens by enabling more efficient fragment evacuation and reducing the need for secondary procedures. Emerging technologies - such as integrated suction-laser tools and pressure-monitoring systems - promise to expand DISS capabilities further.

Conclusion: Direct in-scope suction ureteroscopy represents a significant evolution in endourological practice by addressing key limitations of standard ureteroscopy, namely, fragment management, intrarenal pressure control, and visualisation. There remains a need for high-quality level 1 evidence. With ongoing innovation, future DISS systems may offer complete stone clearance.