Should we choose suction mini-percutaneous nephrolithotomy or flexible ureteroscopy with flexible and navigable suction ureteral access sheath in patients aged 65 years and older? An International Alliance of Urolithiasis and European Association of Urology Section of Endourology collaboration.

OBJECTIVE: We aimed to conduct a multicenter, prospective cohort study comparing the outcomes of suction mini-percutaneous nephrolithotomy (SM-PCNL) and flexible ureteroscopy (FURS) with a flexible and navigable suction ureteral access sheath (FANS) in patients aged ≥65 years. METHODS: A total of 340 patients were enrolled from global registries, of whom 130 underwent FURS with a FANS and 210 underwent SM-PCNL. Baseline, operative, and perioperative data were collected, and patients were followed for 30 days. The primary outcome was the stone-free rate (SFR) assessed by non-contrast CT at 30 days, with secondary outcomes including complications and reinterventions. Predictors of complete stone clearance were evaluated using multivariable logistic regression. RESULTS: Both techniques demonstrated high overall SFRs at 30 days (94% for the SM-PCNL group vs. 98% for FURS with a FANS), with SM-PCNL achieving superior complete SFR (80% vs. 55%, p<0.001). However, FURS with a FANS was associated with a lower median postoperative pain score, a shorter median postoperative hospital stay, and no bleeding-related complications. Multivariable analysis identified SM-PCNL as a positive independent predictor of complete stone clearance. No sepsis occurred in either group, reinforcing the safety of suction-enhanced approaches. CONCLUSION: These real-world data suggest both methods are effective in elderly stone formers, with FURS combined with a FANS favored for lower morbidity rates and SM-PCNL shown to have higher efficacy for complex stones. Treatment should be individualized based on stone complexity, patient factors, and surgeon expertise.