Ureteroscopy — Procedure Guide, Recovery & Risks | MyMedicPlus

Ureteroscopy (URS) is a minimally invasive endoscopic procedure used primarily to diagnose and treat conditions within the ureter and renal collecting system, most commonly urinary tract stones. A thin, rigid or flexible ureteroscope — a specialised endoscope with a working channel, illumination, and camera — is introduced through the urethra and bladder under cystoscopic guidance, and advanced up the ureter to the level of the stone, stricture, or lesion. Rigid ureteroscopes (6-9 Fr diameter) are used for distal and mid-ureteral pathology; flexible digital ureteroscopes (6-8 Fr) offer articulation of the distal tip and can access all calyces of the renal collecting system, making them the instrument of choice for intrarenal stones and upper ureteral stones. Single-use disposable flexible ureteroscopes have become widely adopted, offering equivalent optical quality to reusable instruments while eliminating the risks of inadequate sterilisation and the high repair cost of reusable flexible scopes. When used for stone treatment, the holmium:YAG laser (Ho:YAG) or the newer thulium fibre laser (TFL) — which delivers more efficient stone fragmentation at lower pulse energies — is passed through the working channel and used to precisely fragment the stone into small fragments (dusting technique) or large fragments (fragmentation with basketing) that can pass spontaneously or be removed. Ureteroscopy is the preferred treatment for distal and mid-ureteral stones of any size, and for intrarenal stones up to 1.5-2 cm in selected patients.

Ureteroscopy is primarily indicated for symptomatic urinary tract stones causing obstructive pain (renal colic), obstruction of urine flow threatening renal function, or urinary tract infection complicating stone obstruction (a urological emergency requiring urgent drainage). Specific stone characteristics favouring URS over ESWL include: lower ureteral location, stones larger than 10 mm, stones of high radiodensity (calcium oxalate monohydrate or cystine) resistant to shockwave fragmentation, stones in patients who are obese (reducing ESWL accuracy), anticoagulated patients, patients with pacemakers (where ESWL is contraindicated), and situations where ESWL has failed. Flexible ureteroscopy with laser lithotripsy is increasingly used for renal stones up to 20 mm as an alternative to percutaneous nephrolithotomy (PCNL). It is also performed urgently to place a JJ ureteral stent when a stone causes ureteral obstruction complicated by infection or renal impairment, temporarily relieving the obstruction before definitive stone treatment.

Ureteroscopy is performed under general or spinal anaesthesia with the patient supine in the lithotomy position. Intravenous antibiotics are administered at induction if pre-operative urine culture is positive or if UTI risk factors are present. A rigid cystoscope is introduced first to inspect the bladder, identify the ureteral orifice, and catheterise it with a safety guidewire (typically a hydrophilic 0.035-inch or 0.038-inch wire) under fluoroscopic C-arm guidance. A ureteral access sheath (UAS, 10-12 Fr outer diameter) may be placed over the guidewire to facilitate repeated instrument passage and maintain low intrarenal pelvic pressure during flexible ureteroscopy, reducing the risk of pyelovenous backflow and post-operative sepsis. The ureteroscope is advanced alongside or over the safety guidewire to the level of the stone or lesion under direct endoscopic vision and fluoroscopic guidance. For stone treatment, the holmium YAG laser fibre (200-365 micrometres) is passed through the working channel and positioned 0-1 mm from the stone surface. Laser energy is applied in short pulses to progressively fragment the stone using either the dusting technique (high-frequency, low-energy pulses that reduce stone to sub-millimetre fragments that pass spontaneously in urine) or the pop-corn technique (higher energy pulses causing explosive stone fragmentation into pieces). Larger fragments are retrieved using tipless nitinol stone baskets or graspers. A JJ ureteral stent (double-pigtail stent) is commonly placed at the end of the procedure to maintain ureteral patency, prevent post-operative ureteral obstruction from oedema, and facilitate fragment passage; stents are removed at 1-2 weeks via flexible cystoscopy. Total operative time is 30-60 minutes.

Ureteroscopy achieves stone-free rates of 90–95% for distal and mid-ureteral stones and 85–90% for proximal ureteral stones in a single procedure — significantly higher than ESWL for most stone sizes and locations. For renal pelvis stones under 20 mm, flexible ureteroscopy achieves 75–90% stone-free rates, approaching PCNL efficacy while avoiding percutaneous access and its associated risks. Complete stone removal eliminates the source of obstruction and renal colic, preventing progressive renal damage from prolonged upper tract obstruction. Stone composition analysis from retrieved fragments guides personalised dietary and pharmacological prevention of recurrence. Ureteroscopy is performed under a single anaesthetic as a day case, without external wounds, allowing rapid return to normal activities within 3–7 days. For ureteral TCC, ureteroscopy enables endoscopic diagnosis and ablation of small low-grade tumours, avoiding the morbidity of open nephroureterectomy in selected patients.

Ureteral perforation (a small hole in the ureteral wall) complicates less than 1% of procedures and is usually managed conservatively with a JJ stent for 4–6 weeks. Ureteral avulsion (complete tear) is an extremely rare but serious complication. Post-operative urinary tract infection or urosepsis occurs in 2–5% and is a risk when stone obstruction has caused proximal urine stasis — prophylactic antibiotics are given perioperatively. JJ stent-related discomfort (urinary frequency, urgency, and loin pain with voiding) is experienced by the majority of patients while the stent is in situ. Retained stone fragments requiring re-treatment occur in 15–25% depending on stone burden, composition, and complexity. Ureteral stricture from thermal or mechanical ureteral injury is a late complication in under 1% of cases. Haematuria lasting 24–48 hours is expected and resolves spontaneously.

Most patients are discharged home the same day or after an overnight stay following ureteroscopy. If a JJ stent was placed, it causes urinary frequency, urgency, bladder discomfort, and aching in the flank during urination — alpha-blocker medication (tamsulosin) reduces stent-related symptoms. The stent is removed cystoscopically under local anaesthesia in clinic at 1–2 weeks post-procedure, taking under 5 minutes. Patients are advised to maintain a fluid intake of at least 2–3 litres daily to help flush stone debris and promote fragment passage. Stone fragments may be passed over the 1–2 weeks following surgery and urine should be strained to collect fragments for laboratory analysis. Most patients return to sedentary work within 3–5 days and full physical activities within 7 days. Follow-up imaging (KUB X-ray or low-dose CT) at 4–6 weeks confirms stone-free status. Metabolic stone evaluation and dietary counselling are offered to guide prevention of recurrence.