Postoperative complications in the treatment of upper urinary tract stones with flexible ureteroscopic lithotripsy: from preoperative assessment to postoperative management

doi:10.3969/j.issn.1674-8115.2026.09.013

Abstract

Abstract:

Flexible ureteroscopic lithotripsy (fURS-L) has become the important surgical technique for the treatment of small ureteral and renal calculi with a diameter of ≤2 cm. With the continuous advancement of endoscopic techniques, fURS-L is expected to emerge as the primary modality for upper urinary tract calculi management in the future due to its minimal invasiveness, high safety, and accessibility. Nevertheless, its postoperative complications, such as infection, ureteral stricture, stent-related discomfort, and more severe urosepsis, remain major clinical challenges that restrict improvements in its therapeutic efficacy and hinder its widespread clinical application. This review integrates relevant academic literature to elaborate on recent advances in surgical techniques and equipment innovations of fURS-L (including intelligent pressure control, negative-pressure suction systems, and novel laser applications) and their impacts on the prevention and management of complications. It analyzes preoperative risk predictors of postoperative complications, which encompass patients′ physical conditions, stone burden, and infectious status, and briefly discusses the classification and updated management strategies of postoperative complications. Furthermore, future research directions are proposed, including establishing a standardized reporting system for postoperative complications, refining prediction models based on artificial intelligence and biomarkers to enable early identification and intervention for high-risk patients, evaluating the cost-effectiveness and environmental impacts of disposable flexible ureteroscopes, and optimizing application strategies of advanced technologies in complex clinical cases.

Key words: flexible ureteroscopic lithotripsy (fURS-L), upper urinary tract calculi, preoperative assessment, postoperative management

CLC Number:

R693⁺.4

Liu Junchen, Liu Min. Postoperative complications in the treatment of upper urinary tract stones with flexible ureteroscopic lithotripsy: from preoperative assessment to postoperative management[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2026,(9): 1283-1289.

TrendMD

References 65

[1]	Sunaryo P L, May P C, Holt S K, et al. Ureteral strictures following ureteroscopy for kidney stone disease: a population-based assessment[J]. J Urol, 2022, 208(6): 1268-1275.
[2]	Inoue T, Tanaka H, Masuda T, et al. Japanese survey of perioperative complications and ureteral stricture after ureteroscopy with laser lithotripsy for upper urinary tract stones in multicenter collaborative study[J]. Int J Urol, 2024, 31(7): 795-801.
[3]	Volkin D, Shah O. Complications of ureteroscopy for stone disease[J]. Minerva Urol Nefrol, 2016, 68(6): 570-585.
[4]	de Coninck V, Keller E X, Somani B, et al. Complications of ureteroscopy: a complete overview[J]. World J Urol, 2020, 38(9): 2147-2166.
[5]	Edison E, Mazzon G, Arumuham V, et al. Prevention of complications in endourological management of stones: what are the basic measures needed before, during, and after interventions?[J]. Asian J Urol, 2024, 11(2): 180-190.
[6]	Chen K W, Koo K C, Zhong T S, et al. Real time monitoring of intrarenal pressures while using the flexible and navigable suction ureteral access sheath[J]. World J Urol, 2025, 43(1): 76.
[7]	Wei B, Guo Z, Yu Y, et al. A comparative analysis of flexible ureteroscopy with a flexible and navigable suction ureteral access sheath versus mini-percutaneous nephrolithotomy for treatment of upper urinary tract stones: a systematic review and meta-analysis[J]. Int J Surg, 2026, 112(2): 5025-5037.
[8]	Antonelli J A. Innovations in surgical stone disease[J]. Curr Opin Urol, 2016, 26(3): 240-247.
[9]	Xiong L, Loo N N, Lu Z Q, et al. Ureterolithiasis in human immunodeficiency virus (HIV) patients treated with single-use ureteroscope: a case report[J]. Am J Case Rep, 2022, 23: e938608.
[10]	Salka B, Bahaee J, DiBianco J M, et al. Single-use flexible ureteroscopes: practice patterns, attitudes, and preferences for next-generation concepts[J]. Front Surg, 2024, 11: 1419682.
[11]	Higgins A M, Wolf M J, Becker R E N, et al. How I do it: ureteroscopy and high-power holmium laser lithotripsy to treat renal stones[J]. Can J Urol, 2023, 30(3): 11574-11582.
[12]	Liu H T, Cao B, Chen X, et al. Comparison of Moses laser and Raykeen laser in patients with impacted upper ureteral stone undergoing flexible ureteroscopic holmium laser lithotripsy[J]. BMC Urol, 2024, 24(1): 190.
[13]	Hernandez-Gaytan C A, Proietti S, de Leonardis F, et al. Pulsed thulium:YAG laser for lithotripsy[J]. Eur Urol Focus, 2025, 11(5): 725-729.
[14]	Gauhar V, Traxer O, Castellani D, et al. Could use of a flexible and navigable suction ureteral access sheath be a potential game-changer in retrograde intrarenal surgery? Outcomes at 30 days from a large, prospective, multicenter, real-world study by the European Association of Urology Urolithiasis Section[J]. Eur Urol Focus, 2024, 10(6): 975-982.
[15]	Ulvik Ø, Æsøy M S, Juliebø-Jones P, et al. Thulium fibre laser versus holmium:YAG for ureteroscopic lithotripsy: outcomes from a prospective randomised clinical trial[J]. Eur Urol, 2022, 82(1): 73-79.
[16]	Uleri A, Farré A, Izquierdo P, et al. Thulium fiber laser versus holmium: yttrium aluminum garnet for lithotripsy: a systematic review and meta-analysis[J]. Eur Urol, 2024, 85(6): 529-540.
[17]	Houlihan I, Kang B, De S, et al. Photonic lithotripsy: near-infrared laser activated nanomaterials for kidney stone comminution[J]. Nano Lett, 2023, 23(13): 5981-5988.
[18]	Deng X L, Chen Y J, Zhai Q L, et al. Fluid absorption during flexible ureteroscopy with intelligent control of renal pelvic pressure: a randomized controlled trial[J]. World J Urol, 2024, 42(1): 331.
[19]	Farag M, Timm B, Davis N, et al. Pressurized-bag irrigation versus hand-operated irrigation pumps during ureteroscopic laser lithotripsy: comparison of infectious complications[J]. J Endourol, 2020, 34(9): 914-918.
[20]	Huang J R, Xie D H, Xiong R P, et al. The application of suctioning flexible ureteroscopy with intelligent pressure control in treating upper urinary tract calculi on patients with a solitary kidney[J]. Urology, 2018, 111: 44-47.
[21]	Awad M A, Johnson B A, Pearle M S. New techniques and technologies in flexible ureteroscopy[J]. J Endourol, 2025, 39(S1): S8-S17.
[22]	Gao X J, Zhang Z D, Li X W, et al. High stone-free rate immediately after suctioning flexible ureteroscopy with intelligent pressure-control in treating upper urinary tract calculi[J]. BMC Urol, 2022, 22(1): 180.
[23]	Tang H Y, Che Y L, Wu Z P, et al. Comparison of flexible ureteroscopy with flexible and navigable suction ureteral access sheath and mini-percutaneous nephrolithotripsy for the treatment of impacted upper ureteral stones: a retrospective study[J]. Front Surg, 2025, 12: 1562428.
[24]	Cai W P, Zheng B, Li X W, et al. Clinical advantages of suctioning flexible ureteroscopy with intelligent pressure control on treating large upper urinary tract calculi[J]. Front Surg, 2025, 12: 1554964.
[25]	Gao H Y, Zhang H, Wang Y C, et al. Treatment of complex renal calculi by digital flexible ureterorenoscopy combined with single-tract super-mini percutaneous nephrolithotomy in prone position: a retrospective cohort study[J]. Med Sci Monit, 2019, 25: 5878-5885.
[26]	Peng G H, Song L M, Xie D H, et al. Suctioning flexible ureteroscopic lithotripsy in the oblique supine lithotomy position and supine lithotomy position: a comparative retrospective study[J]. Minerva Urol Nefrol, 2018, 70(6): 612-616.
[27]	Li Z, Fu C, Sun C X, et al. Analysis of metabolic syndrome in bilateral upper urinary tract stones: a retrospective study of 3 905 cases[J]. Heliyon, 2024, 10(10): e31180.
[28]	Hao J X, Du Z Y, Bo Z Q, et al. Impact of metabolic syndrome on post-operative infection in patients undergoing flexible ureteroscopy lithotripsy[J]. Surg Infect, 2024, 25(2): 140-146.
[29]	Zheng Z B, Hu W G, Ji C Y, et al. A study of the difference in biochemical metabolism between patients with unilateral and bilateral upper urinary tract stones[J]. Sci Rep, 2024, 14(1): 30154.
[30]	Prattley S, Voss J, Cheung S, et al. Ureteroscopy and stone treatment in the elderly (≥70 years): prospective outcomes over 5- years with a review of literature[J]. Int Braz J Urol, 2018, 44(4): 750-757.
[31]	Zeng W B, Zhao Z W, Li G M, et al. Clinical efficacy of flexible ureteroscopy with holmium laser lithotripsy for geriatric patients with complex upper urinary tract calculi[J]. Medicine, 2025, 104(1): e41116.
[32]	Tasaka S, Kohada Y, Ikeda M, et al. Utility of the modified 5-item frailty index as a predictor of postoperative febrile urinary tract infection in patients who underwent ureteroscopy with laser lithotripsy[J]. World J Urol, 2024, 42(1): 323.
[33]	Dupuis H, Khene Z E, Surlemont L, et al. Preoperative risk factors for complications after flexible and rigid ureteroscopy for stone disease: a French multicentric study[J]. Prog Urol, 2022, 32(8/9): 593-600.
[34]	单保华, 向丹, 何进, 等. 输尿管软镜碎石术后患者发生并发症的影响因素分析[J]. 临床医学研究与实践, 2024, 9(26): 17-20.
	Shan B H, Xiang D, He J, et al. Analysis of influencing factors of complications in patients after flexible ureteroscopic lithotripsy[J]. Clinical Research and Practice, 2024, 9(26): 17-20.
[35]	Madec F X, Suply E, Luyckx F, et al. Flexible ureterorenoscopy and laser lithotripsy for upper urinary tract stones in neurologic patients with severe motor disability[J]. Prog Urol, 2017, 27(6): 369-374.
[36]	Chugh S, Pietropaolo A, Montanari E, et al. Predictors of urinary infections and urosepsis after ureteroscopy for stone disease: a systematic review from EAU section of urolithiasis (EULIS)[J]. Curr Urol Rep, 2020, 21(4): 16.
[37]	Jarry É, Garot M, Marlière F, et al. Predictive factors of postoperative septic complications after flexible ureteroscopy for urinary stones[J]. Prog Urol, 2022, 32(2): 85-91.
[38]	Chung H J, Lin A T, Lin C C, et al. Patients with urinary incontinence appear more likely to develop upper urinary tract stones: a nationwide, population-based study with 8-year follow-up[J]. PLoS One, 2016, 11(8): e0161223.
[39]	Baş O, Tuygun C, Dede O, et al. Factors affecting complication rates of retrograde flexible ureterorenoscopy: analysis of 1 571 procedures: a single-center experience[J]. World J Urol, 2017, 35(5): 819-826.
[40]	Guo T, Zhang J E, Gao W Z, et al. Analysis of risk factors for urinary tract infection and bleeding after retrograde flexible ureteroscopy for stone removal[J]. Front Surg, 2025, 12: 1573485.
[41]	Tu W C, Zhang X L, Wang J, et al. Influence of stone load on the outcome of same-session flexible ureteroscopy for bilateral upper urinary tract stones: a multicenter retrospective study[J]. Front Med, 2023, 10: 1163371.
[42]	Liu S S, Zhu D Q, Tan J T, et al. Development and external validation of a nomogram for predicting sepsis following flexible ureteroscopy[J]. Eur J Med Res, 2025, 30(1): 479.
[43]	Al-Nabulsi Z, Phan Y C, Abdalla O, et al. Surgical and radiological predictive factors for ureteric stricture formation in patients treated with ureteroscopy for ureteric stones[J]. Scand J Urol, 2021, 55(5): 394-398.
[44]	Shen Y F, Xiang A P, Shao S H. Preoperative hydronephrosis is a predictive factor of ureteral stenosis after flexible ureteroscopy: a propensity scores matching analysis[J]. BMC Urol, 2021, 21(1): 153.
[45]	Xu M, Han X Y, Zhu J, et al. The study of double-J stent free mode of flexible ureteroscopy and laser lithotripsy: a single centre experience[J]. J Int Med Res, 2023, 51(3): 3000605231161214.
[46]	Legemate J D, Marchant F, Bouzouita A, et al. Outcomes of ureterorenoscopic stone treatment in 301 patients with a solitary kidney[J]. J Endourol, 2017, 31(10): 992-1000.
[47]	Zhu P, Hua X, Teng X, et al. Beyond the sheath: unmasking true predictors of post-fURS fever through propensity matched precision[J]. World J Urol, 2025, 43(1): 595.
[48]	Çakıcı M Ç, Kazan Ö, Çiçek M, et al. Predictive risk factors of urinary tract infection following flexible ureteroscopic lithotripsy[J]. Arch Esp Urol, 2021, 74(5): 503-510.
[49]	Bai R R, Gao L, Jiang L, et al. The validity of neutrophil/lymphocyte ratio as a predictive factor for systemic inflammatory response syndrome after flexible ureteroscopy lithotripsy[J]. Urol J, 2021, 19(1): 17-21.
[50]	徐健东, 郑泽贤, 毛蕾雅芳, 等. 输尿管软镜碎石术后寒战进展至发热危险因素评估及列线图预测模型构建[J]. 临床泌尿外科杂志, 2023, 38(1): 24-28.
	Xu J D, Zheng Z X, Mao L Y F, et al. Evaluation of the risk factors of progress from post-RIRS shivering to fever and establishment of nomogram prediction model[J]. Journal of Clinical Urology, 2023, 38(1): 24-28.
[51]	El-Agamy E I, Elhelaly M A, Abouelgreed T A, et al. Randomized comparison of effect of standard antibiotic prophylaxis versus enhanced prophylactic measures on rate of urinary tract infection after flexible ureteroscopy[J]. Arch Ital Urol Androl, 2023, 95(1): 11084.
[52]	Méndez-Guerrero D M, Buitrago-Carrascal C, Puentes-Bernal A F, et al. Antibiotic prophylaxis in flexible ureterorenoscopy with negative urine culture[J]. BJUI Compass, 2023, 4(6): 688-694.
[53]	Liao S C, Xu X, Yuan Y, et al. A comparative study of flexible ureteroscopic lithotripsy for upper urinary tract stones in patients with prior urosepsis following emergency drainage via retrograde ureteral stent or percutaneous nephrostomy[J]. BMC Urol, 2023, 23(1): 196.
[54]	Grosso A A, Sessa F, Campi R, et al. Intraoperative and postoperative surgical complications after ureteroscopy, retrograde intrarenal surgery, and percutaneous nephrolithotomy: a systematic review[J]. Minerva Urol Nephrol, 2021, 73(3): 309-332.
[55]	Tawfeek A M, Osman M M E, Mourad M S, et al. To sheath or not to sheath in flexible ureteroscopy: a randomized controlled trial[J]. Arab J Urol, 2025, 23(4): 324-329.
[56]	Cumpanas A D, Lavasani S A M, Altamirano-Villarroel J, et al. Ureteral stricture occurrence after transmural ureteroscopic ureteral injury: a previously undocumented concern[J]. J Endourol, 2025, 39(7): 679-685.
[57]	de la Cruz J E, Fernández I, Sanz-Migueláñez J L, et al. Assessment of the grades of vesicoureteral reflux in stented ureters: an experimental study[J]. Urol Int, 2021, 105(7/8): 554-559.
[58]	Colceriu M C, Aldea P L, Răchișan A L, et al. Vesicoureteral reflux and innate immune system: physiology, physiopathology, and clinical aspects[J]. J Clin Med, 2023, 12(6): 2380.
[59]	Zhang Y Q, Chen C Q, Hu W, et al. Antireflux ureteral stent improves stent-related symptoms and quality of life: a prospective randomized controlled trial[J]. J Endourol, 2023, 37(7): 761-767.
[60]	Qing J, Hu K, Zhang X, et al. Allium covered metal stent for treatment of malignant ureteral obstruction[J]. Front Surg, 2024, 11: 1445808.
[61]	Yin C, Chen F Z, Jiang J H, et al. Renal pseudoaneurysm after holmium laser lithotripsy with flexible ureteroscopy: an unusual case report and literature review[J]. J Int Med Res, 2023, 51(3): 3000605231162784.
[62]	Deng X X, Zhang W S, Fu D L, et al. Renal pseudoaneurysms after flexible ureteroscopy and holmium laser lithotripsy: a case report[J]. Front Surg, 2022, 9: 896548.
[63]	Li Y H, Lin Y S, Hsu C Y, et al. Renal pseudoaneurysm after rigid ureteroscopic lithotripsy: a case report[J]. World J Clin Cases, 2022, 10(27): 9954-9960.
[64]	Farì G, Vecchio E, Oliva A, et al. A case of fatal embolization during laser lithotripsy[J]. Int J Leg Med, 2021, 135(4): 1541-1547.
[65]	Wu B, Wu L, He H, et al. Predicting risk factors affecting the efficacy of flexible ureteral holmium laser lithotripsy and extracorporeal shock wave lithotripsy for ureteral calculi based on decision tree model[J]. Ann Ital Chir, 2025, 96(1): 78-85.