Ureteroscopy: Kidney Stone Removal Procedure & Recovery

What Is Ureteroscopy and When Is It Needed?

Ureteroscopy is a minimally invasive endoscopic procedure where a thin, flexible scope is inserted through the urethra to locate and remove stones in the kidney or ureter. It is recommended when stones are too large to pass naturally (typically larger than 5-6mm), have not passed after 4-6 weeks, or are causing obstruction, infection, or severe pain.

Kidney stones form when minerals and salts in urine crystallize and accumulate in the kidneys. While many small stones pass naturally through the urinary tract without intervention, larger stones can become lodged in the ureter (the tube connecting the kidney to the bladder), causing severe pain, obstruction, and potentially serious complications including kidney damage and infection.

Ureteroscopy has become the gold standard treatment for ureteral stones and many kidney stones due to its high success rate and minimal invasiveness. Unlike open surgery, which requires incisions through the abdomen or back, ureteroscopy uses the body's natural passages to access and treat stones. The procedure utilizes a ureteroscope—a thin, flexible or rigid tube equipped with a camera and working channel—that allows the surgeon to directly visualize the stone and use specialized instruments to fragment and remove it.

The European Association of Urology (EAU) and American Urological Association (AUA) guidelines recommend ureteroscopy as a first-line treatment option for ureteral stones larger than 10mm and as an alternative to shock wave lithotripsy (ESWL) for smaller stones, particularly when the stone composition, location, or patient factors make ESWL less suitable.

Conditions treated with ureteroscopy

Ureteroscopy is primarily used to treat stones located in the urinary tract, but it can also be used for diagnostic purposes and to treat other conditions. The procedure is particularly effective for:

• Ureteral stones: Stones lodged anywhere along the ureter, with success rates of 85-95%
• Kidney stones: Stones in the renal pelvis or calyces, with success rates of 70-90%
• Stones resistant to ESWL: Hard stones (calcium oxalate monohydrate, cystine) that don't fragment well with shock waves
• Lower pole kidney stones: Stones in a location where ESWL fragments may not clear effectively
• Stones in obese patients: When body habitus makes ESWL technically difficult
• Diagnostic evaluation: Unexplained hematuria (blood in urine) or suspicious lesions in the ureter

Who is a candidate for ureteroscopy?

Most patients with kidney or ureteral stones are suitable candidates for ureteroscopy. The procedure can be performed on both adults and children, and is often preferred over other treatments in specific situations. Your urologist will evaluate several factors when recommending ureteroscopy:

Ureteroscopy may be particularly recommended if you have stones that haven't passed naturally after 4-6 weeks of observation, stones causing persistent pain or recurrent infections, stones larger than 5-6mm that are unlikely to pass spontaneously, stones causing complete obstruction of the ureter, or if you have tried ESWL without success. The procedure is also preferred for patients who require a quick return to work or normal activities, as recovery time is typically shorter than with other surgical approaches.

How Should You Prepare for Ureteroscopy?

Preparation for ureteroscopy includes fasting for 6-8 hours before surgery, stopping certain medications (especially blood thinners) 7-10 days prior, washing with antibacterial soap the night before, and informing your surgical team about all medications and health conditions. Proper preparation reduces complication risk and ensures optimal outcomes.

Preparing properly for ureteroscopy is essential for a safe procedure and smooth recovery. Your healthcare team will provide specific instructions tailored to your situation, but several general preparation steps apply to most patients. Following these guidelines carefully can significantly reduce your risk of complications and help ensure the best possible outcome.

The preparation period typically begins 1-2 weeks before your scheduled procedure. During this time, you'll have a pre-operative appointment where your surgeon will review your medical history, perform any necessary tests, and explain the procedure in detail. This is an excellent opportunity to ask questions and address any concerns you may have about the surgery.

Medications to stop before surgery

Certain medications increase the risk of bleeding during and after surgery. Your surgeon will provide specific guidance, but generally you should stop taking the following medications 7-10 days before ureteroscopy:

• Blood thinners: Warfarin, dabigatran, rivaroxaban, apixaban, and similar anticoagulants
• Anti-platelet medications: Aspirin, clopidogrel (Plavix), prasugrel, ticagrelor
• NSAIDs: Ibuprofen, naproxen, diclofenac, and other non-steroidal anti-inflammatory drugs
• Herbal supplements: Fish oil, vitamin E, ginkgo biloba, garlic supplements, and others that may affect bleeding

If you take blood thinners for a heart condition, artificial heart valve, or history of blood clots, do not stop these medications without specific guidance from both your urologist and the physician who prescribed them. Alternative anticoagulation strategies may be needed to balance surgical bleeding risk with your underlying medical needs.

Fasting requirements

You must fast before ureteroscopy to reduce the risk of aspiration (stomach contents entering the lungs) during anesthesia. Standard fasting guidelines require no solid food for at least 6-8 hours before your scheduled procedure time. Clear liquids (water, clear juices without pulp, black coffee or tea without milk) are typically permitted until 2 hours before surgery, but follow your specific facility's instructions.

Skin preparation

To reduce the risk of surgical site infection, you'll be instructed to shower or bathe with an antibacterial soap (chlorhexidine) the night before or the morning of your procedure. Pay particular attention to the genital and perineal areas. This helps reduce the bacteria on your skin that could potentially cause infection during the procedure.

Preparing children for the procedure

If your child needs ureteroscopy, age-appropriate preparation is important to reduce anxiety and ensure cooperation. Younger children benefit from simple explanations using child-friendly language, while older children and teenagers may want more detailed information. Many hospitals offer pre-operative tours or child life specialist consultations to help prepare pediatric patients for surgery.

How Is Ureteroscopy Performed Step by Step?

During ureteroscopy, you receive general or spinal anesthesia, then a thin scope is inserted through the urethra, bladder, and into the ureter. Using the scope's camera, the surgeon locates the stone and fragments it with a laser or ultrasound. Fragments are removed with a basket or left to pass naturally. A temporary stent is placed to aid healing, and the procedure takes 30 minutes to 2 hours.

Ureteroscopy is performed in an operating room under sterile conditions. Understanding each step of the procedure can help reduce anxiety and ensure you know what to expect. The surgery itself is performed while you're under anesthesia, so you won't feel any pain during the procedure.

Modern ureteroscopy uses advanced technology including high-definition cameras, flexible scopes that can navigate the curves of the urinary tract, and precise energy sources (lasers) that can fragment stones while minimizing damage to surrounding tissue. These technological advances have made the procedure safer and more effective than ever before.

Anesthesia and positioning

You'll receive either general anesthesia (which puts you completely to sleep) or spinal anesthesia (which numbs you from the waist down). General anesthesia is more commonly used as it allows for complete relaxation and easier management of the airway. Once anesthesia takes effect, you'll be positioned on your back with your legs supported in stirrups, allowing the surgeon access to your urethra.

Scope insertion and stone visualization

The surgeon begins by inserting the ureteroscope through the urethra and advancing it through the bladder and up into the ureter. The scope is thin and flexible (typically 2-3mm in diameter for flexible ureteroscopes), allowing it to navigate the natural curves of the urinary tract. A small camera at the tip of the scope transmits images to a monitor, giving the surgeon a clear view of the urinary tract lining and any stones present.

If the ureter is too narrow to accommodate the scope, the surgeon may need to place a temporary stent and reschedule the procedure for a later date, allowing the ureter to dilate. This occurs in approximately 5-10% of cases and is more common when treating stones that have been present for a long time.

Stone fragmentation techniques

Once the stone is visualized, the surgeon uses one of several techniques to break it into smaller pieces that can be removed or will pass naturally:

• Holmium laser lithotripsy: The most common method, using a holmium:YAG laser to fragment stones into fine dust or small pieces. The laser can treat stones of any composition and hardness.
• Ultrasonic lithotripsy: Uses ultrasonic vibrations to break up stones. Effective but less commonly used in ureteroscopy compared to kidney procedures.
• Pneumatic lithotripsy: Uses compressed air to deliver mechanical impacts to the stone. Less commonly used with flexible ureteroscopy.

The holmium laser has become the gold standard for ureteroscopic lithotripsy due to its effectiveness against all stone types and its safety profile. The laser fiber is inserted through the working channel of the ureteroscope and directed at the stone under direct visualization. The surgeon can adjust laser settings to either pulverize the stone into fine dust (dusting technique) or break it into larger fragments for basket extraction.

Fragment removal and stent placement

After fragmentation, stone pieces are either removed using a small wire basket passed through the scope or left to pass naturally in the urine over the following days. Very fine dust created by laser treatment typically passes on its own without needing removal.

At the end of the procedure, the surgeon typically places a temporary ureteral stent—a thin, flexible tube that keeps the ureter open and allows urine to flow freely from the kidney to the bladder. The stent helps prevent blockage from swelling or stone fragments and reduces pain from ureteral spasm. A string may be attached to the stent that exits through the urethra, allowing for easy removal in the clinic, or the stent may be removed cystoscopically 1-2 weeks after surgery.

What Can You Expect During Recovery?

After ureteroscopy, most patients go home the same day or the next morning. Common symptoms include blood in urine (2-3 days), frequent urination, and mild discomfort—usually from the temporary stent rather than the surgery itself. Most people return to desk work within 2-3 days and physical activities within 1-2 weeks. The stent is removed 1-2 weeks post-surgery.

Recovery from ureteroscopy is typically straightforward, with most patients experiencing rapid improvement in their symptoms. The minimally invasive nature of the procedure means there are no external incisions to heal, which significantly reduces recovery time compared to open surgery. However, the temporary ureteral stent can cause discomfort that many patients find more bothersome than the procedure itself.

Understanding what to expect during recovery helps you prepare and recognize which symptoms are normal versus those that may indicate a complication requiring medical attention. Your surgical team will provide specific post-operative instructions, but the following general guidelines apply to most patients.

Immediate post-operative period

After the procedure, you'll spend 1-2 hours in the recovery room as the anesthesia wears off. During this time, nurses will monitor your vital signs, pain level, and urine output. You'll be encouraged to drink fluids to help flush any remaining stone fragments through your urinary system. Most patients are able to go home once they can urinate comfortably, tolerate oral fluids, and have adequate pain control with oral medications.

It's important to have someone drive you home after the procedure, as the effects of anesthesia can impair your judgment and reflexes for 24 hours. You should also avoid making important decisions or signing legal documents during this time.

Common symptoms after ureteroscopy

Several symptoms are common and expected after ureteroscopy. While these can be uncomfortable, they typically resolve within a few days to 2 weeks:

• Blood in urine (hematuria): Your urine may be pink, red, or tea-colored for 2-3 days. This is normal and usually resolves as you drink fluids and pass the remaining stone fragments.
• Burning with urination (dysuria): A burning or stinging sensation when urinating is common and typically improves over several days.
• Frequent urination: You may feel the need to urinate more often than usual, sometimes urgently. This is especially common when a stent is in place.
• Flank discomfort: Mild aching in your side or back is normal, particularly after urination or when the bladder is full.
• Bladder spasms: You may experience sudden urges to urinate or brief sharp pains in the bladder area, especially with a stent.

Managing stent-related symptoms

The ureteral stent often causes more discomfort than the surgery itself. The stent can irritate the bladder and cause symptoms such as frequent urination, urgency, and discomfort at the end of urination. Some patients also experience "flank pain" when urinating, caused by urine refluxing up the stent to the kidney.

To minimize stent discomfort, drink plenty of fluids to keep urine diluted, avoid caffeine and alcohol which can irritate the bladder, take prescribed medications as directed (your doctor may prescribe alpha-blockers or bladder relaxants), and avoid strenuous activity which can increase stent movement and irritation. Remember that stent symptoms are temporary and will resolve completely once the stent is removed.

Activity and work restrictions

Most patients can return to sedentary work within 2-3 days after ureteroscopy. Physical labor, heavy lifting (more than 10 pounds/5 kg), and strenuous exercise should be avoided for 1-2 weeks or until after your stent is removed. Swimming, bathing in tubs, and sexual activity are generally safe to resume 1-2 weeks after surgery, but follow your surgeon's specific recommendations.

What Are the Risks and Complications?

Ureteroscopy is generally safe with a low complication rate. Common minor issues include blood in urine, urinary tract infection (3-5%), and stent discomfort. Rare serious complications include ureteral injury (less than 1%), ureteral stricture, and incomplete stone removal. Seek immediate care for fever above 38.5°C, severe pain, inability to urinate, or heavy bleeding.

Like all surgical procedures, ureteroscopy carries some risks. However, it is considered one of the safest urological procedures, with serious complications occurring rarely. Understanding potential complications helps you recognize problems early and seek appropriate care. The vast majority of patients undergo ureteroscopy without any significant issues.

Complication rates have decreased significantly over the past two decades due to improved technology, better surgical techniques, and more experience among urologists. Studies show that overall complication rates range from 5-10%, with the majority being minor issues that resolve with conservative management.

Common minor complications

The following complications are relatively common but typically resolve without long-term consequences:

• Urinary tract infection (3-5%): Despite antibiotic prophylaxis, some patients develop UTI after the procedure. Symptoms include fever, burning urination, and cloudy or foul-smelling urine. Most respond well to oral antibiotics.
• Stent-related symptoms: As discussed, the temporary stent commonly causes frequency, urgency, and discomfort. These resolve after stent removal.
• Prolonged hematuria: While some blood in urine is expected, occasionally it persists longer than a few days. Increased fluid intake usually resolves this.
• Residual stone fragments: Small fragments may remain after the procedure and either pass naturally or require additional treatment.

Rare serious complications

Serious complications are uncommon but can occur. Being aware of warning signs allows for prompt treatment:

• Ureteral perforation or avulsion (less than 1%): The scope or laser can inadvertently create a hole in or tear the ureter. This may require additional surgery or prolonged stenting.
• Ureteral stricture: Scarring can narrow the ureter, potentially causing obstruction. This may develop weeks to months after the procedure.
• Sepsis: Severe infection spreading to the bloodstream is rare but serious. It requires hospitalization and intravenous antibiotics.
• Bleeding requiring transfusion: Very rare; most bleeding is self-limited.

What Are the Alternatives to Ureteroscopy?

Alternatives to ureteroscopy include watchful waiting for small stones (under 5mm), shock wave lithotripsy (ESWL) for smaller stones, and percutaneous nephrolithotomy (PCNL) for very large kidney stones. The best treatment depends on stone size, location, composition, and patient factors. Your urologist will recommend the most appropriate option for your situation.

Several treatment options exist for kidney and ureteral stones, and the optimal choice depends on multiple factors including stone size, location, composition, and your overall health. Understanding the alternatives helps you participate in shared decision-making with your urologist and ensures you receive the treatment best suited to your specific situation.

Treatment selection follows evidence-based guidelines from the European Association of Urology and American Urological Association, which recommend specific approaches based on stone characteristics. No single treatment is best for all stones—the goal is to match the treatment to the stone and the patient.

Watchful waiting (observation)

Many small stones pass spontaneously without intervention. Conservative management with increased fluid intake and pain control may be appropriate if your stone is small (generally less than 5-6mm), you have tolerable symptoms that can be managed with pain medication, there is no evidence of infection or complete obstruction, and you are willing to wait 4-6 weeks for the stone to pass. During watchful waiting, medications such as tamsulosin (an alpha-blocker) may help relax the ureter and facilitate stone passage.

Shock wave lithotripsy (ESWL)

ESWL uses focused shock waves generated outside the body to fragment stones, which then pass naturally in the urine. It is non-invasive (no instruments enter the body), performed as an outpatient procedure, and effective for kidney stones up to 20mm and upper ureteral stones. However, ESWL may require multiple sessions, is less effective for hard stones (calcium oxalate monohydrate, cystine), and has lower stone-free rates compared to ureteroscopy for most stone types.

Percutaneous nephrolithotomy (PCNL)

PCNL involves making a small incision in the back and inserting a scope directly into the kidney to remove large stones. It is recommended for kidney stones larger than 20mm, staghorn calculi (stones filling the renal collecting system), and when ureteroscopy or ESWL have failed. PCNL has higher stone-free rates for large stones but requires hospitalization and has a longer recovery time than ureteroscopy.

How Can You Prevent Future Kidney Stones?

Preventing kidney stones involves drinking 2.5-3 liters of water daily to produce at least 2 liters of urine, reducing sodium intake to less than 2,300mg daily, limiting animal protein, and eating calcium-rich foods (but not calcium supplements). Stone analysis and metabolic testing can identify specific prevention strategies for your stone type.

After undergoing ureteroscopy, preventing future stones becomes a priority. Kidney stones recur in approximately 50% of patients within 10 years without preventive measures, but this rate can be significantly reduced with appropriate dietary and lifestyle changes. Understanding why stones form and implementing targeted prevention strategies is essential for long-term urinary tract health.

The most important factor in stone prevention is adequate hydration. Dilute urine prevents the minerals that form stones from crystallizing. Your goal should be to produce at least 2-2.5 liters of urine per day, which typically requires drinking 2.5-3 liters of fluid daily. Water is the best choice, though citrus juices (lemon, orange) may provide additional benefit due to their citrate content.

Dietary recommendations for stone prevention

Specific dietary changes can significantly reduce your risk of forming new stones. The optimal diet depends somewhat on your stone type, but several general principles apply to most stone formers:

• Reduce sodium intake: High sodium causes increased calcium excretion in urine. Aim for less than 2,300mg (about 1 teaspoon of salt) daily.
• Moderate animal protein: Limit red meat, poultry, and fish to 170g (6 oz) per day. Animal protein increases uric acid and reduces citrate, both of which promote stone formation.
• Get adequate calcium from food: Counterintuitively, low calcium diets increase stone risk. Aim for 1,000-1,200mg of dietary calcium daily from food sources like dairy products, fortified foods, and leafy greens.
• Avoid calcium supplements: Unlike dietary calcium, calcium supplements may increase stone risk if not taken with meals.
• Limit oxalate-rich foods: If you form calcium oxalate stones, moderate (don't eliminate) intake of spinach, rhubarb, nuts, chocolate, and tea.

Medical prevention

For patients with recurrent stones or identifiable metabolic abnormalities, medication may be recommended. Common preventive medications include thiazide diuretics (reduce calcium in urine), potassium citrate (increases citrate, raises urine pH), and allopurinol (for uric acid stones). Your urologist may recommend a 24-hour urine collection to analyze your urine chemistry and identify specific abnormalities that can be treated.

Frequently Asked Questions About Ureteroscopy