Ureteroscopy (URS) in Turkey

Ureteroscopy (URS) is an endoscopic procedure used in the diagnosis and treatment of stones located in the ureter and kidney. Stones are visualized with a thin optical device advanced through the natural urinary tract and are fragmented using laser or mechanical methods and removed.

In response to the question of how ureteroscopy is performed and in which cases it is applied, the procedure is carried out under general or spinal anesthesia and is especially preferred for ureteral stones, resistant kidney stones, and the evaluation of strictures. Being incision-free accelerates the recovery process.

Within the scope of the recovery process after ureteroscopy and points to consider, patients are usually discharged in a short time, and mild burning and frequent urination may occur. Adequate fluid intake and regular use of medications recommended by the physician reduce the risk of complications.

When evaluating ureteroscopy risks and success rates, the procedure has a high success rate and is minimally invasive. Rarely, infection, bleeding, or ureteral injury may develop; with proper patient selection and an experienced team, these risks are significantly reduced.

How Do Kidney Stones Form and Why Is Ureteroscopy (URS) Necessary?

In the human body, the kidneys function like an extraordinary purification plant that filters the blood and removes waste products through urine. However, in some cases, the concentration of minerals such as calcium, oxalate, and uric acid in the urine increases, and these substances begin to form microscopic crystals because they cannot fully dissolve.

Over time, these crystals combine and grow, forming the hard structures known as kidney stones. These stones may remain silently in the chambers of the kidney or may move along the direction of urine flow and fall into the narrow channels called the ureters that connect the kidney to the bladder.

The ureter is a very narrow and delicate tube. When a stone enters and gets stuck in this canal, the natural flow of urine from the kidney downward is suddenly blocked. Just like water backing up in a clogged pipe, the produced urine begins to accumulate in the kidney. This accumulation causes increasing pressure in the renal pelvis and leads to swelling of the kidney (hydronephrosis). When the outer capsule of the kidney, which is rich in nerve endings, is suddenly stretched due to this pressure, the well-known severe pain called “renal colic” occurs. In order to restore urine flow, prevent permanent kidney damage, and relieve the patient from this unbearable pain, the stone must be removed from the area where it causes obstruction. At this point, ureteroscopy comes into play as a method that allows direct access to the stone without causing harm to the body.

What Symptoms Bring Patients to the Emergency Department Before Ureteroscopy (URS)?

Renal colic pain caused by a kidney stone blocking the urinary canal is considered one of the most severe pains known in medicine. The pain usually begins suddenly without warning. Patients often describe it as a stabbing sensation starting from the flank area below the ribs and radiating toward the groin. The intensity of the pain may fluctuate, sometimes easing and sometimes becoming unbearable. Patients frequently change positions in an attempt to relieve the pain, but no position provides complete relief.

Since the kidneys and gastrointestinal system share similar nerve networks embryologically, this sudden increase in pressure in the kidney directly affects the stomach and leads to severe nausea. As the stone moves downward along the urinary canal or approaches the bladder, it irritates the inner lining of the urinary tract and may cause microscopic or visible bleeding.

The most common symptoms during this process are as follows:

• Severe flank pain
• Pain radiating from the back to the groin
• Nausea
• Severe vomiting
• Cold sweating
• Blood in the urine
• Frequent urge to urinate
• Burning during urination
• Foul-smelling urine
• Unexplained fever

Which Diagnostic Methods Lead to the Decision for Ureteroscopy (URS)?

When a patient presents with severe pain, initiating a fast and accurate diagnostic process is vital. First, the patient’s medical history is taken and a physical examination is performed. Tenderness felt when lightly tapping the flank area is an important sign of kidney swelling. A urinalysis is performed initially to check for the presence of blood cells or signs of infection in the urine. Blood tests are also requested to evaluate kidney function (creatinine levels) and infection parameters.

Imaging methods are the most critical stage of diagnosis. Although ultrasonography is often the first method used due to the absence of radiation, it may not always clearly show stones located in the middle and lower parts of the urinary canal. Today, the gold standard in the diagnosis and treatment planning of stone disease is non-contrast computed tomography (CT). With tomography, the exact location of the stone in the urinary canal, its millimetric dimensions, and its hardness level, known as the “Hounsfield Unit,” can be perfectly determined in three dimensions. The size, hardness of the stone, and the patient’s anatomical structure are the most important data clarifying why ureteroscopic surgery is preferred instead of shock wave treatment (ESWL).

The main methods used during the diagnostic phase are as follows:

• Urinalysis
• Blood tests
• Kidney ultrasonography
• Computed tomography
• Plain X-ray
• Urine culture

What Are Semi-Rigid and Flexible Ureteroscopy (URS) Devices and How Are They Chosen?

The foundation of success in ureteroscopic surgery lies in selecting the correct technological equipment appropriate for the location of the stone. The devices used are basically divided into two main categories. The first group is called “rigid” or “semi-rigid” ureteroscopes. These devices generally have a metallic body and contain high-resolution fiberoptic lenses and light sources. They provide excellent visualization and maneuver stability in the treatment of stones located in the lower and middle parts of the urinary canal close to the bladder. However, due to their structure, they cannot bend much and are insufficient in reaching the upper parts close to the kidney.

The second group consists of “flexible” ureteroscopes, also known as Retrograde Intrarenal Surgery (RIRS) instruments. These devices are products of advanced technology and have the ability to bend up to 270 degrees in all directions under the surgeon’s control. Thanks to this incredible flexibility, all natural curves of the urinary canal can be easily passed, and even the most remote chambers (calyces) within the kidney can be reached directly. Wherever the stone is hidden within the kidney, the device moves like a snake and finds it.

The anatomical and clinical factors considered in device selection are as follows:

• Anatomical location of the stone
• Total stone volume
• Narrowness of the ureter canal
• Structure of kidney chambers
• Hardness of the stone
• Patient’s obesity status
• Previous surgeries

What Are the Differences Between Laser Ureteroscopy (URS) and Pneumatic Stone Fragmentation?

The most important stage after reaching the stone is to break it into a size that can be expelled from the body. The energy sources used for this purpose directly affect the course of surgery. The “pneumatic lithotripsy” method, used more frequently in the past, works like a miniature drill or hammer. It attempts to break the stone by applying mechanical impacts. Although effective in the lower urinary tract, it has a major disadvantage in that the stone may move backward into the kidney (stone migration) due to these impacts.

Today, the undisputed gold standard in stone surgery is “Holmium:YAG” or “Thulium” laser technology. When the laser beam is focused on the stone, it creates intense heat and photothermal effects, turning the stone into fine dust within seconds regardless of its chemical composition (such as calcium monohydrate or cystine stones). This process is called “dusting” in medical terminology. Since the penetration depth of the laser into tissue is only fractions of a millimeter, the risk of damage to the delicate inner lining (mucosa) of the urinary tract is almost negligible. In addition, since it dissolves the stone with light rather than impact, the risk of stone migration is eliminated.

The contributions of laser technology to the surgical process are as follows:

• High success rate
• Near-zero stone migration
• Minimal tissue trauma
• Effective on stones of all hardness levels
• Shorter operation time
• Ability to pulverize stones

What Preparations Should Be Made Before Ureteroscopy (URS) Surgery?

The preoperative preparation period must be managed meticulously to ensure a smooth surgical process and maximum patient safety. The patient’s general health condition, medications used, and accompanying chronic diseases are evaluated in detail. Patients with heart valve disorders, arrhythmias, or a history of thromboembolism are additionally assessed by cardiology specialists. To prevent bleeding from small capillaries in the urinary tract during the procedure, aspirin or other blood-thinning medications used by the patient should be discontinued or adjusted under medical supervision.

The operation must be performed under sterile conditions in terms of infection. Therefore, the urine culture must be clean before the procedure; if there is an infection, antibiotic treatment is applied first. Since the patient’s stomach must be completely empty on the day of surgery, eating and drinking are stopped after a certain hour the night before. The anesthesiologist examines the patient and decides whether the procedure will be performed under spinal anesthesia (numbing from the waist down) or general anesthesia (full sedation).

Standard preoperative preparation steps are as follows:

• Blood tests
• ECG
• Chest X-ray
• Adjustment of blood thinners
• Fasting overnight
• Anesthesia approval
• Infection control

How Is Ureteroscopy (URS) Surgery Performed Step by Step?

The surgical process begins with the patient being taken to the operating room and the planned anesthesia method being applied. After the patient is safely anesthetized or numbed from the waist down, they are placed in a special position similar to a gynecological examination table (lithotomy position). This position allows the most comfortable anatomical access to the natural urinary tract. No incision is made during the procedure; all instruments are inserted through the body’s natural opening, the urethra.

In the first step, the inside of the bladder is carefully examined with a very thin camera. Then, the opening of the thin canal (ureter) through which urine flows from the kidney to the bladder is located. To ensure safety and avoid damage to the urinary canal, a very thin, lubricated, and highly flexible “guidewire” is inserted through this opening toward the kidney. This wire serves as a rail or guide for the camera-equipped instruments used during the procedure. Each stage of the procedure is monitored on a screen using a fluoroscopy device that can take real-time X-ray images.

After the guidewire is placed, the selected ureteroscope (rigid or flexible) is gently advanced over this wire into the urinary canal. While the camera transmits high-resolution images to the screen, the surgeon progresses along the canal and reaches the stone. After evaluating the size, shape, and relationship of the stone with surrounding tissues, a hair-thin laser fiber is inserted through a special channel inside the device. Laser pulses are initiated, and the stone is gradually fragmented into fine particles, just like a sculptor carving stone. These fine particles are naturally flushed out with fluid flow, and if even millimetric fragments remain, they are captured one by one using special thin wire baskets (basket catheters) and removed. After the stone is completely cleared, a temporary silicone tube is placed between the kidney and bladder to support internal healing, and the procedure is completed.

How Does the Recovery Process Progress After Ureteroscopy (URS)?

Since ureteroscopy is an incision-free surgery, patients’ recovery and return to normal life are extremely fast compared to traditional surgeries. After the operation, the patient is taken to the recovery room and closely monitored until the effects of anesthesia wear off. Once vital signs (blood pressure, pulse, respiration) return to normal, the patient is transferred to their room. A few hours after the procedure, fluid intake and light meals can be started. Patients are usually ready for discharge the same evening or the next morning.

One of the most noticeable aspects of the recovery process is related to urination. Due to the slight contact of instruments with the mucosa and the presence of a stent inside, it is normal to observe pink or light red urine in the first few days. In addition, the stent may touch the inner surface of the bladder, causing a constant urge to urinate or brief discomfort during urination. These complaints will decrease as fluid intake increases and days pass. Most patients can return to desk work and normal social life within about one week.

Common post-operative conditions include:

• Pink-colored urine
• Burning during urination
• Frequent urge to urinate
• Mild flank discomfort
• Fatigue
• Stent-related discomfort

What Are the Possible Risks and Complications of Ureteroscopy (URS)?

Despite all advanced technologies and minimally invasive approaches offered by modern medicine, certain risks inherent to every surgical procedure also apply to ureteroscopy. Although this method is generally considered highly safe, some unwanted situations may rarely occur. The most common mild complication is urinary tract infection after the procedure, which is usually easily controlled with appropriate antibiotics.

Among the more serious but quite rare risks is injury to the ureter. Since the urinary canal is very thin and delicate, if the stone is tightly adhered to the canal wall or if anatomical difficulties occur during the procedure, small scratches or minor perforations may develop. In such cases, the silicone stent placed inside is usually sufficient to allow the canal to heal on its own. Another very rare risk is urosepsis, which occurs when infection spreads into the bloodstream; therefore, it is crucial that the urine is sterile before the operation.

Possible risks to be aware of include:

• Urinary tract infection
• Ureteral injury
• Postoperative fever
• Temporary bleeding
• Failure to reach the stone
• Stent obstruction
• Ureteral stricture

Why Is Stent Use Important After Ureteroscopy (URS) and What Is a “Forgotten Stent”?

One of the final and most important steps of ureteroscopy is usually the placement of a thin, soft, flexible silicone tube called a “Double J (DJ) Stent” between the kidney and bladder. Named after its J-shaped curved ends, this stent is designed to stay securely in place. It serves several vital purposes: preventing blockage caused by edema in the urinary canal, facilitating painless passage of microscopic stone fragments, and ensuring smooth healing of the inner lining of the urinary tract.

However, there is a critical point that patients must pay attention to regarding stent use. Stents are usually kept in the body for 1 to 4 weeks depending on the case and are then removed with a simple outpatient procedure that takes only seconds, usually under local anesthesia. If the patient feels well and does not return for follow-up, the stent may be forgotten in the body. In such cases, minerals in the urine accumulate on the silicone tube and cause it to become encrusted (stone formation on the stent). A “forgotten stent” can lead to the formation of large stone masses that threaten the kidney and may require much more complex surgeries for removal.

Important points regarding stent use are as follows:

• Accelerates healing
• Prevents obstruction
• Facilitates stone passage
• Temporary application
• Must be removed on time

What Should Be Done to Prevent New Stone Formation After Ureteroscopy (URS)?

Stone disease is not just a local problem affecting the urinary tract but a systemic health issue related to the body’s overall metabolism. Although ureteroscopy eliminates the existing stone and relieves the patient from immediate discomfort, the likelihood of new stone formation in the future remains high unless the underlying metabolic cause is corrected. Therefore, the real treatment begins after surgery.

Stone fragments removed during surgery should be sent to specialized laboratories for chemical analysis. Determining whether the stone is composed of calcium oxalate, uric acid, cystine, or other substances forms the basis of future preventive strategies. Additionally, 24-hour urine collection and detailed blood tests help identify which minerals are being excessively excreted or insufficiently regulated. The most universal preventive measure is adequate hydration; the more diluted the urine, the lower the chance of crystal aggregation and stone formation. Limiting salt intake also directly reduces calcium excretion in the urine and helps prevent stone formation.

Lifestyle changes and preventive strategies include:

• Drinking plenty of water
• Low-sodium diet
• Reducing animal protein intake
• Consuming lemonade
• Regular exercise
• Maintaining ideal body weight
• Annual ultrasound check-ups