Ureteroscopy

10 min read Last updated April 9, 2026

Surgical approach

  • Endoscopic access via urethra → bladder → ureteric orifice using semi-rigid or flexible ureteroscope
    • Often performed for ureteric stones, flexible ureteroscopy (RIRS) for renal stones
  • Ureteric dilatation and/or ureteric access sheath may be used
    • Reduces intrarenal pressure and improves irrigation outflow but can cause ureteric trauma
  • Irrigation used continuously to maintain vision, laser lithotripsy (Holmium:YAG or Thulium fibre) fragments stone
    • Stone extraction with baskets, fragments may be left to pass
  • Ureteric stent (JJ stent) may be inserted at end (planned or if oedema/trauma/obstruction)
    • May be left on a string for outpatient removal
  • Position: lithotomy, fluoroscopy may be used
    • Risk of nerve injury/compartment syndrome if prolonged lithotomy

Anaesthetic management

  • Type of anaesthesia: usually GA, spinal anaesthesia is possible for distal ureteroscopy but less common for flexible/RIRS
    • GA preferred for immobility, airway control, and tolerance of irrigation/longer duration
  • Airway: SGA often suitable for short uncomplicated cases, ETT if longer case, obese/OSA, aspiration risk, significant comorbidity, or need for controlled ventilation
    • ETT favoured if steep Trendelenburg anticipated (more common in other pelvic endoscopy) or if high airway pressures expected
  • Duration: typically 30–90 min, can be 2–3 h for large stone burden, bilateral procedures, complex anatomy, or flexible ureteroscopy/RIRS
    • Plan for overrun: analgesia, temperature, fluids, and positioning checks
  • How painful: moderate, pain often from ureteric spasm, stent discomfort, bladder irritation, renal colic may persist post-op
    • Multimodal analgesia, consider NSAID unless contraindicated (renal impairment, bleeding risk, asthma history, etc.)
  • Key intra-op aims: immobility, stable haemodynamics, antiemesis, temperature maintenance, and safe lithotomy positioning
    • Antibiotics usually given (often already started) due to risk of urosepsis

Indications and patient factors

  • Indications: ureteric calculi (especially distal/mid), renal calculi via flexible ureteroscopy (RIRS), diagnostic ureteroscopy for suspected urothelial pathology, management of strictures
  • Common comorbidities: CKD, recurrent UTIs, diabetes, obesity/OSA, anticoagulation, pregnancy (selected cases), solitary kidney
  • Pre-op symptoms: renal colic, vomiting/dehydration, haematuria, dysuria, may have stent in situ already

Pre-operative assessment and optimisation

  • Sepsis screening is critical: fever, rigors, tachycardia, hypotension, confusion, review obs, lactate, CRP/WCC, cultures
    • Infected obstructed system is an emergency: priority is drainage (stent/nephrostomy), not definitive stone treatment
  • Renal function and electrolytes: U&amp,E/eGFR, consider hyperkalaemia in obstruction/CKD, correct dehydration
  • Anticoagulation/antiplatelets: follow local urology guidance, ureteroscopy generally lower bleeding risk than PCNL but mucosal bleeding can occur
    • Clarify if laser lithotripsy planned and whether stent insertion only (lower risk) vs extensive manipulation
  • Infection prophylaxis: ensure urine culture/urinalysis reviewed, treat bacteriuria, peri-op antibiotics as per policy
  • Aspiration risk: pain/opioids, vomiting, emergency cases, consider RSI if indicated

Intra-operative anaesthetic technique (GA)

  • Induction: standard IV induction, consider RSI if non-fasted/active vomiting/obstruction-related ileus
  • Maintenance: volatile or TIVA, ensure immobility (small doses of NMBD may help if laser work and movement problematic)
    • Avoid excessive coughing/bucking at critical moments (risk of ureteric injury)
  • Ventilation: usually controlled ventilation, mild hyperventilation not required, maintain normocapnia
  • Monitoring: standard, consider arterial line only if septic/unstable or significant comorbidity
  • Fluids: aim euvolaemia, treat pre-op dehydration, avoid overload (especially CKD/elderly), urine output not a reliable intra-op endpoint due to irrigation
  • Temperature: active warming, irrigation can contribute to heat loss (less than TURP but still relevant in long cases)

Regional/neuraxial options

  • Spinal anaesthesia can be used for distal ureteroscopy (T10–S4 coverage) but may be less suitable for prolonged flexible ureteroscopy/RIRS
    • Advantages: reduced PONV, avoids airway instrumentation, Disadvantages: patient movement, discomfort from lithotomy, limited duration, hypotension
  • Local infiltration not applicable, peripheral nerve blocks generally not helpful

Analgesia and antiemesis

  • Multimodal: paracetamol + NSAID (if appropriate) + small opioid doses, consider intra-op ketamine (low dose) if opioid-tolerant
  • Ureteric spasm/colic: NSAIDs reduce ureteric smooth muscle tone and prostaglandin-mediated pain, consider antispasmodics per local practice
  • PONV: high risk due to opioids, pain, and urological surgery, use dual/triple prophylaxis (e.g., dexamethasone + ondansetron ± droperidol)

Specific complications and anaesthetic implications

  • Urosepsis/septic shock: can occur intra- or post-op due to instrumentation and raised intrarenal pressure with infected urine
    • Features: sudden hypotension, tachycardia, pyrexia, rising airway pressures (less common), metabolic acidosis, treat as sepsis (O2, cultures, broad-spectrum antibiotics, fluids, vasopressors, source control)
  • Bleeding/haematuria: usually minor, significant bleeding rare but consider anticoagulation status and mucosal trauma
  • Ureteric injury/perforation/avulsion: rare but serious, may present with pain, bleeding, prolonged procedure, may require stent or open conversion
  • Extravasation and fluid absorption: irrigation fluid is typically isotonic saline, systemic absorption usually limited but can contribute to volume overload in long/high-pressure cases
    • TURP syndrome is not expected with saline irrigation, but fluid overload/hypothermia can still occur
  • Lithotomy complications: common peroneal nerve palsy, femoral neuropathy, compartment syndrome, back/hip pain, pressure injuries
    • Prevent: padding, avoid extreme hip flexion/abduction, limit duration, document checks
  • Laser hazards: eye injury, airway fire risk is extremely low (no airway laser), but theatre laser safety protocols apply

Post-operative care

  • Common issues: pain/colic, dysuria, frequency/urgency (stent), haematuria, PONV
  • Discharge advice (day case common): hydration, analgesia plan, expected haematuria, when to seek help (fever/rigors, worsening pain, urinary retention, heavy bleeding)
  • Sepsis can present after discharge: ensure clear instructions and low threshold for review

Test yourself…

You are anaesthetising a patient for ureteroscopy and laser lithotripsy. Talk through your anaesthetic plan.

Structure: pre-op assessment → technique → intra-op priorities → analgesia/PONV → post-op.

  • Check indication, urgency, fasting status, vomiting/aspiration risk, and whether infection/obstruction present
  • Review renal function, electrolytes, Hb, coagulation/anticoagulants, urine culture and antibiotic plan
  • GA usually: induction ± RSI, airway SGA for short low-risk cases vs ETT for longer/OSA/aspiration risk
  • Maintenance: volatile/TIVA, ensure immobility, consider small NMBD boluses, active warming
  • Analgesia: paracetamol + NSAID if appropriate + opioid titration, consider antispasmodic strategies, plan for stent discomfort
  • PONV prophylaxis: dual/triple therapy, minimise opioids where possible
  • Positioning: lithotomy checks, padding, limit duration, document
  • Post-op: monitor for sepsis, haematuria, urinary retention, provide safety-net advice
What are the key anaesthetic concerns specific to ureteroscopy?
  • Urosepsis risk from instrumentation, especially with infected obstruction or positive cultures
  • Renal impairment and fluid management (dehydration pre-op, avoid overload intra-op)
  • Lithotomy positioning injuries (nerve palsies, compartment syndrome if prolonged)
  • Need for immobility during ureteroscope manipulation/laser lithotripsy
  • Post-op pain/colic and high PONV incidence
A patient has an obstructed infected kidney and is listed for emergency ureteroscopy. What is the priority and how does it change your anaesthetic approach?

This is a time-critical sepsis/source control scenario.

  • Priority is drainage of the infected obstructed system (ureteric stent or percutaneous nephrostomy), not definitive stone clearance
  • Treat as sepsis: early antibiotics, cultures, lactate, fluid resuscitation, vasopressors if needed, consider HDU/ICU post-op
  • Anaesthesia: GA with secured airway often appropriate, consider invasive monitoring if unstable, cautious induction (vasopressor ready)
  • Post-op: high risk of deterioration, plan critical care escalation and ongoing source control
How would you manage sudden hypotension and pyrexia during ureteroscopy?

Assume urosepsis until proven otherwise while excluding common anaesthetic causes.

  • Immediate actions: call for help, 100% O2, check pulse/ECG, confirm BP, assess depth of anaesthesia, check bleeding, check anaphylaxis signs
  • Treat likely sepsis: obtain cultures (blood/urine if possible), give broad-spectrum antibiotics, fluid bolus, start vasopressor (metaraminol/phenylephrine, consider noradrenaline infusion if persistent)
  • Ask surgeon to reduce irrigation pressure, consider stopping procedure and placing stent for drainage
  • Check ABG/lactate, temperature management, consider arterial line and ICU referral
Discuss fluid and irrigation issues in ureteroscopy compared with TURP.
  • Ureteroscopy typically uses isotonic saline irrigation, electrolyte disturbance from hypotonic absorption (classic TURP syndrome) is not expected
  • However, systemic absorption/extravasation can still cause volume overload, especially with prolonged high-pressure irrigation and impaired renal function
  • Irrigation contributes to hypothermia in longer cases, use active warming
  • Urine output is difficult to interpret due to irrigation, assess volume status clinically and with haemodynamics
What are the causes of pain after ureteroscopy and how would you treat it?
  • Ureteric spasm/colic from manipulation and oedema, treat with NSAIDs (if safe), opioids titrated, hydration as appropriate
  • Stent-related symptoms: frequency, urgency, suprapubic discomfort, flank pain, treat with simple analgesics ± alpha-blocker/anticholinergic per urology plan
  • Bladder irritation from instrumentation, consider antimuscarinic if prescribed, exclude retention
  • Red flag: severe pain with fever/rigors suggests infection/obstruction—needs urgent review
How does chronic kidney disease change your anaesthetic management for ureteroscopy?
  • Drug handling: adjust doses/avoid accumulation (opioids, sedatives), consider short-acting agents
  • Avoid nephrotoxins where possible: NSAIDs may be contraindicated, ensure appropriate antibiotic choice/dose
  • Fluid balance: treat dehydration but avoid overload, consider invasive monitoring if severe CKD with cardiovascular disease
  • Electrolytes: check potassium and acid-base status, manage hyperkalaemia pre-op
Lithotomy position: what complications are you worried about and how do you prevent them?
  • Nerve injuries: common peroneal (fibular head pressure), femoral (hip flexion), sciatic, also obturator stretch
  • Compartment syndrome/rhabdomyolysis in prolonged lithotomy, especially obese patients
  • Prevention: padding, avoid extreme positions, keep legs level/symmetric, limit duration, periodic checks, careful transfer
A common FRCA theme is ‘day-case suitability’. What factors determine whether ureteroscopy can be day case and what are your discharge criteria?
  • Suitable if: stable comorbidities, uncomplicated procedure, pain and PONV controlled, able to pass urine (or clear plan with catheter), no sepsis concerns
  • Discharge criteria: observations stable, mobilising, tolerating oral intake, adequate analgesia, understands haematuria expectations and red flags, escort and follow-up (stent removal plan)
What peri-operative antibiotics issues are relevant to ureteroscopy?
  • Instrumentation of urinary tract carries bacteraemia/urosepsis risk, prophylaxis guided by urine culture and local resistance patterns
  • If positive culture or prior resistant organisms: ensure targeted therapy and consider postponing definitive stone treatment if infection not controlled
  • In suspected sepsis: take cultures early but do not delay antibiotics
Discuss the anaesthetic management of a patient undergoing ureteroscopy for ureteric stone disease.

A common FRCA long viva/short answer theme: provide a structured peri-operative plan and highlight sepsis and positioning.

  • Pre-op: assess severity (pain/vomiting), fasting, aspiration risk, screen for sepsis and infected obstruction, review renal function and electrolytes, check anticoagulants, confirm antibiotic plan
    • If infected obstruction suspected: prioritise drainage and resuscitation, anticipate ICU
  • Technique: GA usually, SGA for short low-risk cases, ETT/RSI if aspiration risk, obesity/OSA, longer case, or instability
  • Intra-op: standard monitoring, maintain immobility, manage fluids (correct dehydration, avoid overload), active warming, lithotomy positioning checks
  • Analgesia: paracetamol + NSAID if appropriate + opioid titration, consider that stent discomfort may dominate post-op symptoms
  • PONV: prophylaxis (at least dual), minimise opioids, consider TIVA in high-risk patients
  • Complications: urosepsis, ureteric injury, bleeding, hypothermia, lithotomy nerve injury, have escalation plan
  • Post-op: monitor for sepsis, urinary retention, uncontrolled pain, day-case criteria and safety-net advice including stent plan
A patient becomes hypotensive during ureteroscopy. Give a differential diagnosis and immediate management.

FRCA expects a broad differential plus decisive initial actions and sepsis awareness.

  • Differential: sepsis/bacteraemia, anaphylaxis (antibiotic/latex), haemorrhage (rare), deep anaesthesia, myocardial ischaemia/arrhythmia, hypovolaemia (dehydration), PE (rare)
  • Immediate management: A-E, 100% O2, confirm BP, check ECG, capnography, depth, bleeding, give vasopressor boluses and fluids as appropriate
  • If sepsis likely: cultures, broad-spectrum antibiotics, lactate/ABG, start vasopressor infusion early, ask surgeon to stop/reduce irrigation pressure and consider stenting only
  • If anaphylaxis suspected: stop trigger, call for help, adrenaline, fluids, antihistamine/steroid, tryptase, ICU
Outline the complications of ureteroscopy and how they present peri-operatively.
  • Infective: urosepsis (hypotension, tachycardia, fever, raised lactate) intra- or post-op
  • Traumatic: ureteric perforation/avulsion (bleeding, prolonged procedure, post-op pain, urinoma), may require stent/open repair
  • Bleeding: haematuria common, significant bleeding uncommon
  • Functional: post-op colic/spasm, urinary retention, stent discomfort
  • Position-related: nerve injury/compartment syndrome from lithotomy
  • Anaesthetic: PONV, aspiration (vomiting/urgent cases), hypothermia in prolonged cases

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