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Iatrogenic upper urinary tract injuries during ureteroscopy for urolithiasis: a comprehensive review on incidence, mechanisms and preventative strategies

Nature Reviews Urology (2025)Cite this article

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Abstract

The incidence of urolithiasis is increasing globally, with a prevalence of 13% in North America and 9% in Europe. Ureteroscopy is a minimally invasive approach for treating conditions affecting the upper urinary tract, including urolithiasis, for which its efficacy and safety is well recognized. There is a risk of complications associated with ureteroscopy, including iatrogenic mechanical ureteric injuries. These injuries are multifactorial in nature, with ureteroscopes and auxiliary endoscopic equipment having an important role, in addition to patient and stone factors. Excessive friction and insertion forces during ureteroscope and ureteric access sheath insertion, apparatus malfunction or thermal injuries during laser lithotripsy might cause injury to the upper urinary tract. Ureteric avulsion is a serious event, which necessitates further intervention such as ureteric reimplantation or nephrectomy. Ureteric mucosal injuries can be managed with a period of ureteric stenting, although stent-related symptoms can be challenging for patients. The ability of endoscopic equipment to injure the ureter is an area that requires further study to reduce incidence and minimize patient morbidity. In this article, we review the operative mechanisms that contribute to iatrogenic mechanical ureteric injuries and discuss preventative strategies.

Key points

  • Ureteric injuries occurring during ureteroscopy for stone surgery are due to a combination of stone, surgeon and equipment factors. The extent to which each aspect contributes to injury remains unknown.

  • Excessive force applied during instrument insertion and manipulation are recognized contributors to ureteric injuries during ureteroscopy, although safe limits of force are yet to be defined.

  • Flexible ureteroscope use is associated with lower rates of ureteric injuries in comparison with rigid ureteroscope use, probably because of instrument design and composition.

  • Laser fibres injure the ureteric mucosa via both thermal and mechanical effects. Thermal laser-induced injuries are associated with subsequent stricture formation.

  • Ureteric injuries stemming from stent and guidewire insertion are rare. Friction between the guidewire and ureteric mucosa is a potential causative factor.

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Fig. 1: Diagrammatic representation of semi-rigid ureteroscopy.

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Acknowledgements

Funding for this review was provided by the StAR MD programme of the Royal College of Surgeons in Ireland

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Authors and Affiliations

  1. Strategic Academic Recruitment Programme, Royal College of Surgeons in Ireland, Dublin, Ireland

    Orla Cullivan, Sorcha O’Meara & Niall F. Davis

  2. Department of Urology, Blackrock Clinic, Dublin, Ireland

    Orla Cullivan, Sorcha O’Meara & Niall F. Davis

  3. Department of Urology and Transplant Surgery, Beaumont Hospital, Dublin, Ireland

    Eva Browne & Niall F. Davis

  4. National and Kapodistrian University of Athens, Athens, Greece

    Andreas Skolarikos

  5. University Hospital Southampton, Southampton, UK

    Bhaskar Somani

  6. Biomaterials Cluster, Bernal Institute, University of Limerick, Limerick, Ireland

    Eoghan M. Cunnane & Michael T. Walsh

  7. School of Engineering, University of Limerick, Limerick, Ireland

    Eoghan M. Cunnane & Michael T. Walsh

  8. Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland

    Fergal J. O’Brien

  9. Trinity Centre for Biomedical Engineering, Trinity College Dublin, Dublin, Ireland

    Fergal J. O’Brien

  10. Advanced Materials and Bioengineering Research Centre (AMBER), RCSI and TCD, Dublin, Ireland

    Fergal J. O’Brien

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Contributions

O.C. researched data for the article, made a substantial contribution to discussion of the content and wrote the article. E.B. researched data for the article. S.O’M. made a substantial contribution to discussion of the content, and wrote and reviewed/edited the manuscript before submission. A.S., B.S. and N.F.D. made a substantial contribution to discussion of the content and reviewed/edited the manuscript before submission. E.M.C., M.T.W. and F.J.O’B. made a substantial contribution to discussion of the content.

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Glossary

Baskets

Retrieval devices composed of wires for insertion into a scope.

Flexible scopes

A fibreoptic or digital telescoping camera with a flexible tip to allow improved access to anatomical structures.

Forniceal rupture

Perirenal extravasation of urine from the renal fornices. Deemed to result from increased renal pelvis pressure, most often associated with urinary obstruction.

French

A unit of measurement used for catheters and surgical instruments. It refers to the outer diameter of the instrument, with 1 French being the equivalent to 0.33 mm; thus a 21-French catheter has an outer diameter of 7 mm. Also known as Charriére and commonly shortened to Fr.

Guidewires

Used during urological procedures to obtain access to the kidney. Instruments such as ureteroscopes or access sheaths can be passed over guidewires to facilitate their entry into the ureter. They can be rigid or flexible in nature, with a hydrophilic coating.

Laser fibres

Devices consisting of a light source and laser medium that are inserted through a scope for disintegration and ablation purposes and have numerous urological applications.

Pyelotubular reflux

Retrograde passage of urine from the renal pelvis and calyces into the collecting ducts and renal tubules.

Pyelovenous reflux

Retrograde passage of urine from the renal pelvis and calyces into the renal vein.

Ureteric access sheaths

Tubular apparatuses consisting of an inner obturator and outer sheath that are inserted over a guidewire into the ureter to facilitate access to the upper urinary tract.

Ureteric intussusception

Condition in which the proximal ureteric wall telescopes into the more distal lumen. Main causes include ureteral wall neoplasms, ureteric calculi or endoscopic procedures of the ureter.

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Cullivan, O., Browne, E., O’Meara, S. et al. Iatrogenic upper urinary tract injuries during ureteroscopy for urolithiasis: a comprehensive review on incidence, mechanisms and preventative strategies. Nat Rev Urol (2025). https://doi.org/10.1038/s41585-025-01067-x

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