There is a widespread perception that urolithiasis (urinary tract stones) surgery is dangerous if the stone is large or deeply embedded within the kidney.
However, recent clinical outcomes are telling a different story, drawing significant attention. At the 45th International Urological Society (SIU 2025) meeting recently held in Edinburgh, UK, the analysis results of 165 ureteroscopy and flexible ureteroscopy procedures performed at Goldman Urology Jamsil branch were unveiled, challenging existing perceptions.
Urolithiasis is generally known to be categorized by difficulty based on its size and location. Stones exceeding 10mm, or those located in the upper ureter or deep within the kidney, are typically classified as high-difficulty stones. Due to this classification, patients often vaguely assume that larger or more deeply embedded stones necessitate more dangerous surgeries.
However, the 165 surgical cases analyzed in this study included a diverse range of examples, from small stones measuring 3mm to relatively large ones reaching 25mm. Furthermore, many stones were located not only in the lower ureter but also in the upper ureter and deep within the kidney. Despite this, all surgical cases proceeded successfully. Moreover, not a single major complication occurred. While some minor reactions such as temporary pain or microscopic bleeding were observed, all were manageable and stabilized within a short period.
These results clearly demonstrate that the size and location of the stone itself do not necessarily equate to risk. In fact, a more crucial factor in stone treatment is not merely which stone is being removed, but rather how the stone is accessed, and what strategy is employed for its fragmentation and removal. It is explained that even for the same stone, the difficulty and safety of the procedure can vary significantly depending on the access method and surgical strategy.
Another common misconception among patients regarding high-difficulty stone surgery pertains to the anesthesia method. Many patients believe that general anesthesia is mandatory if the stone is large or deeply embedded within the kidney. However, this is not always the case in actual clinical practice. The majority of URS (Ureteroscopic Lithotripsy) and RIRS (Retrograde Intrarenal Surgery) procedures performed at Goldman Urology, as presented at this conference, were conducted under spinal or local anesthesia. This offers the advantages of reducing cardiopulmonary burden associated with general anesthesia, faster recovery, and shorter hospital stays. This is particularly significant for elderly patients or those with underlying conditions such as cardiovascular or respiratory diseases, as avoiding general anesthesia greatly enhances safety.
Thus, a large stone size does not necessarily make general anesthesia a prerequisite. Instead, it is crucial to comprehensively consider factors such as the stone's location, the patient's overall systemic condition, and the feasibility of pain control to select the most appropriate anesthesia method.
In the case of endoscopy-based urolithiasis surgery, the proficiency of the medical team is extremely important. While it may outwardly appear to be a standardized procedure, the actual surgical process involves a continuous series of choices. The medical team's judgment is essential in every step, including deciding which access sheath to use, how to set the laser energy based on the stone's hardness and morphology, whether to opt for a dusting method to finely fragment the stone or to divide it into certain sizes for removal, and how to stably maintain intrarenal pressure and secure the surgical field during the operation. Furthermore, the safety and outcome of the surgery can vary significantly depending on how unexpected variables such as bleeding, impaired visibility, or stone migration are managed.
Urolithiasis is a condition that not only causes severe pain but can also lead to ureteral obstruction, infection, and kidney function deterioration if left untreated for a long time. Urolithiasis surgery is not an area that can be evaluated solely by the size of the hospital or the sophistication of its equipment. Instead, the success or failure of the treatment is determined by how much clinical experience individual medical professionals have accumulated, how many diverse stone types and situations they have directly handled, and how robust their accumulated judgment skills are throughout that process.
Dr. Na Jun-chae, Goldman Urology Jamsil Branch