Tong H. et al., 2026: Research Progress in Minimally Invasive Surgical Treatment for Upper Urinary Tract Stones: A Review.

Tong H, Wang X.
Res Rep Urol. 2026 Mar 31;18:574047. doi: 10.2147/RRU.S574047

Abstract

In recent years, minimally invasive techniques have made significant advancements in the management of upper urinary tract stones and have become the mainstream treatment modality. The core procedures currently routinely performed include extracorporeal shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and flexible ureteroscopy with lithotripsy (FURL). SWL is widely adopted due to its non-invasive advantage; however, its stone-free rate (SFR) can be affected by factors such as stone hardness, anatomical location, and patient body type. FURL (or RIRS) is performed through natural body cavities, resulting in minimal trauma; meanwhile, PCNL demonstrates significant efficiency advantages in managing large stone burdens. Currently, PCNL technology continues to evolve toward minimally invasive (miniaturization) and precision-oriented approaches. Concurrently, FURL technology has achieved significant breakthroughs through the integration of key innovations such as intelligent pressure control systems and flexible negative pressure suction sheaths. Therefore, systematically reviewing the latest advancements in minimally invasive surgical treatments for upper urinary tract stones and objectively evaluating their efficacy based on evidence-based medicine (such as comparing the clinical efficacy of PCNL versus FURL combined with novel negative pressure devices) will provide valuable practical guidance for clinicians in developing individualized and optimized treatment plans.

Comment Hans-Göran Tiselius

This report is a review on minimal invasive surgery for urinary tract stones. The purpose of this article was to summarize the technical progress of available methodology.

After mentioning that SWL still is a valuable tool in “specific clinical scenarios” because of its non-invasiveness and low rates of complications, the focus is on PCNL and FURS/RIRS. These two methods are considered basic for modern stone surgery.

For PCNL the major technical advances are different kinds of miniaturization from 24-30 Fr down to 4.8 Fr. The three-dimensional reconstruction techniques for puncture of the renal collecting system is particularly mentioned as is the percutaneous digital flexible nephroscope.

In terms of flexible ureteroscopy (RIRS) the flexible negative pressure suction sheath is mentioned as particularly useful for fragment removal. Another important point is the pressure control system that has added safety to the method. The latter two techniques have made RURL/RIRS competitive methods to PCNL, because studies have shown that treatment of 2-3 cm  large stones resulted in stone-free rates similar to that obtained with PCNL.

The technical improvements in FURL/RIRS and PCNL are impressive and it would have been wonderful if corresponding technique development had occurred also for SWL, the only non-invasive method for stone removal. Unfortunately, little has been made to alter indications for SWL to stones >15 mm in the lower calyces and > 20 mm in other parts of the kidney. Moreover stone-free rates mostly are reported inferior to those recorded for PCNL, FURL and RIRS. To improve the outcome of fragment elimination devices have been invented based on vibration and variation of patient positioning. Most such reports are from China.

Recent techniques such as burst wave lithotripsy, histotripsy and microbubble lithotripsy, despite being available for many years, have not resulted in improved non-invasive stone removal.

This matter is not discussed in this report, but it is the reviewer’s personal opinion that it is unfortunate that SWL has not undergone a technical improvement similar to that seen for PCNL and FURL/RIRS. This lack of progress is both disappointing and surprising because there are definitely possibilities for improved shock wave power and fragment elimination. With the non-invasiveness of SWL followed urologists’ desire to make stone-removal not only non-invasive, but also non-analgesic/non-anesthesia requiring. The clinical development of SWL accordingly has been dictated by obstacles that basically are based on misunderstanding of how pain treatment can be carried out with SWL while maintaining a good disintegration of stones. Early experience showed that the original Dornier HM3 lithotripter was possible to run with only analgesics and sedatives [1-3]. Small intermittent doses of alfentanil and propofol have further increased the flexibility of lithotripters. Modified devices might be more effective than what we currently have. There are options to alter both energy density and shock wave geometry and accordingly improve SWL with a modified focus than only to make the treatment free from analgesics.

Reference

1.Pettersson B, Tiselius HG, Andersson A, Eriksson I. Anesthesia-free extracorporeal shock wave lithotripsy of distal ureteral stones without a ureteral catheter. J Urol. 1989 Nov;142(5):1189-92. doi: 10.1016/s0022-5347(17)39025-0.

2.Tiselius HG. Anesthesia-free extracorporeal shock wave lithotripsy of distal ureteral stones without a ureteral catheter. J Endourol. 1993 Aug;7(4):285-7. doi: 10.1089/end.1993.7.285.

3.Chaussy CG, Tiselius HG.
Engineering Better Lithotripters.Curr Urol Rep. 2015 Aug;16(8):52. doi: 10.1007/s11934-015-0524-8.PMID: 26077353 Review.

Hans-Göran Tiselius