What are the possible complications of ureteroscopy with holmium or thulium laser lithotripsy and placement of a double‑J (double‑J ureteral) stent?

Complications of Ureteroscopy with Holmium/Thulium Laser Lithotripsy and Double-J Stent Placement

Ureteroscopy with laser lithotripsy and double-J stent placement carries an overall complication rate of approximately 10-13%, with most complications being minor (Clavien-Dindo Grade I-II), while major complications (Grade III-V) occur in less than 1.2% of cases.

Overall Complication Profile

The most recent systematic review of thulium fiber laser lithotripsy demonstrates a pooled overall complication rate of 10.42% (95% CI: 8.01%-13.10%), with major complications (Clavien-Dindo III-V) occurring in only 1.19% of cases 1. The 2025 EAU guidelines report similar rates, with 18.43% experiencing Clavien Grade I-II complications and 2.48% experiencing Grade III-IV complications 2.

Specific Complications by Category

Infectious Complications

• Fever: 2.45% 1
• Urosepsis/Sepsis: 0.77% 1, with higher risk when retrograde ureteral catheters are used in patients with extrinsic ureteral obstruction 3
• Urinary tract infection: Variable rates (0-9%) 4
• Bacteriuria: 7.7-23% in non-infected stones 2
• Acute pyelonephritis: 0.59% 1

Critical caveat: In obstructing stones with infection, attempting stone removal without drainage can lead to life-threatening sepsis. Urgent drainage via stent or nephrostomy tube plus culture-directed antibiotics is mandatory 5.

Vascular Complications

• Bleeding requiring intervention: 1.07% 1
• Renal pseudoaneurysm: Rare but serious complication, typically presenting with delayed gross hematuria (days to weeks post-procedure) 6, 7
• Arteriovenous malformation: Extremely rare, with only two reported cases in literature 7
• Macroscopic hematuria: 17.2% 2

Important warning: Patients with diabetes, chronic kidney disease, or large stone burden are at higher risk for vascular complications. Pseudoaneurysms typically present 4-47 days post-operatively with gross hematuria and require selective renal artery embolization 6.

Ureteral Complications

• Ureteral injury/perforation: 1.37% 1, with rates reduced to <5% with modern techniques 4
• Ureteral stricture: 0.70% 1, with long-term rates of 2% or less 4
• Ureteral obstruction: 1-4% 4

Stone-Related Complications

• Steinstrasse (stone street): 4% 2
• Residual fragments: 21-59% regrowth rate 2
• Renal colic: 2-4% 2
• Need for auxiliary procedures: 6-9% 2

Stent-Related Complications

Routine post-URS stenting is unnecessary after uncomplicated procedures and may increase morbidity 2. However, stenting is advised in specific situations.

Indications for Mandatory Stenting:

• Ureteral trauma or perforation
• Significant residual stone fragments
• Active bleeding
• Infection/UTI present
• Pregnancy
• Bilateral procedures or solitary kidney 2, 4, 5

Stent-Specific Complications:

• Lower urinary tract symptoms: Significantly higher in stented patients, affecting quality of life 4, 8
• Pain: Significantly increased with stenting 8
• Stent migration: Recognized complication, including rare extra-renal displacement 9
• Stent encrustation and obstruction: Variable rates
• Stent breakage: Rare
• Need for secondary cystoscopy: Required for removal unless pull-string attached 4

A 2011 meta-analysis of 1,573 patients demonstrated that routine stenting after uncomplicated ureteroscopic lithotripsy does not improve stone-free rates, fever, UTI rates, or unplanned medical visits, but significantly increases lower urinary tract symptoms and pain 8.

Rare but Life-Threatening Complications

• Superior mesenteric artery thrombosis: First reported fatal case in 2026, occurring 10 days post-URSL in patient with vascular risk factors 10
• Thromboembolic events: Exceedingly rare but potentially lethal

Risk Factors for Increased Complications

Based on meta-regression analysis 1:

• Operative time: Significant predictor of complications (p=0.041)
• Stone location: Pure renal stones have higher complication rates (13.83%) vs. ureteral stones (10.64%)
• Stone size: Not a significant predictor (p=0.358)
• Patient factors: Diabetes, chronic kidney disease, atherosclerotic disease, prior stroke 6, 7, 10

Holmium vs. Thulium Laser Safety Profile

Both lasers demonstrate comparable safety profiles 1. However, thulium fiber laser results in faster stent transection and greater stent damage when treating entombed stents, increasing fracture risk during removal 11. For routine lithotripsy, both are considered safe with holmium:YAG remaining the gold standard 2.

Prevention Strategies

To minimize complications:

• Avoid prolonged operative times
• Use careful laser technique with appropriate energy settings
• Control intrarenal pressure during procedure
• Avoid routine stenting in uncomplicated cases
• Use alpha-blockers to improve stent tolerability when stenting is necessary 2
• Obtain urine culture from collecting system when draining infected obstructed systems 5
• Consider medical expulsive therapy (MET) post-lithotripsy to aid stone passage 2

Post-Operative Monitoring

Unexplained or worsening abdominal pain post-operatively should raise immediate suspicion for mesenteric ischemia or other vascular complications 10. Maintain low threshold for D-dimer screening and contrast-enhanced CT in patients with vascular risk factors presenting with concerning symptoms.

Delayed gross hematuria (days to weeks post-procedure) warrants urgent CT angiography to evaluate for pseudoaneurysm, particularly in diabetic or chronic kidney disease patients 6, 7.