Mortality after ureteroscopy is a devastating and very uncommon complication, but it is believed to be under-reported. This systematic review assessed the number of deaths reported since 1990 and identified risk factors and predictors of mortality.

Fifteen papers in which mortality was reported were evaluated, revealing 72 deaths in ten countries. Patient age varied from 21 to 89 years (60% were over 65) and death occurred three times more commonly in women than in men, possibly because of a higher susceptibility to UTI, though this was uncertain. Surprisingly, in 30 cases the cause of death was not listed, while in 23 urosepsis was the leading cause. The largest study, with 40 deaths, reported that at least 10% were related to inadequate urine culture evaluation or antibiotic prescription.

Stone size was 10–38 mm and the procedural duration ranged from 30 to 120 min. Mortality after ureteroscopy is commonly a consequence of urosepsis, and preventing this complication is the first step in avoiding deaths. Like the EAU guidelines, the authors strongly recommend preoperative urine cultures and administration of suitable antibiotic prophylaxis before surgery. They suggest there is a need to improve preoperative prophylaxis as sepsis can occur even when appropriate antibiotics are given.

Prolonged operative times have been linked to increased risk of complications, with some authors suggesting that the operative time should ideally not exceed 90 min, with 120 min being the maximum. Along similar lines, the EAU guidelines recommend RIRS as the first option for stones <2 cm. Some deaths were reported in patients with stones >2 cm. In such cases the use of a ureteral access sheath seems reasonable to reduce intrarenal pressure.

Five patients who died had a BMI >25, suggesting that metabolic syndrome and obesity increase the complication rate owing to the presence of more comorbidities. Diabetes was commonly reported and is known to be present in obese patients and to increase septic complications.

What is clear is that surgeons need to have interdisciplinary, patient-centred, and tailored treatments available to avoid complications.

Infective events are one of the most common complications after ureteroscopy and encompass a wide range of scenarios, from isolated fevers to urosepsis that may lead to death. This systematic review and meta-analysis evaluated in detail the risk factors for urosepis after ureteroscopy. Overall postoperative urosepsis rates ranged from 0.2% to 17.8% of cases, with a pooled incidence of 5% (95% CI: 2.4–8.2). Factors independently associated with a higher risk of urosepsis were: preoperative stent placement (OR = 3.94, p <0.001), positive preoperative urine culture (OR = 3.56, p <0.001), ischemic heart disease (OR = 2.49, p = 0.002), older age (p = 0.002), longer procedure time (p = 0.02), and diabetes mellitus (OR = 2.04, p = 0.04). Positive preoperative urine culture and preoperative stent placement were identified as the main determinants for urosepsis.

This study indicates that preoperative urine cultures and appropriate preoperative antibiotics are mandatory for the prevention of urosepsis. Also, it is advisable to avoid long-term stents before surgery. Finally, ischemic heart disease, procedure time, and diabetes mellitus were the factors least strongly associated with urosepsis, which may be attributable to under-reporting and high heterogeneity among studies.

There is an ongoing discussion regarding what constitutes a successful surgery in stone patients as well as how to define a stone-free status. Generally, in the literature the postoperative absence of stones is considered to represent a stone-free status; however, the presence of small residual fragments is widely accepted and is regarded as clinically insignificant (this is particularly true for fragments of <4 mm). What is clear, however, is that a stone-free status is not the same as a successful surgery and that the quality of life of patients must also be considered.

This multicenter evaluation from the North American Stone Quality of Life Consortium compared the health-related quality of life (QoL) of stone-free patients and those with clinically insignificant fragments using the WISQOL questionnaire, which evaluates four domains: social functioning, emotional functioning, stone-related impact, and vitality.

Of 313 patients, 60.4% were stone free and had similar QoL scores to those with residual fragments (with a mean size of 7 mm) (115.4 ± 23.6 vs 110.5 ± 27.8 respectively, p = 0.12). No significant differences were identified on the four domains of the questionnaire. Patients with residual fragments who underwent rescue procedures to achieve a stone-free status had significantly lower QoL scores (88.4 ± 30.1 vs 116.6 ± 25.0, p <0.0001).

This study reveals that achieving a stone-free status does not represent a better QoL for the patient. In fact, surgeons must be aware not to overtreat the patient as secondary procedures designed to achieve a stone-free status may even reduce the QoL. In the scenario where residual stones are asymptomatic and non-obstructive, active interventions such as suitable medication and diet may reduce recurrences and stone growth or even act as chemolytic agents. Urolithiasis is a very complex situation in which many factors interfere with the efficiency of the surgery, and the patient’s QoL must be taken into account when evaluating the success of the treatment.