Success rate and pain management in ureteroscopic lithotripsy under local anesthesia: a retrospective analysis of 151 consecutive cases.

Ureteroscopic lithotripsy under local anesthesia combined with multimodal analgesia (LA-URS) offers significant advantages; however, reported success rates vary widely (69.8%-88%), and limited understanding of intraoperative pain sources has hindered broader adoption. This study aimed to evaluate a standardized perioperative protocol for LA-URS and identify key pain sources.We retrospectively analyzed 151 consecutive patients who underwent LA-URS performed by a single surgeon between January 2023 and December 2025. A three-phase perioperative protocol included: (1) preoperative structured communication and psychological preparation; (2) gentle intraoperative manipulation, low-pressure irrigation, and VAS-guided analgesia; and (3) standardized postoperative care. Patients were stratified by endoscope type: flexible ureteroscopy (retrograde intrarenal surgery, RIRS; n = 82) and rigid ureteroscopy (URS, n = 69), based on stone location. Pain intensity was assessed at five key time points.The overall success rate was 98.0% (148/151). Peak pain occurred during ureteral mechanical dilation (VAS 3.68 ± 1.52 during rigid scope advancement), with VAS ≥ 4 in 44.6% of patients. Pain decreased significantly during lithotripsy (VAS 2.03 ± 1.53), with VAS ≥ 4 in 14.9% (66.6% relative risk reduction, P < 0.001). Sheath insertion during RIRS generated pain comparable to lithotripsy. Gender was the only significant predictor of pain (males > females, P = 0.003); age, BMI, and stone size showed no effect. No major complications occurred.This standardized perioperative protocol achieved a 98% success rate for LA-URS. Intraoperative pain primarily resulted from mechanical ureteral dilation rather than lithotripsy; excessive irrigation pressure may exacerbate discomfort. These findings suggest that traditional risk stratification criteria may warrant re-evaluation, and that LA-URS may be applicable to a wider patient population pending prospective validation.While this protocol provides a framework for LA-URS implementation, multicenter prospective validation is needed.