Current evidence of flexible ureteroscopic laser lithotripsy under local anesthesia: feasibility, safety, and clinical application

Flexible ureteroscopic laser lithotripsy (FURL) is commonly performed under general or neuraxial anesthesia, but local anesthesia (LA) has been explored as an alternative for selected patients. This structured narrative review summarizes current evidence for LA-FURL while explicitly separating LA alone, LA combined with systemic analgesia or conscious/moderate sedation, peripheral regional blocks, and neuraxial anesthesia. An updated literature search identified a small but growing body of direct LA-FURL evidence, consisting predominantly of retrospective or single-arm clinical series together with recent larger prospective cohorts. These studies suggest that FURL can be completed and tolerated under LA in selected patients, with stone-free rates generally in the range reported by individual series; however, differences in stone burden, anesthesia protocols, access-sheath technology, imaging modality, timing, and definitions of stone-free status preclude a pooled estimate or a claim of equivalence to general anesthesia. Observational complication profiles are encouraging, but comparative safety and non-inferiority versus general anesthesia have not been established. Technical measures such as careful patient preparation, gentle instrumentation, suction-assisted access sheaths, attention to intrarenal pressure, and selective pre-stenting may be useful, but most have not been validated as LA-FURL-specific standards. Evidence from ureteroscopy under conscious sedation is considered separately because it represents a distinct anesthetic strategy. Overall, LA-FURL is a promising option for appropriately selected patients and experienced teams, particularly when avoidance of general or neuraxial anesthesia is desirable, but the current evidence base remains heterogeneous and largely nonrandomized. Prospective comparative studies with standardized definitions of procedural completion, stone-free status, pain, complications, patient-reported outcomes, and cost are required before broader recommendations can be made.