Skip to main content

Semi-Rigid Ureteroscope

Tapered fiberoptic ureteroscope with passive (but not active) tip flexibility — distal tip 4.5–8 Fr, proximal shaft 6–11.9 Fr, ~ 5 cm of passive flex, straight working channel (1.8–5.5 Fr). The workhorse instrument for distal and mid-ureteral access in stone, stricture, and ureteral-tumor work; for the reconstructive surgeon, it is the diagnostic and treatment tool for iatrogenic ureteral injury after pelvic surgery, ureteral-stricture evaluation, and ureteral-tumor surveillance / endoscopic ablation. Introduced by Dretler and Cho in 1989 as "a new genre" for laser lithotripsy; the modern small-caliber generation followed in the late 1990s.[1][2][3][4]

Design​

ComponentDetail
OpticsFiberoptic coherent glass-fiber bundle to proximal eyepiece / camera; inline lens standard; offset lens variants give a straight working channel for rigid lithotripsy probes
Distal tip4.5–8 Fr — ultrathin variants down to 4.5 Fr
Proximal shaft6–11.9 Fr — tapered; common configurations 4.5/6, 6/7.5, 6.5/7, 7.2/11.9 Fr (distal/proximal)
Working channel1.8–5.5 Fr — laser fibers (200–600 μm), baskets, graspers, biopsy forceps
Tip flexibilityPassive only, ~ 5 cm; no active deflection mechanism (no thumb lever / pull wires)
LightExternal fiber-optic source

Key design distinction​

  • Passive flexibility, not active deflection — conforms to a gentle ureteral curve but cannot navigate the UPJ or calyces (which require the flexible ureteroscope).
  • Tapered profile — narrow tip negotiates the intramural ureter; larger proximal shaft gives pushability and rigidity for control.
  • Straight working channel in offset-lens models — accepts rigid pneumatic / ultrasonic lithotripsy probes that flexible scopes cannot.
  • Significantly more durable than flexible URS — lower repair cost and longer lifespan.[5][6]

Reconstructive-Urology and Urogyn Uses​

The semi-rigid ureteroscope is the working tool for distal and mid-ureteral pathology that arises in reconstructive practice:

Iatrogenic ureteral injury after pelvic / urogyn surgery​

  • Intraoperative or early postoperative ureteroscopy to define the level and severity of injury (laceration, ligation, kink, devascularization) discovered during sacrocolpopexy, hysterectomy, deep endometriosis resection, oncologic clearance, or transvaginal-mesh excision.
  • Defines feasibility of endoscopic management vs open repair (ureteroureterostomy, Boari flap, psoas hitch, reimplant).
  • Allows retrograde guidewire passage and stent placement in continuity injuries.

Ureteral stricture evaluation and endoscopic treatment​

  • Diagnostic mapping of stricture length, location, and luminal characteristics before reconstructive planning (open-ended ureteral catheter plus contrast can complement).
  • Endoscopic management of selected short strictures — balloon dilation or laser incision with stent (durability lower than reconstructive repair, but appropriate in selected short / radiation-induced / unfit-for-surgery cases).[3][4]

Upper-tract urothelial tumor​

  • Diagnostic ureteroscopy and biopsy of ureteral tumors during the workup that precedes nephroureterectomy or kidney-sparing endoscopic management.[2][3][4]
  • Endoscopic laser ablation of low-grade distal / mid-ureteral lesions in selected patients.

Migrated-stent retrieval and foreign-body management​

  • Retrieval of distally migrated ureteral stents — ~ 4.4% of cases in large URS series.[2]

Stone management (stone is out-of-scope for WARWIKI as a primary topic)​

  • For completeness: semi-rigid URS is the dominant treatment of distal (SFR 94.2% CROES) and mid-ureteral (89.4%) stones; for proximal ureteral stones, ultrathin (4.5/6 Fr) semi-rigid URS matches flexible URS stone-free rates (81.9% vs 87.8%, p = 0.22) at ~ half the cost.[7][8][6]

Technique — Standard Approach​

  1. Dorsal lithotomy under regional or general anesthesia; C-arm fluoroscopy available.[3]
  2. Cystoscopy to identify the ureteral orifice (rigid or flexible).
  3. Safety guidewire (0.035-inch, often hydrophilic Glidewire) into the renal pelvis under fluoroscopy.
  4. Negotiate the orifice — ureteral dilation is not required in > 50% of cases with modern small-caliber instruments.[2] When needed: balloon dilation, the UAS as dilator, or sequential fascial dilators.
  5. Advance under direct vision inspecting the mucosa.
  6. Therapy — Ho:YAG laser (365 μm, 0.8–1.0 J × 10–15 Hz) for stones / stricture / tumor; pneumatic lithotripsy via offset-lens models; basket extraction.[9]
  7. Inspect for residual fragments and mucosal injury.
  8. Stent at conclusion (60–80% of cases) when ureteral edema, perforation, residual fragments, or infection.[10]

Smaller Scope = Better — Omar 2022 RCT​

Direct head-to-head of 4.5/6 Fr vs 6/7.5 Fr semi-rigid URS for distal / mid-ureteral stones:[11]

Outcome4.5/6 Fr6/7.5 Frp
Stone-free rateHigherLower0.004
Balloon dilation needed0%33%0.0001
Traxer grade 1 injury2%14%0.001
Hematuria1%8%0.01
Stent required10%30%0.0004
Failure due to tight ureter0%8%0.003
Hospital stayShorterLonger0.0001

The clinical message: use the smallest scope that meets the operative requirement.

Semi-Rigid vs Flexible Ureteroscope​

FeatureSemi-rigidFlexible
Distal tip4.5–8 Fr6.3–9.5 Fr
Active deflectionNone (passive flex only ~ 5 cm)180–230° up / 95–220° down
Renal-pelvis / calyceal accessNot possible (cannot pass UPJ)Full intrarenal access
Distal-ureter stone SFR94.2% (CROES)Similar
Proximal-ureter stone SFR77% (standard) / 81.9% (ultrathin)87%
Rigid lithotripsy probesYes (offset-lens models)No
Durability / costMore durable, lower cost / repairMore fragile; single-use emerging
Dilation requirementOften not needed (esp. ultrathin)UAS commonly used

The semi-rigid is the first-choice tool for distal / mid-ureteral work; flexible URS is required to enter the renal pelvis or calyces. A common workflow is semi-rigid first, then flexible through the now-dilated ureter to inspect proximally for residual fragments.[3]

Safety Profile​

  • Ureteral perforation — ~ 1–8% with standard semi-rigid URS; falls with ultrathin scopes.[2][11][7]
  • Stone / fragment retropulsion — particularly with pneumatic lithotripsy in the proximal ureter.
  • Failure to access — 4–8% with standard scopes; lower with ultrathin.[2][11]
  • Ureteral stricture — the most significant long-term complication:
    • Population-based stricture rate 2.9% after URS vs 1.5% after SWL alone; OR 1.71 for URS as the cause of stricture beyond stone disease itself.[12]
    • Risk factors: ureteral perforation (OR 11.8), UAS use (OR 4.6), operative time > 60 min (OR 5.7).
    • PULS grade 3 (transmural) injury → 13.3% stricture rate (OR 40).[13][14]
  • Stent-related symptoms — urgency, frequency, hematuria, flank / pelvic pain — the dominant source of postoperative morbidity when stents are placed.[10]

Practical Pearls​

  • Maintain a safety guidewire throughout; in the post-pelvic-surgery / scarred / radiated ureter, the threshold for retaining the safety wire is lower than in routine endourology (the cost of lost access can mean conversion to open repair). See Guidewires.
  • Never force the scope past resistance — switch to smaller caliber, dilate, or pre-stent for 1 week and return.
  • Pre-stenting for ≥ 1 week results in ureteral enlargement and easier subsequent ureteroscopy.[15]
  • Antegrade irrigation via percutaneous nephrostomy can prevent stone retropulsion during upper-ureteral semi-rigid URS — useful adjunct.[9]
  • Pass a flexible URS at the end through the dilated ureter to inspect proximal segments / pelvis.[3]

Limitations​

  • No intrarenal access — UPJ and calyces require the flexible scope.
  • Inferior to flexible URS for proximal-ureter stones at standard caliber (77% vs 87%); ultrathin closes this gap.[7]
  • Sex-difference in passage — original Dretler/Cho series 61% male vs 96% female; modern ultrathin scopes have markedly narrowed this gap.[1]
  • Retropulsion risk with pneumatic lithotripsy.

See also: Rigid Cystoscope, Flexible Cystoscope, Guidewires, Open-Ended Ureteral Catheters, Double-J Stent, Balloon Dilator.

References​

1. Dretler SP, Cho G. "Semirigid ureteroscopy: a new genre." J Urol. 1989;141(6):1314–6. doi:10.1016/s0022-5347(17)41292-4

2. Ferraro RF, Abraham VE, Cohen TD, Preminger GM. "A new generation of semirigid fiberoptic ureteroscopes." J Endourol. 1999;13(1):35–40. doi:10.1089/end.1999.13.35

3. Giusti G, Proietti S, Rodríguez-Socarrás ME, et al. "Semirigid ureteroscopy: step by step." J Endourol. 2020;34(S1):S13–6. doi:10.1089/end.2018.0286

4. Whitehurst LA, Somani BK. "Semi-rigid ureteroscopy: indications, tips, and tricks." Urolithiasis. 2018;46(1):39–45. doi:10.1007/s00240-017-1025-7

5. Ayyappan KS, Menzies-Wilson R, Jaafari AM, Al-Sattar H, Turney B. "Benchtop comparison of seven ureteroscopes: evaluating physical properties and deflection with flexible and navigable suction access sheaths." BJU Int. 2026;137(Suppl 3):S86–92. doi:10.1111/bju.70124

6. Gharib TM, Abdel-Al I, Elatreisy A, et al. "Evaluation of ultrathin semirigid ureteroscopy in terms of efficiency and cost compared to flexible ureteroscopy in treating proximal ureteric stones: a prospective randomized multicenter study." World J Urol. 2023;41(9):2527–34. doi:10.1007/s00345-023-04507-8

7. Perez Castro E, Osther PJ, Jinga V, et al. "Differences in ureteroscopic stone treatment and outcomes for distal, mid-, proximal, or multiple ureteral locations: the CROES Ureteroscopy Global Study." Eur Urol. 2014;66(1):102–9. doi:10.1016/j.eururo.2014.01.011

8. Matlaga BR, Jansen JP, Meckley LM, Byrne TW, Lingeman JE. "Treatment of ureteral and renal stones: a systematic review and meta-analysis of randomized, controlled trials." J Urol. 2012;188(1):130–7. doi:10.1016/j.juro.2012.02.2569

9. Jung W, Byun HJ, Lee DS. "The role of antegrade irrigation via percutaneous nephrostomy on surgical outcomes in semirigid ureteroscopy among patients with upper ureteral stones." Biomed Res Int. 2019;2019:8657609. doi:10.1155/2019/8657609

10. Ordonez M, Hwang EC, Borofsky M, et al. "Ureteral stent versus no ureteral stent for ureteroscopy in the management of renal and ureteral calculi." Cochrane Database Syst Rev. 2019;2:CD012703. doi:10.1002/14651858.CD012703.pub2

11. Omar M, Dorrah M, Khalifa A, et al. "Randomized comparison of 4.5/6 Fr versus 6/7.5 Fr ureteroscopes for laser lithotripsy of lower/middle ureteral calculi: towards optimization of efficacy and safety of semirigid ureteroscopy." World J Urol. 2022;40(12):3075–81. doi:10.1007/s00345-022-04173-2

12. Sunaryo PL, May PC, Holt SK, et al. "Ureteral strictures following ureteroscopy for kidney stone disease: a population-based assessment." J Urol. 2022;208(6):1268–75. doi:10.1097/JU.0000000000002929

13. Ulvik Ø, Harneshaug JR, Gjengstø P. "Ureteral strictures following ureteroscopic stone treatment." J Endourol. 2021;35(7):985–90. doi:10.1089/end.2020.0421

14. Cumpanas AD, Lavasani SAM, Altamirano-Villarroel J, et al. "Ureteral stricture occurrence after transmural ureteroscopic ureteral injury: a previously undocumented concern." J Endourol. 2025;39(7):679–85. doi:10.1089/end.2024.0702

15. De Coninck V, Keller EX, Rodríguez-Monsalve M, et al. "Systematic review of ureteral access sheaths: facts and myths." BJU Int. 2018;122(6):959–69. doi:10.1111/bju.14389