Obstructing urolithiasis complicated by urosepsis is a urological emergency requiring urgent intervention. The standard approach involves initial urinary decompression followed by delayed definitive stone treatment, often on an outpatient basis; however, the role of primary ureteroscopy with laser lithotripsy remains unclear. This multi-institutional prospective study evaluates the safety, efficacy, and clinical outcomes of early definitive ureteroscopy compared to the conventional staged approach.

A multi-institutional observational study of prospectively collected data was conducted between 2019 and 2023. Patients presenting with obstructing urolithiasis and urosepsis were classified into two groups: Group A (primary ureteroscopy and definitive stone treatment within 24 hours) and Group B (delayed intervention following decompression, but within the same hospital admission). All patients received appropriate intravenous antibiotics prior to surgical intervention. Primary outcomes included stone-free rates (SFR) within 30 days of admission, and hospital length of stay (LOS). Secondary outcomes assessed post-operative complications, as per the Clavien-Dindo classification system. Statistical analyses were conducted to obtain odds ratios for categorical data, or Fisher's exact testing for comparison of medians for the outcomes of interest as appropriate.

A total of 44 patients met the inclusion criteria, with 29 undergoing early ureteroscopy and 15 receiving delayed intervention. Mean time to theatre was <1 days in group A and 5 days in group B. The stone-free rate was significantly higher in the early intervention group (89.7%) compared to the delayed treatment group (60%) (OR 5.78, p=0.029). Median length of hospital stay was significantly shorter in the early treatment cohort (3 vs. 8 days, p=0.038), highlighting a potential reduction in hospital resource utilisation. Each group had two grade 2 Clavien-Dindo postoperative complications with no significant difference between groups (p = 0.48).

This study provides compelling evidence that primary ureteroscopy with laser lithotripsy may be a safe and effective treatment approach for select patients with obstructing urolithiasis and associated urosepsis. Early definitive intervention was associated with significantly improved stone-free rates and a shorter length of hospital stay without increasing postoperative complications. These findings challenge the conventional practice of routine initial decompression and suggest that, in appropriately selected cases, early ureteroscopy may offer superior clinical and healthcare resource benefits. We present a new algorithm based model to determine which patients may be suitable for primary stone removal in urolithiasis patients with concomitant urosepsis.