In recent years, with the introduction of various lumpectomy instruments and the rapid promotion of urological lumpectomy technology, the treatment of urinary stones has made great progress. With the use of lumpectomy, the extraction rate of various urinary stones is greatly improved, complications are reduced, and patients’ hospital stay is shortened, pain is reduced, and recovery is rapid. The application of traditional open surgery in the treatment of urinary stones has been very limited. The main lumpectomy techniques for urinary stones include transurethral ureteroscopy, percutaneous nephrolithotomy, and laparoscopic stone extraction. Each technique has its own indications and operational characteristics, and should be applied in a standardized manner.1 Ureteroscopic lithotripsy In recent years, the indications for transurethral ureteroscopic lithotripsy have been expanded. In the last edition of the European Society of Urology guidelines for urolithiasis, ureteroscopy was not recommended as the first-line treatment for upper ureteral calculi. In recent years, the effectiveness of ureteroscopy in the treatment of upper ureteral stones has been improved. In the new EAU guidelines, ureterolithotomy is indicated for upper, middle and lower ureteral stones of 5 mm or more. Together with extracorporeal shock wave lithotripsy, it is the first-line treatment for ureteral stones. In contrast to ESWL, ureteroscopy can also be used in patients who are overly obese and in some cases unsuitable for ESWL who cannot stop their anticoagulants. Ureteroscopy also allows for the management of bilateral ureteral stones in a single procedure. A meta-analysis has shown that ureteroscopic stone extraction is satisfactory, with stone removal rates of 81% to 94% compared to 73% to 82% for ESWL. Ureteroscopy is especially suitable for middle and lower ureteral stones, and the stone retrieval rate is 86% and 94%, respectively, which is better than 73% and 74% of ESWL. For upper ureteral stones, the results of ureteroscopic lithotripsy and ESWL were similar, with 81% and 82%, respectively. ESWL is more suitable for upper ureteral stones smaller than 10 mm and has a higher success rate than ureteroscopy. Ureteroscopic lithotripsy is more suitable for upper ureteral stones larger than 10 mm, and its success rate is about 10% higher than that of ESWL. Another advantage of ureteroscopy is that the number of treatments is low and the stone removal rate is fast, with most patients requiring only one treatment to obtain a high stone removal rate. In contrast, ESWL has an increased chance of multiple treatments, with an average of 1. 22 to 1. 79 treatments. Compared to ESWL, there is almost no stone formation after ureteroscopic lithotripsy. The disadvantages of ureteroscopy are that it is performed under anesthesia and that it is an invasive procedure with relatively high complications. The incidence of recent complications such as ureteral injury is 3%-6%, and the incidence of long-term complications such as ureteral stricture is 1%-2%, both of which are higher than that of ESWL. Before surgery, patients should be informed of the advantages and disadvantages of ureteroscopy and ESWL. If urinary tract infection is suspected, prophylactic application of sensitive antibiotics should be performed to reduce the incidence of postoperative infection and sepsis. Coagulation abnormalities should be corrected. The diameter of the front end of the ureteroscope is F6.5-8.0, and the size of the operating channel is F4.0-5.0. Because of the slim body of the mirror, it is easy to insert the ureter under the guidance of the guidewire, and it is not necessary to routinely dilate the ureteral opening. If ureteral stenosis is encountered and the ureteroscope cannot be passed, retrograde imaging can be performed under fluoroscopy to show the stenosis, and then the stenosis can be dilated with a balloon and the ureteroscope can be used for lithotripsy. Holmium laser is the best tool for ureteroscopic lithotripsy, which can break stones into small pieces with less chance of stone migration and damage to the ureteral mucosa, and is suitable for stones of various compositions and hardness. Holmium laser lithotripsy power is generally set at 20W or less. To avoid damage to the ureteral mucosa and instruments, the Holmium laser fiber should extend more than 2 mm from the ureteroscope and at least 2 mm from the ureteral mucosa; lithotripsy is less commonly used because of the damage to the ureteral mucosa and ureteroscope body, guidewire, and mesh basket. The efficiency of pneumatic ballast lithotripsy is higher, but the incidence of stone migration is also higher, especially in the upper and middle ureter. Newer tools to prevent stone migration, such as the N2trap and Stone cone, have improved the rate of upper segment stone removal. It is not necessary to remove the stone fragments completely, and the risk of ureteral injury can be increased by repeatedly entering and exiting the ureter with the instruments. After ureteroscopic lithotripsy, if there is ureteral stenosis, injury, isolated kidney, renal insufficiency, large residual stones, etc., a ureteral stent tube should be left in place.2 Flexible ureteroscopy for stone extraction In recent years, the use of flexible ureteroscopy has been gradually promoted, mainly for the treatment of upper ureteral and pelvic stones. The EAU guidelines for urinary tract stones state that for renal pelvic stones less than 20 mm, RIRS is the third option after ESWL and PCNL, and is particularly suitable for kidney stones for which ESWL is ineffective. Compared with PCNL, RIRS avoids serious complications such as bleeding and organ damage associated with percutaneous nephrotomy. The preoperative preparation and postoperative management are similar to those of rigid ureter. The procedure is performed in the lithotomy position. A safety guidewire is placed into the ureter through the cystoscope or semi-rigid ureteroscope, then a second guidewire is placed into the ureteral dilatation sheath, and a soft ureteroscope is placed through the ureteral dilatation sheath to visualize the upper ureter and the pelvis. The most suitable tool for soft ureteroscopic lithotripsy is the holmium μ laser, which generally uses a 200 m fiber that reduces the impact on the curvature of the anterior end of the flexible ureteroscope and reduces damage to the flexible ureteroscope. Theoretically, the flexible scope can handle stones in the upper and lower calyces. Lithotripsy can be performed either in situ or by transferring the stones from the lower calyces to the upper calyces using a mesh basket. The stones are gradually fragmented along the edge of the stone. Holmium laser with low energy and high frequency can break the stone into powder form. Larger stone fragments can be removed with a lithotripsy basket or a lithotripter, and the new nickel-titanium alloy basket facilitates lithotripsy and reduces damage to the calyx mucosa. The use of ureteral dilating sheaths facilitates the reduction of pressure in the renal pelvis during operation and the removal of fragments, reducing the chance of repeated ureteroscopic access to the ureter.3 Percutaneous nephrolithotomy Percutaneous nephrolithotomy PCNL can treat most kidney stones.EAU guidelines for urinary tract stones state that PCNL is the preferred method for kidney stones larger than 20 mm in length or 300 mm in area, especially for deerstalker-shaped kidney stones. PCNL is the preferred method for kidney stones larger than 20 mm in length or 300 mm in size, especially for antler-shaped kidney stones. Uric acid stones can be used as a third option after lithotripsy and ESWL. For stones in the inferior calyces, which are more difficult to drain after ESWL due to anatomical factors, PCNL is now accepted as the first choice for stones larger than 15 mm. PCNL can also treat upper ureteral stones that have failed ESWL and ureteroscopy or stones larger than 15 mm, as well as those that cannot be treated by ureteroscopy, such as urinary flow diversion or transplanted kidney stones, which are usually located above the lower edge of the lumbar 4 vertebrae, with a stone retrieval rate of 85% to 100%. The stone retrieval rate is 85% to 100%, and complications are rare. Percutaneous nephrolithotomy can achieve a very satisfactory stone removal rate of nearly 100% for simple pelvic stones in PCNL and 80%-95% for deerstalker-shaped renal stones in PCNL. The middle and lower posterior renal calyces are usually selected for puncture. Preoperative antibiotics should be used to stop anticoagulants and correct bleeding tendency in the presence of urinary tract infections, and female patients should avoid menstruation. CT can clarify the spatial distribution of stones in the renal collecting system and determine the adjacent relationship between the kidney and the surrounding organs in order to choose the best puncture route and avoid damage to the surrounding organs. General anesthesia or combined lumbar and rigid anesthesia was used. During surgery, the ureteral catheter is left in the lithotomy position, and its role is mainly to retrograde water injection to expand the renal pelvis and calyces, to create artificial hydronephrosis, to facilitate percutaneous renal puncture, and to prevent stone fragments from moving down into the ureter during surgery. The problem with the prone position is that it is not convenient for anesthesia management, and it is inconvenient for some patients with poor cardiopulmonary function. If the main body of the kidney stone is located in the upper calyces or if the upper ureteral stone needs to be treated at the same time, puncture of the upper posterior calyces through the intercostal space is also an option. In cases where puncture is difficult, CT-guided puncture may also be performed. After successful puncture, a guidewire is left in place, the skin is incised, and a fascial dilator or a metal overlay dilator is used for gradual dilation. The channel size F14-30, F14-20 is called microchannel mPCNL. Generally speaking, the larger the channel, the faster the stone extraction, but the chance of bleeding increases slightly. For complex stones, multi-channel puncture can be used. The lithotripsy tools include holmium laser, pneumatic ballistics, ultrasound suction, and dual-catheter ultrasound, each of which has its own characteristics. A DJ tube and nephrostomy are left in place after surgery. In simple cases, if the stone is removed and there is no significant bleeding, a nephrostomy tube can be left in place, which is called tubeless PCNL. For bilateral stones, bilateral PCNL can also be performed, and the combination of PCNL with flexible scopes is one of the treatment advances. There are two types of combination, one is PCNL combined with flexible nephroscope, soft cystoscope, which is used via nephrostomy, and the other is PCNL combined with flexible ureteroscope, i.e. PCNL combined with RIRS, which requires the patient to be placed in an oblique supine position. The advantage of both methods is to improve the stone removal rate and reduce the number of puncture channels, thus reducing the occurrence of complications, but the operation is more complicated and more expensive.4 In the past 20 years, with the widespread use of ESWL and endoscopic techniques, the proportion of open surgery for stone removal has gradually decreased, and in many hospitals, the proportion of open surgery for stone removal is only 1-5%. In some cases, surgical extraction still has a place. If the decision is made to perform surgical stone extraction, laparoscopic surgery is a minimally invasive alternative to open surgery. Indications for surgery include renal ureteral stones that have failed ESWL or endoscopic surgery, inability to undergo ESWL or endoscopic surgery such as abnormalities of the skeletal system that prevent positioning, ectopic kidneys, excessive obesity, anatomic factors such as the need for simultaneous management of stones and ureteral or pelvic-ureteral junction stenosis, the need for simultaneous surgery to treat other diseases, non-functioning kidneys that require nephrectomy, certain complex stones, multiple calyceal stones, and large stones in children, Large stones in children, etc. Surgical procedures include laparoscopic ureterotomy, pelvic dissection, pelvic ureteroplasty with stone extraction, parenchymal dissection without atrophy, nephrectomy, etc. It should be clear that, while understanding the various minimally invasive techniques, each of these techniques cannot treat all urinary stones, for example, stones smaller than 5 mm can be observed and medically assisted, and infection control, improvement of renal function, management of pain and acute or severe obstruction should be performed before deciding on aggressive surgical stone extraction. Many factors influence the choice of urinary tract stone treatment, including the surgeon’s experience, proficiency in minimally invasive techniques, the availability of various lumpectomy and lithotripsy tools, and the condition of the patient and the specific urinary tract stone.