Incidence and context-specific risk patterns of ureteral avulsion and perforation during ureteroscopy: EAU endourology systematic review and meta-analysis.

Abstract

Ureteral perforation and avulsion are rare but potentially severe complications of ureteroscopy (URS), and their reported incidence varies substantially because of heterogeneous populations, techniques, and denominators. The objective of presented meta-analysis was to estimate the procedure-level incidence of ureteral perforation and avulsion during URS for ureteral stones and explore study-level factors associated with these complications. This systematic review and meta-analysis followed the PRISMA 2020 guidelines and was prospectively registered in PROSPERO (CRD420261441125). PubMed/MEDLINE, Embase, Scopus, Web of Science, the Cochrane Library, and Google Scholar were searched on June 1, 2026. Random-effects meta-analyses of proportions used logit transformation and REML estimation. Heterogeneity, prediction intervals, small-study effects, influence diagnostics, subgroup analyses, and exploratory univariable meta-regression were assessed. Risk of bias was evaluated using the JBI Critical Appraisal Checklist for Case Series. Fifteen studies comprising 20,635 ureteroscopic procedures were included. The pooled incidence of ureteral perforation was 1.89% (95% CI 1.11-3.19%; I²=93.5%), with a prediction interval of 0.26-12.45%. Perforation incidence was 1.39% in studies not restricted to impacted stones versus 13.71% in impacted-only cohorts. The pooled incidence of ureteral avulsion was 0.32% (42 events; I²=64.9%), with a prediction interval of 0.04-2.76%; corresponding subgroup rates were 0.24% and 2.44%, respectively. Among non-impacted-only studies, a higher male proportion was associated with greater study-level odds of perforation (OR 2.03 per 10% increase; 95% CI 1.26-3.26; p = 0.003). Other examined demographic, stone, instrument, and lithotripsy variables were not significantly associated with either outcome; meta-regression findings remain exploratory. Ureteral perforation and avulsion remain uncommon but clinically important URS complications. Impacted stones identify a markedly higher-risk procedural context, supporting risk-stratified, atraumatic ureteroscopic strategies.