Despite its importance, IRP control during fURS has traditionally relied on indirect and operator-dependent strategies, such as manual irrigation adjustments or the use of ureteral access sheaths. These approaches lack real-time feedback and do not allow precise or consistent pressure regulation.
Technological advances in fURS now enable real-time IRP monitoring and automatic adjustment of irrigation flow through various mechanisms.4 The aim is to replicate what is achieved with pneumoperitoneum in laparoscopic surgery, but in this case, applied to IRP. For example, a recent publication by Yang et al.5 describes a platform that measures IRP through a suction ureteral access sheath and automatically regulates suction, with the goal of maintaining IRP at no more than 30 mmHg.
In this context, our study represents the first-in-human evaluation of an automated fluid management system (Asurys) integrated with a pressure-sensing ureteroscope (LithoVue Elite). This system enables continuous intrarenal pressure monitoring and dynamically adjusts irrigation flow to maintain pressure within predefined safety thresholds.
Our findings demonstrate that automated pressure control is both feasible and safe in a clinical setting. The mean intrarenal pressure remained within recommended limits (29.4 ± 13.1 cmH₂O), and although transient pressure peaks above 40 cmH₂O were observed in a subset of patients, these were brief and not associated with adverse clinical outcomes. Importantly, the overall complication rate was low, with only one Clavien-Dindo grade II urinary tract infection and no cases of sepsis or systemic inflammatory response syndrome.
Beyond safety, this technology introduces a paradigm shift in endourology. By decoupling pressure control from manual operator adjustments, automated systems may standardize procedural quality, reduce variability between surgeons, and optimize the balance between irrigation flow and intrarenal pressure. This could translate into improved visualization without compromising safety, potentially enhancing procedural efficiency and outcomes.
However, several limitations must be acknowledged. This was a small, descriptive study without a control group, limiting the ability to draw definitive comparative conclusions. Additionally, continuous pressure traces were not systematically recorded in all cases, precluding detailed temporal analysis of pressure fluctuations.
Future research should focus on larger, controlled studies comparing automated pressure systems with conventional irrigation strategies, as well as evaluating their impact on clinically relevant outcomes such as stone-free rates, infectious complications, and cost-effectiveness.
In conclusion, automated intrarenal pressure control during fURS is a promising innovation that may redefine intraoperative safety standards in endourology. Our initial clinical experience provides a foundation for further investigation into its role in routine practice.
Written by: Juan Fullá,1,2 Diego Saldivia,2 José A. Salvadó3
- Clínica MEDS, Santiago, Chile, Universidad de Chile
- Universidad de Chile, Santiago, Chile
- University Hospitals Cleveland Medical Center, Ohio, USA
- Pearle MS, Matlaga BR, Antonelli JA, Chi T, Hsi RS, Knudsen B, et al. Surgical Management of Kidney and Ureteral Stones: AUA Guideline. American Urological Association; 2026. https://www.auanet.org/guidelines-and-quality/guidelines/surgical-management-of-kidney-an d-ureteral-stones
- Tokas T, Skolarikos A, Herrmann TRW, Nagele U; Training and Research in Urological Surgery and Technology (T.R.U.S.T.) Group. Pressure matters 2: intrarenal pressure ranges during upper-tract endourological procedures. World J Urol. 2019;37(1):133-142. doi:10.1007/s00345-018-2379-3
- Hong A, Leroi M, Alberto M, Bolton D, Jack G. The exponential relationship between raised intrarenal pressure and bacteraemia. BJU Int. Published online July 24, 2025. doi:10.1111/bju.16856
- Yoshida T, Tsuruoka N, Haga Y, Kinoshita H, Lee SS, Matsunaga T. Automatic irrigation system with a fiber-optic pressure sensor regulating intrapelvic pressure for flexible ureteroscopy. Sci Rep. 2023;13(1):22853. doi:10.1038/s41598-023-47373-5
- Yang Z, Zhai Q, Wu J, Song L, Huang Y, Sun T. Intelligent pressure-controlled retrograde intrarenal surgery vs microchannel percutaneous nephrolithotomy to treat 2–3 cm renal calculi. Urolithiasis. 2025;53(1):129. doi:10.1007/s00240-025-01799-w