Objective To compare the clinical efficacy of flexible ureteroscopic lithotripsy (FURS) under local and general anesthesia in the treatment of upper urinary tract calculi，and preliminarily explore the management strategy of perioperative pain. Methods Retrospective analysis was performed on the clinical data of 341 patients with upper urinary calculi who received FURS treatment in the First Affiliated Hospital of Chongqing Medical University from September 2021 to January 2023. According to the different anesthesia methods, they were divided into local anesthesia group (LA group，165 cases) and general anesthesia group (GA group，176 cases). Stone free rate（SFR）, postoperative complications, surgical time, hospital stay, hospitalization costs, anesthesia costs, 2-h and 6-h postoperative VAS scores and hemodynamic indicators were compared between the two groups. Visual analogue scores (VAS) at different time points during the perioperative period in LA group were compared. Results There were no significant differences in gender, age, body mass index, stone characteristics, underlying disease, duration of ureteral stent indwelling, inflammatory markers and other preoperative general data between the two groups (P＞0.05). There were no significant differences in SFR and total complication rate between the two groups (P＞0.05). The surgical time, hospital stay, hospitalization cost and anesthesia cost in LA group were lower than those in GA group, with statistical significance (P＜0.05). After operation, VAS scores in LA group at 2 hours and 6 hours were higher than those in GA group, with statistical significance (P＜0.05). VAS assessment at different time points in the LA group showed the highest pain score when performing the ureteroscopy, second when placing the ureteral access sheath and the lowest when performing holmium laser lithotripsy, with statistical significance (P＜0.05).Conclusion The FURS can be safely and effectively performed under local anesthesia or general anesthesia, and local anesthesia provides lower anesthesia risk, faster recovery, shorter hospital stay，lower hospital cost and less inflammation. Under local anesthesia, the pain of FURS during ureteroscopy is the most obvious, but better clinical effects can also be achieved through comprehensive evaluation, adequate preoperative education and timely initiation of perioperative pain management programs