OBJECTIVE Ureteroscopy is central to the surgical management of ureteral stones. Fluoroscopy is conventionally used for intraoperative guidance, although there is growing effort to decrease the exposure of patients and staff to ionizing radiation. We developed a radiation-free approach to ureteroscopy using ultrasound guidance to manage ureteral stones. To our knowledge we present the first randomized trial to study its safety and efficacy. METHODS This single center, randomized clinical trial from 2011 to 2013 enlisted patients who presented with symptomatic ureteral stones 8 mm or less without a significant ipsilateral stone burden. Patients were randomly assigned to ultrasound or fluoroscopic guided ureteroscopy after temporizing ureteral stent placement. Intraoperative ultrasound guidance was performed using real-time imaging with the transducer placed at the patient flank to visualize the collecting system of the ipsilateral kidney. We compared operative time, stone size, stone-free status and complication rates between the 2 groups. RESULTS A total of 50 patients were enrolled in study with 25 per arm. There was no difference in stone size (5.9 vs 5.7 mm), patient age (56 vs 52 years) or body mass index (31 vs 30 kg/m(2)) in the test group compared to controls. The ultrasound guidance cohort showed no significant difference in the stone-free rate (86% vs 86%) or the complication rate (8% vs 16%) compared to controls. Operative time was no longer in the ultrasound guidance cohort. CONCLUSIONS In this feasibility study we found that ureteral stones may be definitively managed in a timely, effective and safe fashion without ionizing radiation in the general population using this novel technique of ultrasound guided ureteroscopy.