Objective To evaluate the value of flexible ureteroscope for management of renal calyceal diverticulum calculi with ultrasound guided puncture of diverticulum. Methods From August 2014 to May 2015, six men and 3 women, median age 50 years, with 7 symptomatic caliceal diverticulum calculi and 2 symptom free, were treated by flexible ureteroscopic methods. Flexible ureteroscope recognization of diverticulum ostium with the help of ultrasound guided puncturing into diverticular cavity in lateral lithotomy position were performed. After the needle entering the diverticula cavity, saline-diluted methylthioninium chloride was injected or guidewires were inserted gently through needle sheaths. At the same time, the orifice or wall of the diverticular cavity was recognized under flexible ureteroscope. A 200-mm holmium laser fiber is used to fragment large diverticular calculi, larger fragments were extracted with basket. Laser incise the stenotic infundibulum or diverticular wall. Results Of the 9 cases, calyceal diverticulum necks leading to calyx were identified in 6 cases, another 3 cases were not found but determined their locations. The thinker diverticular walls of the later 3 cases were incised with laser. The stone free rate, fragment success rate and symptom free rate was 77.8% (6/9), 88.9% (8/9) and 100.0% (7/7), respectively. Only one case were underwent repeated procedure for the residual fragments, and the fragments were all cleared successfully. Diverticula became disappeared or shrinked in 4 and 5 cases 3 months postoperation, respectively. Conclusion Flexible ureteroscope combining with the ultrasound guided puncture of diverticular cavity for management of caliceal diverticula may provide a safe and effective option. Ultrasound guided needle puncture into calyceal diverticula may facilitate flexible ureteroscopic treatment of renal calyceal diverticula calculi.