Mainstream anammox has attracted much attention as an energy-efficient nitrogen removal technology. However, its stable operation remains challenged by complex mainstream conditions, limiting engineering implementation. This review synthesized the biological foundations, operational control strategies, and engineering practices underlying stable mainstream anammox operation. Process stability depends on effective coupling between ammonia-oxidizing bacteria and anammox bacteria (AnAOB), sustained suppression of nitrite-oxidizing bacteria (NOB), and efficient enrichment and retention of AnAOB. Accordingly, key intensification strategies were highlighted, including fine-tuned dissolved oxygen control, decoupling of hydraulic and solids retention times, reinforcement of biofilm and granular sludge structures, and the use of physical selectors and membrane separation. Application cases demonstrate that, despite proven feasibility, autotrophic nitrogen removal in mainstream anammox remains limited and may decline during long-term operation. Finally, future research directions were proposed, including multi-omics-based elucidation of AnAOB metabolic regulation under low-temperature and low-substrate conditions, quantitative modeling of organic matter and anammox interactions, cross-scale linkages between microscale structure and macroscopic performance, and data-driven intelligent operation and control. This review provides a theoretical basis and practical guidance for the optimization and engineering application of mainstream anammox processes.



