Urolithiasis (2015) 43:99–100 DOI 10.1007/s00240-014-0735-3


Double ureteral access sheath (UAS) technique for complicated distal ureteral stone Takashi Kawahara · Hiroki Ito · Hideyuki Terao · Hiroji Uemura · Yoshinobu Kubota · Junichi Matsuzaki 

Received: 12 August 2014 / Accepted: 23 October 2014 / Published online: 6 November 2014 © Springer-Verlag Berlin Heidelberg 2014

Ureteral access sheaths (UASs) are useful devices for decreasing intrarenal irrigation pressure and allow for easy control during flexible uretersocopy (URS). We herein report a case of lower ureteral stonesin which we used a double UAS technique, as the guide wire could not be inserted under retrograde cystoscopic guidance, and successfully treated the patient with ureteroscopic lithotripsy using a holmium: yttrium aluminum garnet laser (Ho:YAG) lithotripter. An 18-year-old male was referred to our hospital because his right lower ureteral calculi (13 mm) were resistance to SWL. Prior to performing ureteroscopic lithotripsy, we applied preoperative stenting; however, the inner ureteral orifice was not detected due to significant edema of the mucosa, even after injecting indigo carmine. Following nephrostomy, the guide wire was inserted into the ureter, but not through the bladder. Transurethral resection was then performed to identify the ureter. We subsequently inserted the guide wire into the ureter, followed by a UAS via the antegrade approach. The flexible URS device consequently went straight into the ureter next to the stone, allowing for observation of the target stone and the distal end of the ureter. The guide wire was then passed through the bladder under ureteroscopy, and the rUAS device was inserted under visualization using antegrade ureteroscopic guidance. Stone fragments were created using holmium: T. Kawahara (*) · H. Ito · H. Uemura · Y. Kubota  Department of Urology, University Graduate School of Medicine, 3‑9, Fukuura Kanazawa‑ku, Yokohama, Kanagawa 2360004, Japan e-mail: [email protected] T. Kawahara · H. Ito · H. Terao · J. Matsuzaki  Department of Urology, Ohguchi Higashi General Hospital, Yokohama, Kanagawa, Japan

yttrium aluminum garnet laser (Ho:YAG) laser lithotripsy ureteroscopically via the antegrade approach and subsequently removed through the rUAS device (Fig. 1). The use of a UAS facilitates URS and the retrieval of stone fragments, while reducing the intrarenal pressure, thereby improving the irrigation flow and decreasing the length of surgery. The development of flexible URS, Ho:YAG laser lithotripsy and basket devices to retrieve stone fragments has made UAS an essential tool for the treatment of renal stones. Although there is no evidence of ureteral stricture resulting from UAS, Boddy et al. [1] found that persistent ureteral edema and urinary tract obstruction occurred up to 96 h after mechanical distal ureteral dilation in a mini pig model. In addition, the use of larger diameter sheaths has been shown to decrease the blood flow by up to 65 % [2]. Although evidence of postoperative ureteral stricture following ureteroscopic lithotripsy is still lacking, ureteroscopic lithotripsy is thought to have a potential risk of causing this complication. It may be possible to obtain a stone-free status without inserting another UAS; however, retrieving stone fragments requires a longer operative time due to the long stone to UAS distance. Furthermore, antegrade UAS insertion cannot be used to observe the intrarenal pressure, which may be associated with the risk of postoperative urinary tract infection. In the present case, after inserting the UAS via the retrograde approach, the stone fragments were easily washed out from the rUAS device, and ureteral dilation was performed due to the risk of prolonged postoperative ureteral stricture, even if a stone-free status was obtained. For these reasons, we inserted the UAS via the retrograde approach. Indeed, an additional UAS should not be inserted unnecessarily. In cases in which the retrograde approach cannot be used, this double UAS technique serves as a new option for treating lower ureteral calculi in patients with severely



Urolithiasis (2015) 43:99–100

edematous urothelial mucosa. We herein reported a case of lower ureteral calculi in which the retrograde approach could not be performed due to severe edema of the mucosa that was ultimately successfully treated with a double UAS technique. Conflict of interest  We declare no conflict of interest.

References 1. Boddy SA, Nimmon CC, Jones S, Ramsay JW, Britton KE, Levison DA, Whitifield HN (1988) Acute ureteric dilatation for ureteroscopy. Exp study Br J Urol 61:27–31 2. Kawahara T, Ito H, Terao H, Kakizoe M, Kato Y, Uemura H, Kubota Y, Matsuzaki J (2013) Early ureteral catheter removal after ureteroscopic lithotripsy using ureteral access sheath. Urolithiasis 41:31–35

Fig. 1  Double UAS technique


Double ureteral access sheath (UAS) technique for complicated distal ureteral stone.

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