title: Does a ureteral access sheath facilitate ureteroscopy?
abstract: OBJECTIVE
  Ureteral access sheaths were initially developed to facilitate difficult ureteroscopic access. However, to our knowledge no formal evaluations have been performed to assess the routine use of ureteral access sheaths. Therefore, we prospectively analyzed intraoperative time, symptomatic outcome, major complications, stone-free rate and overall costs related to the routine use of a new ureteral access sheath during standard ureteroscopic procedures.
  
  
  METHODS
  Patients undergoing 6.5Fr semirigid or 7.5Fr flexible ureteroscopy were prospectively randomized to unaided ureteroscopy with no access sheath or ureteroscopy via a 12-14Fr ureteral access sheath. Patients who required ureteral dilatation were randomized to the ureteral access sheath used as a dilator or a standard 18Fr ureteral balloon dilator. Patients were evaluated postoperatively on days 0, 1 and 6 with a questionnaire to assess pain, irritative symptoms and complications. The stone-free rate and long-term complications were determined by excretory urography or computerized tomography at 3 months.
  
  
  RESULTS
  Enrolled in the study were 59 consecutive patients, who underwent a total of 62 ureteroscopic procedures. Of the 47 patients (76%) who did not require ureteral dilatation 23 (49%) underwent ureteroscopy via the ureteral access sheath and 24 (51%) underwent unaided ureteroscopy. Seven of the 15 patients (28%) who required ureteral dilatation underwent access sheath dilatation, while balloon dilatation was performed in 8. There was no significant difference in postoperative symptoms, complication rate or stone-free status in the access sheath and nonaccess sheath groups in patients not requiring ureteral dilatation (p <0.05). A significant increase in postoperative symptoms was noted when the balloon was used as a dilator compared to the access sheath. Operative time and costs in all patients who underwent access sheath dilatation were less than in those in whom the access sheath was not used. In the 15 patients who required dilatation 71% of access sheath and 100% of balloon dilatations were successful.
  
  
  CONCLUSIONS
  Routine use of a ureteral access sheath appears to facilitate semirigid and flexible ureteroscopy by decreasing operative time and costs, allowing direct visualization of ureteroscope insertion with simple ureteral re-entry and assisting renal and ureteral access with minimal associated morbidity. A ureteral access sheath should be considered for routine ureteroscopic procedures.
authors.affiliation: Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: J
authors.initials: J
authors.lastname: Kourambas
authors.forename: R R
authors.initials: RR
authors.lastname: Byrne
authors.forename: G M
authors.initials: GM
authors.lastname: Preminger
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004867:Equipment Design; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D020709:Ureteroscopes; D018666:Ureteroscopy / Q000379:methods*