title: Ureteral access sheath facilitates inspection of incision of ureteropelvic junction.
abstract: OBJECTIVE
  The Acucise (Applied Medical, Rancho Santa Margarita, California) electrocautery balloon is a highly successful device used in managing congenital and secondary ureteropelvic junction obstruction. Correct orientation of the cutting wire is essential during insertion of the Acucise catheter to avoid injury to crossing vessels. Moreover, confirmation of the lateral ureteropelvic junction incision is typically verified by fluoroscopic identification of extravasated contrast material. We describe a technique of facilitated passage of the Acucise balloon through a ureteral access sheath followed by ureteroscopic visualization of the incision, affording the opportunity to improve the incision with the holmium laser if necessary.
  
  
  METHODS
  After retrograde pyelography and guidewire placement, a 12/14Fr, 35 cm. ureteral access sheath is fluoroscopically introduced to the proximal ureter. The Acucise balloon is advanced across the ureteropelvic junction and the balloon is partially inflated to confirm proper placement. Following lateral Acucise incision, flexible ureteroscopy allows direct visualization of the ureteropelvic junction, confirming a through-and-through incision. Completion of a partial incision can be performed if needed with a 200 micro holmium laser fiber followed by routine stent placement.
  
  
  RESULTS
  During the last 8 months we have used the Acucise device through a ureteral access sheath to treat congenital or secondary ureteropelvic junction obstruction in 8 patients. All incisions demonstrated extravasation of contrast material on retrograde pyelography, and 6 incisions (75%) were noted to be transmural by flexible ureteroscopic inspection. Two patients (25%) with only a partial incision despite contrast extravasation underwent extended incision using the holmium laser. Short-term followup demonstrated patency of the ureteropelvic junction in 7 of the 8 patients (87.5%) with 1 eventually requiring a secondary open pyeloplasty.
  
  
  CONCLUSIONS
  The ureteral access sheath greatly facilitates placement of the Acucise device and allows rapid ureteroscopic confirmation of the incision. Insertion and removal of the ureteral access sheath and flexible ureteroscope do not compromise or significantly increase the duration of the procedure. Moreover, flexible ureteroscopic visualization allows confirmation of a complete transmural incision and potentially increases success rates of this minimally invasive approach to ureteropelvic junction obstruction. Continued followup is necessary to confirm the long-term benefits of this procedure.
authors.affiliation: Department of Urology, Naval Medical Center, San Diego, California, USA.
authors.forename: Brian K
authors.initials: BK
authors.lastname: Auge
authors.forename: Ning Z
authors.initials: NZ
authors.lastname: Wu
authors.forename: Paul K
authors.initials: PK
authors.lastname: Pietrow
authors.forename: Fernando C
authors.initials: FC
authors.lastname: Delvecchio
authors.forename: Glenn M
authors.initials: GM
authors.lastname: Preminger
mesh_terms: D002404:Catheterization / Q000295:instrumentation; D004598:Electrosurgery / Q000295:instrumentation*; D005471:Fluoroscopy; D006801:Humans; D007682:Kidney Pelvis / Q000601:surgery*; D015641:Radiography, Interventional; D015607:Stents; D014513:Ureter; D014517:Ureteral Obstruction / Q000601:surgery*; D018666:Ureteroscopy; D014546:Urinary Catheterization / Q000295:instrumentation* / Q000379:methods