title: Semirigid ureteroscopy of the proximal ureter can be aided by external lower-abdominal pressure.
abstract: OBJECTIVE
  Smaller semirigid ureteroscopes with large working channels and excellent optics are widely available. Ureteroscopic treatment of upper-ureteral stones has become increasingly popular, although flexible ureteroscopy is more frequently the method of choice. Access to the upper ureter with a semirigid ureteroscope (SR-URS) can be challenging and hazardous, especially when negotiating the iliac vessels. We sought to determine whether lower-abdominal pressure (LAP) facilitated SR-URS access to the upper ureter for safe laser lithotripsy.
  
  
  METHODS
  Thirty-two consecutive patients who underwent ureteroscopic management of upper- ureteral stones were evaluated. Twenty-four (75%) were male; seventeen (53%) had a right-sided stone. The mean largest stone diameter was 10.2 +/- 4.6 mm. These 32 patients were compared with a matched cohort of patients who underwent SR-URS procedures without the use of LAP.
  
  
  RESULTS
  Access to the upper ureter was possible in 30 patients (94%). The LAP was helpful in 18 patients (56%): it facilitated passage of the SR-URS in 16 patients (50%) and laser fiber placement in 11 cases (34%). Access to the upper ureter was possible in all women. The mean operative time was 54 minutes in the LAP group and 75 minutes in the matched cohort without LAP (P = 0.026). There were no significant deformities of the SR-URS and no complications.
  
  
  CONCLUSIONS
  Contrary to popular practice, the upper ureter can be accessed safely and efficiently with a 7.5F SR-URS in nearly all patients. Lower-abdominal pressure can be helpful to negotiate passage of the endoscope over the iliac vessels or to place the laser fiber on stones.
authors.affiliation: Division of Urology, Department of Surgery, St. Michael's Hospital, University of Toronto, 61 Queen Street East, Toronto, Ontario, Canada M5C 2T2.
authors.forename: A Joel
authors.initials: AJ
authors.lastname: Dagnone
authors.forename: Brian D M
authors.initials: BD
authors.lastname: Blew
authors.forename: Kenneth T
authors.initials: KT
authors.lastname: Pace
authors.forename: R John D'A
authors.initials: RJ
authors.lastname: Honey
mesh_terms: D000328:Adult; D000368:Aged; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D017602:Lithotripsy, Laser / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods; D011028:Pneumoperitoneum, Artificial; D011336:Probability; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D014514:Ureteral Calculi / Q000175:diagnosis* / Q000628:therapy*; D020709:Ureteroscopes; D018666:Ureteroscopy / Q000379:methods*; D014567:Urography