ADULT UROLOGY

ASSESSMENT OF STRICTURE FORMATION WITH THE

URETERAL ACCESS SHEATH
FERNANDO C. DELVECCHIO, BRIAN K. AUGE, RICARDO M. BRIZUELA, ALON Z. WEIZER,
ARI D. SILVERSTEIN, COSTAS D. LALLAS, PAUL K. PIETROW, DAVID M. ALBALA, AND
GLENN M. PREMINGER

ABSTRACT
Objectives. To analyze the long-term incidence of ureteral stricture formation in a series of patients in whom
a new-generation ureteral access sheath was used. A new generation of ureteral access sheaths has been
developed to facilitate ureteroscopic procedures. However, some have questioned their safety and whether
the device might cause significant ureteral trauma.
Methods. Between September 1999 and July 2001, 150 consecutive ureteroscopic procedures with
adjunctive use of an access sheath were performed. A retrospective chart review to April 2002 was done. Of
the 150 patients, 130 underwent ureteroscopy for ureteral stones. Patients who underwent endoureter-
otomy or treatment of transitional cell carcinoma were excluded from this analysis. Sixty-two patients had
follow-up greater than 3 months and were included in the analysis. Overall, 71 ureteroscopic procedures
were performed, with 9 patients undergoing multiple procedures. Ninety-two percent of the patients had
pathologic findings above the iliac vessels. The average patient age was 45.3 years (range 17 to 76), and
70% and 30% of the patients were male and female, respectively. The mean clinical follow-up was 332 days
(range 95 to 821), and follow-up imaging was performed within 3 months after ureteroscopy in all patients.
Results. The 10/12F access sheath was used in 8 ureteroscopic procedures (11.2%), the 12/14F access
sheath in 56 (78.9%), and the 14/16F access sheath in 7 (9.8%). One stricture was identified on follow-up
imaging of 71 procedures performed, for an incidence of 1.4%. The patient developed the stricture at the
ureteropelvic junction after multiple ureteroscopic procedures to manage recurrent struvite calculi. The
access sheath did not appear to be a contributing factor.
Conclusions. The results of our series indicate that the ureteral access sheath is safe and beneficial for
routine use to facilitate flexible ureteroscopy. However, awareness of the potential ischemic effects with the
use of unnecessarily large sheaths for long periods in patients at risk of ischemic injury should be considered.
We advocate the routine use of the device for most flexible ureteroscopic procedures proximal to the iliac
vessels. UROLOGY 61: 518–522, 2003. © 2003, Elsevier Science Inc.

T he downsizing of endoscopes and the develop-

ment of safer and more efficient intracorporeal
lithotriptors and lasers have expanded the indica-
tions of ureteroscopy from a purely diagnostic tool
to a therapeutic device currently used for a wide
range of indications. Similarly, endoscopic exper-
tise gained by urologic surgeons has played an
enormous role in significantly reducing the ure-
From the Comprehensive Kidney Stone Center, Division of Urol-
ogy, Department of Surgery, Duke University Medical Center,
Durham, North Carolina
Reprint requests: Glenn M. Preminger, M.D., Division of Urol-
ogy, Department of Surgery, Duke University Medical Center,
Box 3167, Room 1527D, White Zone, Durham, NC 27710
Submitted: May 28, 2002, accepted (with revisions): October 7,
2002
teral stricture rates secondary to ureteroscopy from
approximately 10% in early series to single digit
figures in modern series.1–5 The development of
ureteral strictures as a result of adjuncts used to
facilitate the procedure (ie, the ureteral access
sheath) has recently been theorized.6 Therefore,
we retrospectively analyzed the incidence of ure-
teral strictures in a series of patients in whom a
new-generation ureteral access sheath was used to
facilitate flexible ureteroscopy.
MATERIAL AND METHODS
A total of 150 consecutive ureteroscopies with the use of a
new-generation ureteral access sheath (Applied Medical,
Rancho Santa Margarita, Calif ) were performed. Sixty-two pa-

© 2003, ELSEVIER SCIENCE INC. 0090-4295/03/$30.00

518 ALL RIGHTS RESERVED doi:10.1016/S0090-4265(02)02433-0

TABLE I. Patient characteristics
Characteristic % patients with residual radiopaque stone burden were subse-
Ureteroscopic procedures (n) 71
Mean age (yr) 45.3 (17–76)
Gender (M/F) (n) 43/19 70/30
Preoperative stent 20 28
Preoperative obstruction 51 72
Postoperative stent 62 87
Balloon dilation 6 8.4
Follow-up (days)
Range 95–821 — Sixty-two patients undergoing 71 ureteroscopic
Mean 331.7 — procedures with the aid of the ureteral access
KEY: M/F ⫽ male/female.
tients were identified with complete follow-up and were ret-
rospectively enrolled for analysis (Table I). The average pa-
tient age was 45.3 years (range 17 to 76), and 70% of the
patients were male. Ninety-two percent of the patients had
renal or proximal ureteral pathologic findings managed intra-
corporeally with a 7.5F flexible ureteroscope. The ureteral
access sheath was used to facilitate treatment of distal ureteral
stones in 5 patients early in our experience. However, its use
for calculi in this location was abandoned thereafter, because
it proved to be too difficult to stabilize the sheath within the
distal ureter. All patients with stones above the iliac vessels
were treated with a flexible ureteroscope, and no attempt was
made to use a semirigid endoscope through the access sheath.
Overall, 71 ureteroscopic procedures were performed, with 9
patients having multiple procedures. The stone size was be-
tween 6 and 25 mm in diameter (mean size 10.7). The mean
operative time was 42 minutes.
The indications for ureteroscopy were renal or ureteral cal-
culus disease. Patients with pre-existing ureteral stricture dis-
ease or with upper tract transitional cell carcinoma were ex-
cluded from the study series, because subsequent stricture
formation in this group of patients could be related to their
primary disease and therefore could bias our results.
The ureteral access sheath used, available in three different
diameters (10/12F, 12/14F, and 14/16F) and variable lengths
(20, 28, 35, or 55 cm), is a soft, malleable, hydrophilic, two-
piece device with a removable inner tapered obturator and an
outer working sheath. The sheath size is chosen on the basis of
patient size, gender, and position of the pathologic findings
within the collecting system. The access sheath was used in
patients with large stone burdens in whom multiple re-entry
into the collecting system for stone fragment clearance was
anticipated; it was also used as a ureteral dilator. The access
sheath is placed directly over a safety guidewire with fluoro-
scopic guidance.7 The tip of the access sheath is placed just
below the stone during treatment of ureteral stones and at the
ureteropelvic junction for management of renal calculi. All
stones were fragmented with a 200-␮m holmium laser fiber
using power settings of 0.6 J at 6 Hz.8 A nitinol basket or
grasper was used in 39% of patients with ureteral calculi to
remove stone fragments (after laser fragmentation) through
the access sheath. Moreover, the nitinol devices were used in
62% of patients with renal calculi to reposition stones within
the collecting system and remove fragments after laser litho-
tripsy.9
The initial follow-up evaluation consisted of intravenous
urography with renal tomography or spiral computed tomog-
raphy to determine stricture rates and stone-free status. There-
after, additional imaging was tailored to the individual patient
on the basis of the findings from the initial study. Patients with
a normal imaging study (ie, no evidence of residual stones and
UROLOGY 61 (3), 2003
no evidence of stricture) were scheduled for repeat imaging 12
to 15 months after this first follow-up study. Asymptomatic
quently followed up with plain abdominal radiography and
tomography, and contrasted imaging studies were obtained in
symptomatic patients. All patients had an imaging study per-
formed within the first 3 months after surgery. The long-term
clinical follow-up ranged between 95 and 821 days (mean
332).
RESULTS
sheath and with complete follow-up longer than 3
months were identified for analysis. A 10/12F ac-
cess sheath was used in 8 (11.2%), a 12/14F access
sheath in 56 (78.9%), and a 14/16F access sheath in
7 (9.8%). Twenty patients (32.2%) had a stent
placed preoperatively, none of whom required bal-
loon dilation of the ureteral orifice at the time of
surgery. Balloon dilation to 18F was necessary in
6 cases (8.4%) to facilitate passage of the access
sheath. A postoperative stent was positioned at
the conclusion of 62 ureteroscopic procedures
(87.3%) and maintained for 3 to 5 days.
An asymptomatic stricture occurred in only one
renal unit of 71 ureteroscopic procedures (1.4%).
This patient was a T6 paraplegic with recurrent
struvite calculi who developed a left ureteropelvic
junction stricture 3 months after his second uret-
eroscopy. His last ureteroscopy was performed us-
ing a 12/14F ureteral access sheath that was placed
just above the iliac vessels, well below the stricture
site. No balloon dilation was required, and a ure-
teral stent was left indwelling for 7 days after the
procedure. The patient had undergone two prior
percutaneous nephrolithotomies with ureteral
catheterization, one shock wave lithotripsy, and
two ureteroscopic procedures, one for a proximal
and one for a distal ureteral stone.
The overall stone free rate for 71 ureteroscopic
procedures was 77.4%. When stratified by loca-
tion, the stone free rate was 81% for renal stones,
72% for proximal and mid-ureteral stones, and
100% for distal stones. Considering residual frag-
ments less than 4 mm, the overall success rate
was 90.3%, and the renal and proximal/mid suc-
cess rate approached 95% and 86%, respectively
(Table II).
COMMENT
Technological advancements leading to the de-
velopment of the flexible actively deflectable
ureteroscope have revolutionized intracorporeal
access to the proximal ureter and intrarenal col-
lecting system. Reports of complications from the
early use of large-caliber, rigid instruments de-
scribed minor injuries such as ureteral perforation,
519

TABLE II. Ureteroscopy performed with the
aid of the ureteral access sheath
SFR/Patients (%)
Stone Patients URS
Location (n) (n) Abs AbsⴙRel
Kidney 21 24 17 (81) 20 (95)
Proximal-mid 36 42 26 (72) 31 (86)
Distal 5 5 5 (100) 5 (100)
Total 62 71 48 (77.4) 56 (90.3)
KEY: URS ⫽ ureteroscopic procedure; SFR ⫽ stone free rate; Abs ⫽ absolute stone
free rate; Abs⫹Rel ⫽ absolute stone free rate plus residual stones ⬍4 mm in size.
mucosal injury, and urinary extravasation.10 –13
However, major complications occurred in more
than 10% of cases, including ureteral avulsion,
complete obstruction, vesicoureteral reflux, and
ureteral stricture.12,14 –17 Stricture rates ranged
from 2% to 10%, with prior ureteral surgery and
ureteral or pelvic radiation therapy cited as nega-
tive influences on ureteral blood flow, contributing
to poor healing and scar formation.4,15,18 Uretero-
scopes used early on to perform retrograde endo-
pyelotomy were large-caliber scopes (9 to 12F),
and, although used successfully, these endoscopes
were associated with a stricture rate of 20%.19,20
As the ureteroscope diameter decreased to 7.5F
and 6.5F, and the malleability of semirigid endo-
scopes and actively deflectable flexible uretero-
scopes has improved, so too have the complication
rates secondary to ureteroscopy decreased.21–23
Strictures are now rare, comprising 1% to 2% of all
complications in large series.23–25
Because repeated insertion and withdrawal of a
ureteroscope increases the likelihood of ureteral
damage, adjuncts to prevent ureteral injury have
been sought. The concept of a ureteral access
sheath is not new. In the early 1970s, Takayasu and
Aso26 described the use of a “guide tube” or prim-
itive access sheath as an aid to ureteroscopy. Early
devices designed to aid ureteroscope insertion and
stability involved a cystoscopic sheath for uretero-
scope passage. A peel-away ureteral and renal ac-
cess system was developed in the mid-1980s. This
access system involved the use of sequential rigid
dilators and a peel-away outer sheath that required
multiple steps before ureteroscope insertion. Al-
though these devices improved stone fragmenta-
tion and stone removal and facilitated other uret-
eroscopic procedures, its use contributed to
perforation in up to 30% of cases.27,28
The new-generation ureteral access sheath is a
two-piece hydrophilic-coated device of varying
lengths and diameters designed to facilitate flexible
and semirigid ureteroscopy. During the current
study, the access sheath was used primarily during
flexible ureteroscopic procedures and not in con-
junction with semirigid ureteroscopes.7 Not only
520
does the access sheath facilitate repeated insertion
and withdrawal of the endoscope, it also protects
the ureteral orifice and wall from trauma they
might otherwise sustain while advancing the in-
strument through the native ureter. Moreover, the
ability to irrigate the intrarenal collecting system
continuously has resulted in improved clearance of
renal stones compared with our series of patients
before the routine use of the access sheath.29 A
recent report from our institution demonstrates
that the ureteral access sheath reduces both oper-
ative time and costs and obviates the need for rou-
tine balloon dilation in most patients undergoing
flexible ureteroscopy.7
Recently, concerns have been raised as to the
long-term safety of the ureteral access sheath with
regard to stricture formation secondary to pres-
sure-induced ischemia. However, no clinical stud-
ies have been performed to explore the potential
trauma induced by the ureteral access sheath. This
current review of ureteroscopic procedures using
the ureteral access sheath demonstrated a stricture
rate of only 1.4%, consistent with modern series of
flexible ureteroscopy without the assistance of the
access sheath. A review of the operative notes from
the 1 patient who developed a ureteral stricture
failed to disclose intraoperative complications that
could account for the problem. It is likely that re-
peated ureteral manipulation during percutaneous
and retrograde procedures rather than the use of
the access sheath may have placed this patient at
higher risk of stricture formation.
It could be argued that imaging follow-up studies
within 3 months of ureteroscopy is not long
enough to capture all potential strictures. How-
ever, several reports have indicated that failure of
the ureteroscopic incision of secondary uteropel-
vic junction obstruction or incision of benign ure-
teral strictures occurs within 1.5 to 4.5 months
postoperatively. Furthermore, strictures related to
impacted stones were detected at a mean of 2.6
months after stone extraction.22,30 These data sug-
gest that although long-term follow-up is war-
ranted, if the access sheath had caused significant
ureteral injury, most sheath-induced traumatic
strictures should have been apparent during the
follow-up period.
Despite the apparent safety of the ureteral access
sheath, patient factors may contribute to ureteral
injury during ureteroscopy with or without the use
of the access sheath. These factors include prior
ureteral or retroperitoneal surgery, retroperitoneal
radiotherapy, severe peripheral vascular disease,
and collagen vascular disorders affecting small to
medium-size blood vessels. Animal studies at our
institution investigating the effects of the access
sheath on ureteral blood flow failed to demonstrate
acute ischemic damage based on blood flow mea-
UROLOGY 61 (3), 2003
surements and histopathologic changes. However,
this study demonstrated that ureteral blood flow
decreased more rapidly, more profoundly, and
took longer to return to baseline values, when us-
ing a large caliber 14/16F ureteral access sheath.6
We would therefore recommend using the smallest
diameter access sheath that will allow the operator
to efficiently and effectively perform the proce-
dure. We commonly use the smaller 10/12F and
12/14F access sheaths, reserving the 14/16F sheath
for those individuals who have undergone preop-
erative ureteral stent placement, with a subse-
quently dilated ureter.
Because our facility is a tertiary care center, many
patients, after their ureteroscopic procedures, fail
to return for follow up imaging at 3 months post-
operatively if feeling well, translating into lower
than expected follow-up rates. It is common for
these patients to undergo follow-up imaging with
the referring urologist or family practitioner if trav-
eling a great distance to our clinic. It is our pre-
sumption that, given typical referral patterns, pa-
tients who develop a ureteral stricture would be
sent back to our institution for definitive manage-
ment. However, only patients with complete fol-
low-up at our institution were considered for this
analysis.
A review of our data demonstrated a relatively
low stone-free rate for stones located in the proxi-
mal or mid-ureter (above the iliac vessels). This
finding was probably due to a combination of fac-
tors. Initially, when using the access sheath, stone
were fragmented to less than 2 mm in size, assum-
ing that, with the access sheath in place, the frag-
ments would be washed out during the course of
the procedure. However, after review of these data,
we attempt to thoroughly retrieve all fragments at
the end of the procedure with a nitinol basket or
grasper.
Moreover, the low stone-free rates could repre-
sent fragmented debris from the kidney that is “in
transit” through the ureter. Finally, the suboptimal
stone-free rates could be attributed to the sensitiv-
ity of the imaging modalities used at follow-up (in-
travenous urography with renal tomography or he-
lical computed tomography). Currently, we
perform an imaging study during the follow-up of
all patients who have undergone ureteroscopy, de-
spite the known low stricture rates of uncompli-
cated procedures. Studies from our institution
have demonstrated a relatively significant rate of
silent obstruction (3.7%) during review of our own
ureteroscopy series.29
CONCLUSIONS
The ureteral access sheath facilitates flexible ure-
teroscopy by protecting the native ureter and al-
UROLOGY 61 (3), 2003
lowing for repeated atraumatic ureteral reentry.
Moreover, all of the advantages of the ureteral ac-
cess sheath are achieved with a significant decrease
in operative time and costs. Additional studies are
warranted to evaluate the impact of using the larg-
est access sheath in patients at high risk of ischemic
ureteral injury, because the 14/16F sheath was
used in less than 10% of our patient population.
The current series demonstrates the safety of the
ureteral access sheath during ureteroscopic stone
manipulation. Therefore, we advocate the routine
use of the ureteral access sheath for flexible uret-
eroscopic procedures above the iliac vessels.
REFERENCES
1. Watson GM, Landers B, Nauth-Misir R, et al: Develop-
ments in the ureteroscopes, techniques and accessories asso-
ciated with laser lithotripsy. World J Urol 11: 19 –25, 1993.
2. Stoller ML, Wolf JS Jr, Hofmann R, et al: Ureteroscopy
without routine balloon dilation: an outcome assessment.
J Urol 147: 1238 –1242, 1992.
3. Stackl W, and Marberger M: Late sequelae of the man-
agement of ureteral calculi with the ureterorenoscope. J Urol
136: 386 –389, 1986.
4. Kostakopoulos A, Sofras F, Karayiannis A, et al: Uret-
erolithotripsy: report of 1000 cases. Br J Urol 63: 243–244,
1989.
5. Andersen JR, Ostri P, Jansen JE, et al: A retrospective
evaluation of 691 ureteroscopies: indications, procedures,
success rate and complications. Urol Int 51: 191–197, 1993.
6. Lallas CD, Auge BK, Raj GV, et al: Laser Doppler flow-
metric determination of ureteral blood flow after ureteral ac-
cess sheath placement. J Endourol 16: 583–590, 2002.
7. Kourambas J, Byrne RR, and Preminger GM: Does a
ureteral access sheath facilitate ureteroscopy? J Urol 165:
789 –793, 2001.
8. Kourambas J, Delvecchio FC, and Preminger GM: Low-
power holmium laser for the management of urinary tract
calculi, strictures, and tumors. J Endourol 15: 529 –532, 2001.
9. Kourambas J, Delvecchio FC, Munver R, et al: Nitinol
stone retrieval-assisted ureteroscopic management of lower
pole renal calculi. Urology 56: 935–939, 2000.
10. Hosking DH, and Ramsey EW: Rigid transurethral ure-
teroscopy. Br J Urol 58: 621–624, 1986.
11. Chang R, and Marshall FF: Management of uretero-
scopic injuries. J Urol 137: 1132–1135, 1987.
12. Lytton B, Weiss RM, and Green DF: Complications of
ureteral endoscopy. J Urol 137: 649 –653, 1987.
13. Huffman JL: Ureteroscopic injuries to the upper uri-
nary tract. Urol Clin North Am 16: 249 –254, 1989.
14. Kramolowsky EV: Ureteral perforation during uretero-
renoscopy: treatment and management. J Urol 138: 36 –38,
1987.
15. Silverstein JI, Libby C, and Smith AD: Management of
ureteroscopic ureteral injuries. Urol Clin North Am 15: 515–
524, 1988.
16. Biester R, and Gillenwater JY: Complications following
ureteroscopy. J Urol 136: 380 –382, 1986.
17. Flam TA, Malone MJ, and Roth RA: Complications of
ureteroscopy. Urol Clin North Am 15: 167–181, 1988.
18. Ono Y, Ohshima S, Kinukawa T, et al: Long-term re-
sults of transurethral lithotripsy with the rigid ureteroscope:
injury of intramural ureter. J Urol 142: 958 –960, 1989.
19. Clayman RV, Basler JW, Kavoussi L, et al: Uretero-
nephroscopic endopyelotomy. J Urol 144: 246 –252, 1990.
521
 20. Meretyk I, Meretyk S, and Clayman RV: Endo-
pyelotomy: comparison of ureteroscopic retrograde and ante-
grade percutaneous techniques. J Urol 148: 775–783, 1992.
21. Carter SS, Cox R, and Wickham JE: Complications as-
sociated with ureteroscopy. Br J Urol 58: 625–628, 1986.
22. Roberts WW, Cadeddu JA, Micali S, et al: Ureteral stric-
ture formation after removal of impacted calculi. J Urol 159:
723–726, 1998.
23. Francesca F, Scattoni V, Nava L, et al: Failures and
complications of transurethral ureteroscopy in 297 cases: con-
ventional rigid instruments vs. small caliber semirigid uretero-
scopes. Eur Urol 28: 112–115, 1995.
24. Abdel-Razzak OM, and Bagley DH: Clinical experience
with flexible ureteropyeloscopy. J Urol 148: 1788 –1792,
1992.
25. Elashry OM, Elbahnasy AM, Rao GS, et al: Flexible
ureteroscopy: Washington University experience with the
9.3F and 7.5F flexible ureteroscopes. J Urol 157: 2074 –2080,
1997.
26. Takayasu H, and Aso Y: Recent development for py-
eloureteroscopy: guide tube method for its introduction into
the ureter. J Urol 112: 176 –178, 1974.
27. Rich M, Lee WJ, and Smith AD: Applications of the
peel-away introducer sheath. J Urol 137: 452–454, 1987.
28. Newman RC: Ureteral access system: technique and
results. Urol Clin North Am 15: 323–328, 1988.
29. Weizer AZ, Auge BK, Silverstein AD, et al: Routine
post-operative imaging is important following ureteroscopic
stone manipulation. J Urol 168: 46 –50, 2002.
30. Jabbour ME, Goldfischer ER, Klima WJ, et al: Endopy-
elotomy after failed pyeloplasty: the long-term results. J Urol
160: 690 –693, 1998.
EDITORIAL COMMENT
The goal of this retrospective study was to determine
whether the use of ureteral access sheaths increases postoper-
ative ureteral stricture formation. This is a relevant question,
given the popularization of retrograde approaches to signifi-
cant upper urinary tract pathology. In the analysis of 62 pa-
tients, only a single stricture was detected. However, one won-
ders whether other lesions were missed because of (a) early
imaging at 3 months, potentially before stricture develop-
ment, and (b) clinical assessment only thereafter. It is inter-
esting to note a relatively short mean operative time (42 min-
utes). How many passages of the ureteroscope were
necessary? We think most urologists agree that ureteral access
sheaths are safe, when properly used, and ultimately this study
raises the issue of whether they are necessary. Developments
such as hydrophilic coatings and the ability to place the sheath
without multiple, sequential dilations have likely reduced
complications due to shear forces. We continue to perform
retrograde ureteroscopy and renoscopy routinely without an
access sheath or ureteral dilation, simply being careful during
manipulation and also selecting those patients with lower
stone burden and therefore requiring fewer passages. Despite
the advances in ureteroscopic lithotripsy such as the holmium
laser, our preference is to still manage large upper urinary tract
522
nephrolithiasis by a percutaneous route. This results in better
stone-free rates with acceptable morbidity.
Marshall L. Stoller, M.D.
Maxwell V. Meng, M.D.
University of California, San Francisco
School of Medicine
Department of Urology
San Francisco, California
doi:10.1016/S0090-4295(02)02434-2
© 2003, ELSEVIER SCIENCE INC.
ALL RIGHTS RESERVED
REPLY BY THE AUTHORS
The percutaneous approach remains our first choice for the
management of complex renal and upper ureteral pathologic
findings. Yet, when a retrograde approach is indicated, a ure-
teral access sheath greatly aids flexible ureteroscopy by de-
creasing the need for ureteral dilation and facilitating with-
drawal and re-entry of the endoscope during the management
of stones, strictures, or tumors. Previous studies have demon-
strated that routine use of the ureteral access sheath makes
upper tract endoscopy faster and less expensive.1 The current
report provides additional evidence to support previously per-
formed studies, which validate the safety of the access sheath.2
Imaging studies performed 3 months after ureteroscopy
should uncover the vast majority of ureteroscopy-induced
ureteral injuries. Although many urologists do not routinely
image patients after uncomplicated ureteroscopic procedures,
we believe that postureteroscopic imaging is an important ad-
junct to uncover silent obstruction.3
Flexible ureteroscopy can be performed safely and effi-
ciently without a ureteral access sheath. Yet, we believe that
the combination of advantages afforded by this new genera-
tion of access sheaths supports our recommendation to use a
ureteral access sheath routinely during flexible ureteroscopic
procedures.
REFERENCES
1. Kourambas J, Byrne RR, and Preminger GM: Does a ure-
teral access sheath facilitate ureteroscopy? J Urol 165: 789 –
793, 2001.
2. Lallas CD, Auge BK, Raj GV, et al: Laser Doppler flow-
metric determination of ureteral blood flow after ureteral ac-
cess sheath placement. J Endourol 16: 583–590, 2002.
3. Weizer AZ, Auge BK, Silverstein AD, et al: Routine post-
operative imaging is important after ureteroscopic stone ma-
nipulation. J Urol 168: 46 –50, 2002.
Fernando C. Delvecchio, M.D.,
Glenn M. Preminger, M.D.
Duke University Medical Center
Durham, North Carolina
doi:10.1016/S0090-4295(02)02435-4
© 2003, ELSEVIER SCIENCE INC.
ALL RIGHTS RESERVED
UROLOGY 61 (3), 2003