Endovisually guided zero radiation ureteral access sheath placement during ureterorenoscopy

Background: Almost all endourologic procedures use fluoroscopic imaging in some steps, which exposes both the patient and the surgical team to considerable amounts of radiation. Primary reports on results of a simple direct visual endoscopic access sheath placement technique which does not use fluoroscopy at all are presented. Material and methods: First a semi-rigid ureteroscopy was carried out up to the renal pelvis, then the access sheath (36cm, 11/13Fr) without the obturator was placed over a 7.5Fr semi-rigid ureteroscope and ureteroscopy was repeated over the guide wire to the point where the sheath could be inserted without force as if the ureteroscope would act as the guide wire (rod), which is controlled under direct endoscopic vision. Results: Eighty-eight cases out of 106 procedures were successful regarding the insertion of the ureteral access sheath (UAS) under direct vision using a 36cm 13/11 Fr sheath. Fourteen ureters had non-negotiable strictures needing stenting for passive dilation. The mean time for UAS insertion was 19s. The stone free-rate was 78.12%. Among our 106 cases, there were six cases of the upper tract urothelial cancers. Conclusion: Ureteral access sheath placement could be safely performed using a semi-rigid ureteroscope under direct visual control and resulted in shorter operative time, without radiation exposure during the RIRS procedure of both the patient and the surgery team.