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Impact of ureteral access sheath use on outcomes of flexible ureteroscopy for renal stones

Volume 10, Issue 2

Original Article / Published: November 2022


K. Petkova, P. Petrov, D. Petrova, O. Gatsev, V. Todorova, K. Hristov, I. Saltirov

Department of Urology and Nephrology, Military Medical Academy, Sofia, Bulgaria


Introduction and objective: Improvements in endoscopic technologies have led to an expansion of flexible ureteroscopy indications in the treatment of renal and ureteral stones. Ureteral access sheath (UAS) was introduced in the clinical practice to facilitate endoscopic access into the upper urinary tract, reduce intrarenal pressure during the procedure and allow the extraction of fragments. The objective of this study is to analyze the impact of UAS on the efficacy and safety of flexible ureteroscopy (fURS) for the treatment of renal stones.

Material and methods: a prospectively collected database including 251 consecutive patients treated with fURS between January 2018 and November 2022 was analyzed. Patients were divided into two groups: group 1 – without UAS, 21 patients (8.3%) and group 2 – with UAS, 231 patients (91.7%). UAS was used at the surgeon’s discretion and 3 patients (1.2%) underwent a sheathless procedure due to failure of UAS insertion. Data on patients’ preoperative characteristics and fURS efficacy and safety were compared.

Results: There were no statistically significant differences in patients’ preoperative characteristics except for stone size and surface, which were significantly larger in group 2 (9.6±4.1 vs 13.8±5.2 mm; р<0.001 and 68.6±74.2 vs 128.3±109.3 mm2, p=0.002, respectively). Operating time was significantly longer in group 2 (33.6±12.9 vs 42.0±12.9 min, p=0.005). Stone-free rate after a single procedure and at 3rd postoperative month was similar between groups (95.2% vs 87%, p=0.486 and 95.2% vs 88.7%, p=0.709, respectively). The intra- and postoperative complication rates were higher for group 1 (4.8% vs 0.8%, р=0.011 and 14.3% vs 12.1%, p=0.062, respectively). Multivariate regression model identified stone surface (р<0.001), number of stones (p=0.005) and calcium oxalate monohydrate stone composition (р=0.005), but not UAS use (p=0.580), as independent predictors for stone-free rate following fURS.

Conclusions: The results of this study suggest that UAS use has no impact on the efficacy of fURS and is not associated with an increased rate of intra- and postoperative complications.


  1. Skolarikos A, Neisius A, Petrik A et al., members of the EAU Guidelines of Urolithiasis Panel. EAU guideline of Urolithiasis. Retrieved from Accessed November 6th, 2022.
  2. Takayasu H, Aso Y. Recent development for pyeloureteroscopy: guide tube method for its introduction into the ureter. J Urol. 1974 Aug;112(2):176-8. doi: 10.1016/s0022-5347(17)59675-5.
  3. Jung H, Osther PJ. Intraluminal pressure profiles during flexible ureterorenoscopy. Springerplus. 2015 Jul 24;4:373. doi: 10.1186/s40064-015-1114-4.
  4. Auge BK, Pietrow PK, Lallas CD, Raj GV, Santa-Cruz RW, Preminger GM. Ureteral access sheath provides protection against elevated renal pressures during routine flexible ureteroscopic stone manipulation. J Endourol. 2004 Feb;18(1):33-6. doi: 10.1089/089277904322836631.
  5. Landman J, Venkatesh R, Ragab M, Rehman J, Lee DI, Morrissey KG, Monga M, Sundaram CP. Comparison of intrarenal pressure and irrigant flow during percutaneous nephroscopy with an indwelling ureteral catheter, ureteral occlusion balloon, and ureteral access sheath. Urology. 2002 Oct;60(4):584-7. doi: 10.1016/s0090-4295(02)01861-7.
  6. El-Nahas AR, Almousawi S, Alqattan Y, Alqadri IM, Al-Shaiji TF, Al-Terki A. Dusting versus fragmentation for renal stones during flexible ureteroscopy. Arab J Urol. 2019 Apr 26;17(2):138-142. doi: 10.1080/2090598X.2019.1601002.
  7. Traxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol. 2013 Feb;189(2):580-4. doi: 10.1016/j.juro.2012.08.197.
  8. Delvecchio FC, Auge BK, Brizuela RM, Weizer AZ, Silverstein AD, Lallas CD, Pietrow PK, Albala DM, Preminger GM. Assessment of stricture formation with the ureteral access sheath. Urology. 2003 Mar;61(3):518-22; discussion 522. doi: 10.1016/s0090-4295(02)02433-0.
  9. Lildal SK, Sørensen FB, Andreassen KH, Christiansen FE, Jung H, Pedersen MR, Osther PJS. Histopathological correlations to ureteral lesions visualized during ureteroscopy. World J Urol. 2017 Oct;35(10):1489-1496. doi: 10.1007/s00345-017-2035-3.
  10. Stern KL, Loftus CJ, Doizi S, Traxer O, Monga M. A Prospective Study Analyzing the Association Between High-grade Ureteral Access Sheath Injuries and the Formation of Ureteral Strictures. Urology. 2019 Jun;128:38-41. doi: 10.1016/j.urology.2019.02.032.
  11. Huang J, Zhao Z, AlSmadi JK, Liang X, Zhong F, Zeng T, Wu W, Deng T, Lai Y, Liu L, Zeng G, Wu W. Use of the ureteral access sheath during ureteroscopy: A systematic review and meta-analysis. PLoS One. 2018 Feb 28;13(2):e0193600. doi: 10.1371/journal.pone.0193600.
  12. Traxer O, Wendt-Nordahl G, Sodha H, Rassweiler J, Meretyk S, Tefekli A, et al. Differences in renal stone treatment and outcomes for patients treated either with or without the support of a ureteral access sheath: The Clinical Research Office of the Endourological Society Ureteroscopy Global Study. World J Urol. 2015 Dec;33(12):2137-44. doi: 10.1007/s00345-015-1582-8.
  13. Geraghty RM, Jones P, Somani BK. Worldwide Trends of Urinary Stone Disease Treatment Over the Last Two Decades: A Systematic Review. J Endourol. 2017 Jun;31(6):547-556. doi: 10.1089/end.2016.0895.
  14. De Coninck V, Somani B, Sener ET, Emiliani E, Corrales M, Juliebø-Jones P, et al. Ureteral Access Sheaths and Its Use in the Future: A Comprehensive Update Based on a Literature Review. J Clin Med. 2022 Aug 31;11(17):5128. doi: 10.3390/jcm11175128.
  15. Wong VK, Aminoltejari K, Almutairi K, Lange D, Chew BH. Controversies associated with ureteral access sheath placement during ureteroscopy. Investig Clin Urol. 2020 Sep;61(5):455-463. doi: 10.4111/icu.20200278.
  16. Zilberman DE, Lazarovich A, Winkler H, Kleinmann N. Practice patterns of ureteral access sheath during ureteroscopy for nephrolithiasis: a survey among endourologists worldwide. BMC Urol. 2019 Jul 4;19(1):58. doi: 10.1186/s12894-019-0489-x.
  17. Berquet G, Prunel P, Verhoest G, Mathieu R, Bensalah K. The use of a ureteral access sheath does not improve stone-free rate after ureteroscopy for upper urinary tract stones. World J Urol. 2014 Feb;32(1):229-32. doi: 10.1007/s00345-013-1181-5.
  18. Sari S, Cakici MC, Aykac A, Baran O, Selmi V, Karakoyunlu AN. Outcomes with ureteral access sheath in retrograde intrarenal surgery: a retrospective comparative analysis. Ann Saudi Med. 2020 Sep-Oct;40(5):382-388. doi: 10.5144/0256-4947.2020.382.
  19. Yitgin Y, Yitgin E, Verep S, Gasimov K, Tefik T, Karakose A. Is Access Sheath Essential for Safety and Effective Retrograde Intrarenal Stone Surgery? J Coll Physicians Surg Pak. 2021 Oct;31(10):1202-1206. doi: 10.29271/jcpsp.2021.10.1202.
  20. 20.Damar E, Senocak C, Ozbek R, Haberal HB, Sadioglu FE, Yordam M, Bozkurt OF. Does ureteral access sheath affect the outcomes of retrograde intrarenal surgery: a prospective study. Minim Invasive Ther Allied Technol. 2022 Jun;31(5):777-781. doi: 10.1080/13645706.2021.1941117.
  21. Lima A, Reeves T, Geraghty R, Pietropaolo A, Whitehurst L, Somani BK. Impact of ureteral access sheath on renal stone treatment: prospective comparative non-randomised outcomes over a 7-year period. World J Urol. 2020 May;38(5):1329-1333. doi: 10.1007/s00345-019-02878-5.
  22. Bozzini G, Bevilacqua L, Besana U, Calori A, Pastore A, Romero Otero J, et al. Ureteral access sheath-related injuries vs. post-operative infections. Is sheath insertion always needed? A prospective randomized study to understand the lights and shadows of this practice. Actas Urol Esp (Engl Ed). 2021 Jul 31:S0210-4806(21)00125-X. English, Spanish. doi: 10.1016/j.acuro.2020.11.010.
Volume 10, Issue 2


ureteral access sheath, flexible ureteroscopy

How to cite this article:

Petkova K, Petrov P, Petrova D, Gatsev O, Todorova V, Hristov K, Saltirov I. Impact of ureteral access sheath on outcomes of flexible ureteroscopy for renal stones. Journal of Endourology and Minimally Invasive Surgery (Bulgaria), 2022; 10(2): 43-48

Corresponding author:

Assoc. Prof. Kremena Petkova, MD, PhD

Department of Urology and Nephrology
Military Medical Academy of Sofia

3 “Georgi Sofiiski” blvd.
Sofia 1606, Bulgaria

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