Review Article Does ureteral access sheath have an impact on ureteral injury? Downloaded from http://journals.lww.com/urol by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW Mehmet Kazim Asutay1,2, Marco Lattarulo2,3, Despoina Liourdi2,4, Abdulrahman Mohamed Al-Aown5, Konstantinos Pagonis2, Noor Nedal2,6, Amelia Pietropaolo7,8, Esteban Emiliani8,9, Evangelos Liatsikos2, Panagiotis Kallidonis2,8 nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/26/2023 1 Department of Urology, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey, 2Department of Urology, University of Patras, 4 Department of Internal Medicine, Ag. Andreas General Hospital, Patras, Greece, 3Department of Urology, ASST Spedali Civili di Brescia, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy, 5Department of Urology, Armed Forces Hospital Southern Region, Khamis Mushait, 6Department of Urology, Umm Al‑Qura University, Makkah, Kingdom of Saudi Arabia, 7Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom, 8Young Academic Urologists-Endourology and Lithiasis Working Group, European Association of Urology, Arnhem, The Netherlands, 9Department of Urology, Fundacio Puigvert, Barcelona, Catalunya, Spain Abstract Objective: To present a well-organized review about ureteral access sheath impact on ureteral injury. Materials and Methods: Systemic search on literature was done. Total of 3766 studies observed by two urologists and results were unified. A Prisma diagram was used for eliminating irrelevant studies and at the end of elimination process 28 studies were found eligible for this review. Results: Not only clinical studies but also comparative experimental animal studies show that there is no significant data to claim that ureteral access sheath insertion causes more ureteral injury. Pre-stented patients were found to be at lower risk for ureteral injury. Risk of progression to ureteral injury seems to be low even if ureteral injury occurs with insertion of ureteral access sheath. Conclusion: Summary of studies’ results indicate that use of ureteral access sheath doesn’t increase ureteral injury. This review may help understanding safety profile of ureteral access sheath on evidence-based level. There is not enough data to make a statement that ureteral access sheath prevents ureteral injury. Keywords: Retrograde intrarenal surgery, ureteral access sheath, ureteral injury, ureteral stricture, ureteroscopy Address for correspondence: Dr. Abdulrahman Al‑Aown, Department of Urology, Armed Forces Hospital Southern Region, Khamis Mushait, Kingdom of Saudi Arabia. E‑mail: aown22@hotmail.com Received: 09.10.2020, Accepted: 19.07.2021, Published: 20.01.2022. INTRODUCTION intrarenal surgery (RIRS) which has been widely adopted in the endourological armamentarium. There is a controversy Ureteroscopy is a widely used surgical procedure for on literature about whether to use or not to routinely use minimally invasive treatment of upper urinary tract ureteral access sheaths (UASs) during the performance of stones and urothelial tumors. The introduction of flexible RIRS. UASs are useful for urologic procedures that need ureteroscopes allowed for the development of retrograde This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to Access this article online remix, tweak, and build upon the work non‑commercially, as long as appropriate credit Quick Response Code: is given and the new creations are licensed under the identical terms. Website: www.urologyannals.com For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com DOI: How to cite this article: Asutay MK, Lattarulo M, Liourdi D, Al‑Aown A, 10.4103/UA.UA_163_20 Pagonis K, Nedal N, et al. Does ureteral access sheath have an impact on ureteral injury? Urol Ann 2022;14:1-7. © 2022 Urology Annals | Published by Wolters Kluwer - Medknow 1 Asutay, et al.: Ureteral access sheath multiple ureteroscope entries. Moreover, the presence of the Experimental animal studies UAS may improve irrigation conditions resulting in improved UASs have been proposed to facilitate flexible ureteroscopy intraoperative visualization while keeping intrarenal pressure in the treatment of urolithiasis. UASs allow multiple pass and irrigation fluid temperature within safety limits. The use of ureteroscope, reduce operative times, and improve of UAS may improve operative times and stone‑free rates. visualization. Moreover, the use of UAS decreases Nonetheless, UASs may also increase the complication intrarenal pressure levels which could be related to renal Downloaded from http://journals.lww.com/urol by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW rates by injuring directly the organ or by inducing ureteral damage.[3] On the other hand, any ureteral injury related to ischemia. the use of a UAS may be related to chronic effects. The objective of this review is to present an updated In the current systematic review, 3 of the experimental nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/26/2023 evidence on the use of UASs and to clarify any possible animal studies were investigating the changes that UAS relation with ureteral wall injuries and related complications insertion induces on the cellular microenvironment of such as ureteral stricture. the ureter [Table 1]. Two studies showed that the insertion of UAS increased the fibroblastic precursors.[4,5] The one MATERIALS AND METHODS study was performed in a rabbit model, either 2 or 3 Fr ureteral catheter was introduced to ureter for 1–4 h. A systematic review of the literature was conducted The fibrotic activity in the ureters was investigated after according to the requirements of the PRISMA statement. a month.[4] Seventy‑two ureter units were investigated. [1,2] Longer catheterization time and increased diameter of catheter were found to be associated with increased fibrotic The database search (January 2019) included PubMed, activity. The other study included 22 pigs, a 13–15 Fr SCOPUS, Cochrane, Embase, and Web of Science. There UAS was inserted either for 2 min or for 2 h. The ureteral was no restriction for language and year of publication. COX‑2 and TNF‑alpha levels were analyzed.[5] Higher Manual search was also acceptable. The search keywords preinflammatory mediators were found to be related to the included ureter, ureteral, ureteric, ureteros* (ureter in Greek presence of the UAS and longer indwelling periods (2 h). language), and sheath. On the contrary, a study with porcine model showed that Eligibility criteria for the articles to be included in despite the presence of inflammation on early postoperative this review were prospective studies (randomized or period, there was no chronic histological effect.[6] 9.5/11.5 quasi‑randomized), nonrandomized prospective, or Fr UAS was inserted to pig ureters and left for variable time retrospective studies comparing the clinical outcome with periods ranging from 2 min to 2 h. Histological evaluation the use of UAS and without its use in ureteroscopy and was performed in specimens removed immediately, experimental studies evaluating parameters related to the 1 week, and 2 weeks after the intervention. No chronic use of UAS for ureteroscopy. Primary endpoint was ureteral inflammation was observed. Sings of acute inflammation wall injury related to the use of UASs and their prevention. were evident in immediately harvested tissue samples but not in the specimens at 2 weeks. Two independent reviewers eliminated irrelevant studies according to PRISMA recommendations. Any discrepancies Ureteral ischemia due to the use of UAS was investigated were solved with the aid of the senior author. The reviewers in a swine animal model study.[7] Ureteral blood flow extracted any relative information from the eligible articles was measured in ureters with indwelling UASs with a according to a standardized pro forma. size of 10/12Fr, 12/14 Fr, and 14/16 Fr and a control group (non‑‑UAS). There was more than 50% decrease in RESULTS baseline ureteral blood flow when larger UASs were used. There was no evidence of histologic damage at 72 h, and Three thousand seven hundred and sixty‑six studies were there were no ureteral injuries. Nonetheless, there was no identified with the literature search resulting in 3121 items evidence on the chronic effects of ureteral blood flow after the exclusion of duplicates. PRISMA diagram is decrease in the ureteral anatomy, histology, or physiology. presented in Figure 1. A total number of 28 studies were In another study, the insertion forces of a UAS on ex vivo eligible for the current review. Six of these studies were porcine ureter were measured with and without safety animal experiments. There were 22 clinical studies, 2 for guidewire.[8] The results showed that the use of a safety pediatric, and 20 for adult patients. Thirteen clinical studies guidewire increased the insertion forces but there was no were prospective in nature. significant difference in rates of ureteral injury. 2 Urology Annals | Volume 14 | Issue 1 | January-March 2022 Asutay, et al.: Ureteral access sheath Records identified through Additional records identified Identification database searching through other sources (n = 3766) (n = 0) Downloaded from http://journals.lww.com/urol by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW Records after duplicates removed (n = 3121) Screening nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/26/2023 Records excluded Irrelevant subject: 79 Records screened Case report: 5 (n = 120) No comparative: 3 Review: 3 Full-text articles assessed Full-text articles excluded, for eligibility with reasons (n = 30) Eligibility Irrelevant Topic: 2 Studies included in qualitative synthesis (n = 28) Studies included in Included quantitative synthesis (meta-analysis) (n = N.A. ) Figure 1: PRISMA Diagram used in literature review An interesting perspective was evaluated by Lildal et al. Pardalidis et al. in a prospective randomized study in a prospective comparative blinded study in porcine compared the use of a UAS or ureteral balloon dilatation model.[9] The authors investigated if the use of topical for the facilitation of the access to distal ureteral stones.[13] beta‑blockers (isoproterenol) could decrease ureteral injuries 98 patients were totally included. Ureteral perforation related to the use of UAS.[10] Isoproterenol solution was was seen in 8% of patients after balloon dilatation while compared to saline solution (control). The isoproterenol there were no ureteral perforations in the case of the solution ureteral injury rates were less than those of the UAS group (P < 0.05). Complication rates were lower saline group, but the statistical analysis was inconclusive. with the use of UAS, and the operative time was shorter in comparison to the balloon dilation (45.5 vs. 58.5 min). Clinical studies about stricture formation and grading Strictures were not encountered in any of the group after systems 1 year of follow‑up. Sixteen out of 28 studies included in the current review provided information on the safety of UAS [Table 2]. Most Data from 359 consecutive patients, who had RIRS with of the studies used the ureteral injury scale proposed by the use of a UAS, were retrospectively analyzed by Traxer Traxer et al. in an attempt to classify the level of ureteral et al., and new classification for severity of ureteral injury was injury.[11] A retrospective cohort with 165 patients compared proposed (the Traxer ureteral injury classification).[11,14] Among the efficacy and safety of the 9.5/11 Fr to the 12/14 Fr the 359 patients, 167 (46.5%) had a ureteral injury. Forty UAS. None of the patients were previously stented.[12] eight (13.3%) of these patients had severe ureteral injuries Mean follow‑up time was 115 days. None of the patients including not only the mucosa but also the muscle layers or developed a ureteral stricture. Even the use of wider UASs even the serosa. The risk of ureteral injury for patients without was not related to the formation of strictures. previous stent placement was found to be 7 times more than Urology Annals | Volume 14 | Issue 1 | January-March 2022 3 Asutay, et al.: Ureteral access sheath Table 1: Animal studies about the safety of ureteral access sheaths Study type Comparison Result P Lallas et al. In vivo porcine Ureteral blood flow for different size of UAS No significant difference >0.05 Graversen et al. Ex vivo porcine Injury rates of UAS with and without safety wire No significant difference 1 Gucuk et al. In vivo rabbit FGF‑2 levels on UAS model Higher FGF‑2 levels with larger catheter <0.05 Lildal et al. In vivo porcine COX‑2 and TNF‑a levels and histologic analysis after Higher COX‑2 and TNF‑a with larger UAS <0.05 UAS insertion and with longer duration Ozsoy et al. In vivo porcine Early and late histologic changes after insertion of UAS Early acute inflammation, no late chronic NA Downloaded from http://journals.lww.com/urol by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW change Lildal et al. In vivo porcine Effect of beta‑agonists on UAS insertion force Easier to insert UAS with beta agonist 0.8 irrigation solution UAS: Ureteral access sheaths, NA: Not applicable, FGF‑2: Fibroblast growth factor‑2, TNF‑a: Tumor necrosis factor‑alpha, COX: Cyclooxygenase‑2 nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/26/2023 Table 2: Studies compare ureteral access sheath injury/complication rates Study type Comparison Result P Kourambas et al. Retrospective Complications with or without ureteral access sheath on No significant difference >0.05 RIRS patients Barboour et al. Retrospective Hydronephrosis on follow‑up with or without UAS RIRS No significant difference >0.05 Bas et al. Retrospective Complications after RIRS for proximal ureteral and renal No significant difference >0.05 stones with or without UAS Lildal et al. Retrospective Comparison of ureteral lesions with 10/12Fr UAS or larger More superficial ureteral injury lesions <0.05 size UAS or without UAS seen with UAS Tefik et al. Cohort‑prospective UAS injuries; presented patients versus others Less UAS‑related injury in prestented NA patients Traxer et al. Prospective Factors that have an impact on UAS Prestented patients have a lower risk for <0.0001 UAS injury Stoller et al. Retrospective Stricture formation with different sizes of UAS on RIRS No difference NA Tracy et al. Retrospective Comparison of ureteral lesions with 10/12Fr, 12/14Fr, and No significant difference 0.87 14/16 Fr UAS or without UAS Parpadilis et al. Retrospective UAS compared to balloon dilatation for distal ureteral Significant lower ureteral perforation with <0.05 stones UAS Gorin et al. Retrospective UAS for endoscopic treatment of upper urinary urothelial No complication rates NA tumors Stern et al. Prospective Stricture rates on intermediate term follow‑up after RIRS Low probability for stricture progression NA with UAS Multescu et al. Prospective RIRS for renal stones with or without UAS Similar complication rates 0.44 Cooper et.al. Retrospective Impact on UAS on postoperative hydronephrosis No significant difference >0.05 Geraghty et al. Prospective RIRS for renal stones with UAS versus without UAS. No significant difference 0.82 Complication rates Loftus et al. Prospective Two different types of UAS, access rates, and injury rates No difference between two UAS 0.42 RIRS: Retrograde intrarenal surgery, UAS: Ureteral access sheaths, NA: Not applicable Table 3: Studies about insertion of ureteral access sheaths with or after ureteroscopy Study type Complication rates P value for comparison of ureteral injury Karabulut et al. Retrospective No significant difference of complications under direct vision 0.079 Boulalas et al. Prospective Significant lower injury rates with UAS when preoperative <0.05 assessment of ureter is done with ureteroscopy Hu et al. Retrospective No injuries NA Sonmez et al. Retrospective Significantly less injuries under visual insertion of UAS 0.032 UAS: Ureteral access sheaths, NA: Not applicable prestented patients. Male patients and older patients had time after surgery was ranged between 2 and 3 months and higher rates of high‑grade injuries. A comparison of injuries did not reveal ureteral strictures. Another interesting point according to UAS size was not reported. Although ureteral of the study was that there is no significant impact of UAS lesions after insertion of UAS were not rare, prestenting was use on complication rates (P = 0.82). a very important factor for decreasing the injury rates. A recent prospective study investigated the possible In a prospective study, data from patients who underwent correlation of high‑grade ureteral injuries after UAS RIRS surgery with or without the use of UAS was insertion to the formation of a stricture.[16] High‑grade compared.[15] All cases had stones >2 cm. A UAS was used injuries after RIRS surgery were observed in 56 (12.5%) in 58.8% of cases. The UAS was not inserted if surgeon out of 446 patients. Median follow‑up was 35.8 months. defined ureter as “too narrow to insert a UAS.” Follow‑up Strictures were observed in only 3 (5.6%) cases. The authors 4 Urology Annals | Volume 14 | Issue 1 | January-March 2022 Asutay, et al.: Ureteral access sheath concluded that the severity of the ureteral injury was not A retrospective study investigated 1332 URS cases at related to ureteral stricture progression. Nonetheless, the 8 weeks after the procedure.[21] Data from 1060 patients who short duration of postoperative double‑J stent indwelling returned for routine upper tract imaging were evaluated. time (median: 16 days, 1–48 days) was correlated to Postoperative hydronephrosis was noted on 12% of the formation of a stricture but it remained statistically patients. Low body mass index (P = 0.0016), greater stone insignificant (P = 0.11). size (P = 0.0003), increased operative time (P < 0.0001), Downloaded from http://journals.lww.com/urol by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW preoperative ureteral stent placement (P = 0.0299), and In a retrospective comparative study, 126 patients and postoperative ureteral stent placement (P = 0.0031) were 111 patients underwent RIRS with the use of 10/12Fr factors predicting for postoperative hydronephrosis. UAS and without any UAS, respectively.[17] There was no nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/26/2023 significant difference in the rates of ureteral wall injury Considering the above evidence, a brief conclusion among the groups. Only one patient had Grade 3 (0.8%) regarding the safety of UAS could be made. It seems ureteral wall injury related to UAS and there was no Grade 4 that the use of UASs did not have a significant impact injury. Only one patient had ureterovesical stricture after a on the development of postoperative ureteral strictures. follow‑up period of 18 months. Moreover, higher grades The routine use of a UAS during RIRS seems to be safe. of ureteral injury were more common in group that UAS Postoperative follow‑up with ultrasound is important to was not used. Septic complications were observed in detect cases with ureteral stricture formation. 28.7% and 68.3% of the cases with and without the use Technique for optimal insertion of ureteral access sheath of a UAS (P = 0.034). The authors advocated that the use Two of the clinical studies of the current review compared of UAS was not only safe but also provided better view the insertion of the UAS fluoroscopically over a safety with less septic complications probably due to the lower wire or under direct vision with the use of a semirigid internal pressure. ureteroscope.[22,23] Specifically, Hu et al. presented an observational study including 81 upper ureteral stone In a prospective randomized study, 47 patients who did cases.[22] The UAS was inserted under direct vision with not need ureteral dilatation were enrolled. 23 (49%) of a 6F semirigid ureteroscope. Stone‑free rate was 100% the patients underwent ureteroscopy with the use of UAS and no major complications were seen over a 2‑month and 24 (51%) of cases were treated without a UAS and follow‑up period. In another study, 84 RIRS cases were with dilation of the ureter with a balloon.[18] There was prospectively investigated. The patients were divided into no significant difference between groups in terms of two groups: in the first group, a UAS was inserted over a symptoms, complication rates, or stone‑free status in the safety guidewire whereas in the second group, a UAS was UAS and non‑UAS groups. inserted under direct vision (outer part of UAS was worn on semirigid ureteroscope).[23] Follow‑up time was 1 month. Operative time was shorter, and costs were lower in UAS Fluoroscopy screening time, UAS placement time, and group in comparison to the balloon dilation group. There operation time were significantly shorter in the second were significantly more postoperative symptoms in patients group. Complications were classified according to Traxer to whom ureteral dilation was done by balloon dilatation ureteral injury classification system. A total of 16.6% of rather than using UAS. patients had Grades 1 and 2 ureteral injury. There were no major complications. Follow‑up period ranged between 2 Two retrospective studies investigated the incidence of and 3 months. The complication rate was found higher in stricture formation after UAS insertion and provided similar over‑the‑wire technique group, but the results were not results. Stricture rates with the use of UAS were between statistically significant (P = 0.079). The only significant 0.9% and 1.4%. Considering that the stricture rate of the advantage of the direct vision insertion of UAS was the cases not managed by the use of a UAS was not higher shorter operative and fluoroscopy times during insertion than the cases without any UAS use, a UAS during RIRS of UAS (58.7 and 51.2 min, 11.7 and 0 min, respectively) should not be considered as a contributing factor for in comparison to the over‑the‑wire approach. Insertion ureteral stricture formation.[19,20] On the contrary, another of the UAS under direct vision of semirigid ureteroscope retrospective study showed higher ureteral lesion rates when was studied in another retrospective study.[24] There were a 10/12Fr UAS was used in comparison to cases that a UAS 19 patients on direct vision UAS group and 22 patients was not used.[9] Odds ratio for the ureteral lesion after the in classic fluoroscopic insertion group. Results show that use of UAS was 1.84, but after adjusting age and gender data, insertion of UAS under direct vision had significantly less the comparative outcomes were statistically insignificant. ureteral injury complications and less fluoroscopy time. Urology Annals | Volume 14 | Issue 1 | January-March 2022 5 Asutay, et al.: Ureteral access sheath To provide clues for the optimal safety of UASs, Boulalas 10/12 Fr UAS was used on 8 (11.2%), and 14/16 Fr UAS et al. compared two groups of patients undergoing RIRS.[25] was used on 7 (9.8%). Only one patient had a stricture at the Hundred consecutive patients were included in the study, ureteropelvic junction. This complication was considered 77% of patients had “compliant ureter” which represented as unrelated to the UAS since the stricture site was above ureters eligible for 12/14 Fr UAS insertion. A semirigid the level of UAS insertion. Although the comparison of ureteroscopy was done before the UAS insertion to different sizes of UASs can provide clues on the relation Downloaded from http://journals.lww.com/urol by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW inspect the ureter and estimate if the lumen of the ureter of UAS to ureteral injury, there is not a control group and was compatible with 14 Fr or greater in diameter UAS. If the ureteral injury rates after the surgery were not reported. ureter did not seem compliant, a smaller diameter UAS or non‑UAS at all was used. This approach is used in all the A retrospective study investigated 257 RIRS patients who were treated with either a 12/14 Fr UAS or a 14/16 Fr UAS nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/26/2023 patients, and the complication rates were 10%. Most of them were Grade 1 ureteral injuries. Ureteral complications or without any UAS.[29] The study attempted to evaluate a such as stricture formation were significantly lower if the possible correlation of a larger UAS size to higher rates patient had a complaint of ureter. of ureteral injury. There was no significant difference in the ureteral injury between any of the groups. Stone Lokus et al. performed ureteroscopy by using two different burden treated per minute was higher in 14/16 Fr group types of UAS in a randomized trial including 95 patients; in comparison to the other groups and it was the only Cook Flexor or Boston Scientific Navigator both with statistically significant parameter. a diameter of 12/14 Fr were used.[26] Ureteroscopy was Treatment of upper urinary tract tumors done for the treatment of urinary stones. Thirty percent Gorin et al. investigated the safety profile of UAS in the of the patients had stones located in the kidney, 63% treatment of  upper tract urothelial carcinomas (UTUC).[30] in the ureter, and 7% of patients had both ureteral and RIRS with the use of a UAS for the diagnosis and treatment kidney stones. There was no difference between two of upper urinary tract tumors was performed in 64 patients. different types of UAS in terms of ureteral injury rates. UAS was used if there were no previous strictures in Large stone burden, male gender, longer time of sheath semirigid ureteroscopy. Brand of the UAS was mentioned insertion, and when the surgeon felt resistance to insert but the size of UAS and follow‑up periods were not clearly UAS were associated with high‑grade (Grade 2 or 3) ureteral mentioned. No strictures were reported during the follow‑up. injury (P = 0.018). Grade 0 (no injury) and Grade 1 injuries The investigators concluded that the use of UAS in UTUC were seen on 76.2% of patients compared to 23.8% for cases was safe and associated with low complication rates. high‑grade (Grades 2 and 3) injuries. Pediatric population Considering the above studies, it is unclear that is the Berreqni et al. performed 16 RIRS cases on 13 pediatric optimal method for the insertion of UASs in terms of patients who had a bodyweight <20 kg. All patients were significant differences in ureteral injury rates [Table 3]. stented 2 weeks before surgery.[31] 9.5/11.5 Fr size UAS was used in all cases. During the follow‑up period which Impact of insertion force extended up to a year, ureteral strictures or any chronic On a small group of patients (n = 7), the magnitude of complication implicating ureteral wall injury was not the insertion forces of UAS with different diameters observed. The authors concluded that RIRS with UAS was measured.[27] Treated stones had a maximal diameter insertion seemed to be a safe even for preschool children. between 10 and 24 mm. Stones were located either at renal Anbarasan et al. reported the results of RIRS in 21 pediatric calyx or ureteropelvic junction. Stricture formation was patients (school age, <16 years of age) in a retrospective followed up by urinary ultrasound imaging and further study. Mean follow‑up of patients was 26 months.[32] investigated if there was hydronephrosis. Although the Cases treated with the use of 9.5F UAS were not related follow‑up period was not clearly mentioned, there was to long‑term complications. no stricture formation in any of the patients. The authors concluded that the magnitude of the needed force to insert CONCLUSION the UAS was lower when patients were prestented. UASs cannot be directly related to ureteral injury according Impact of the size of ureteral access sheath to the current evidence. Prestented patients seem to have a A retrospective study by Stoller et al. classified ureteral lower risk for ureteral injuries; and even if ureteral injuries injuries according to UAS size.[28] 71 cases of RIRS were occur, the probability of progression to chronic ureteral included. A 12/14 Fr UAS was used on 56 (78.9%) cases, a stricture seems to below. 6 Urology Annals | Volume 14 | Issue 1 | January-March 2022 Asutay, et al.: Ureteral access sheath Financial support and sponsorship without the use of ureteral access sheaths: Results from a university hospital with a review of literature. Scand J Urol 2016;50:216-9. Nil. 16. Stern KL, Loftus CJ, Doizi S, Traxer O, Monga M. A prospective study analyzing the association between high-grade ureteral access sheath Conflicts of interest injuries and the formation of ureteral strictures. Urology 2019. 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Lallas CD, Auge BK, Raj GV, Santa-Cruz R, Madden JF, Preminger 25. Boulalas I, De Dominicis M, Defidio L. Semirigid ureteroscopy prior GM. Laser Doppler flowmetric determination of ureteral blood retrograde intrarenal surgery (RIRS) helps to select the right ureteral flow after ureteral access sheath placement. Journal of Endourology access sheath. Arch Ital Urol Androl 2018;90:20-4. 2002;16:583-90. 26. Loftus CJ, Ganesan V, Traxer O, Schold JD, Noble M, Sivalingam S, 8. Graversen JA, Valderrama OM, Korets R, Mues AC, Landman J, Badani et al. Ureteral wall injury with ureteral access sheaths: A randomized KK, et al. The effect of extralumenal safety wires on ureteral injury prospective trial. J Endourol 2020;34.9:932-936. and insertion force of ureteral access sheaths: Evaluation using an ex 27. Tefik T, Buttice S, Somani B, Erdem S, Oktar T, Ozcan F, et al. Impact vivo porcine model. Urology 2012;79:1011-4. of ureteral access sheath force of insertion on ureteral trauma: In vivo 9. Lildal SK, Andreassen KH, Jung H, Pedersen MR, Osther PJS. preliminary study with 7 patients. Ulus Travma Acil Cerrahi Derg Evaluation of ureteral lesions in ureterorenoscopy: impact of access 2018;24:514-20. sheath use. Scand J Urol 2018;52:157-61. 28. Stoller ML, Meng MV, Delvecchio FC, Preminger GM. Assessment 10. Lildal SK, Andreassen KH, Christiansen FE, Jung H, Pedersen MR, of stricture formation with the ureteral access sheath. Urology Osther PJS. Pharmacological Relaxation of the Ureter When Using 2003;61:522. Ureteral Access Sheaths during Ureterorenoscopy: A Randomized 29. Tracy CR, Ghareeb GM, Paul CJ, Brooks NA. Increasing the size of Feasibility Study in a Porcine Model. Advances in Urology 2016;2016. ureteral access sheath during retrograde intrarenal surgery improves 11. Traxer O, Thomas A. Prospective evaluation and classification of surgical efficiency without increasing complications. World J Urol ureteral wall injuries resulting from insertion of a ureteral access sheath 2018;36:971-8. during retrograde intrarenal surgery. J Urol 2013;189:580-4. 30. Gorin MA, Santos Cortes JA, Kyle CC, Carey RI, Bird VG. Initial 12. Shvero A, Herzberg H, Zilberman D, Mor Y, Winkler H, Kleinmann clinical experience with use of ureteral access sheaths in the N. Is it safe to use a ureteral access sheath in an unstented ureter? BMC diagnosis and treatment of upper tract urothelial carcinoma. Urology Urol 2019;19:80. 2011;78:523-7. 13. Pardalidis NP, Papatsoris AG, Kapotis CG, Kosmaoglou EV. Treatment 31. Berrettini A, Boeri L, Montanari E, Mogiatti M, Acquati P, De Lorenzis of impacted lower third ureteral stones with the use of the ureteral E, et al. Retrograde intrarenal surgery using ureteral access sheaths is a access sheath. Urological Research 2006;34:211-4. safe and effective treatment for renal stones in children weighing <20 14. De Coninck V, Keller EX, Rodriguez-Monsalve M, Audouin M, Doizi kg. Journal of Pediatric Urology 2018;14:59.e1-.e6. S, Traxer O. Systematic review of ureteral access sheaths: facts and 32. Anbarasan R, Griffin SJ, Somani BK. Outcomes and Long-Term myths. BJU Int 2018;122:959-69. Follow-Up with the Use of Ureteral Access Sheath for Pediatric 15. Geraghty RM, Ishii H, Somani BK. Outcomes of flexible ureteroscopy Ureteroscopy and Stone Treatment: Results from a Tertiary and laser fragmentation for treatment of large renal stones with and Endourology Center. J Endourol 2019;33:79-83. Urology Annals | Volume 14 | Issue 1 | January-March 2022 7