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How to pull impacted ureteral sheath?

Situation: At the end of RIRS procedure, the 12/14Fr ureteral access sheath was impacted in the ureter. What will you do in this kind of situation?

If we pull the sheath without caution, we may find the disconnected ureter around the sheath!!

Solution: I experienced impacted sheath once, among 600+ RIRS cases that I have performed. And that time, I did not have an appropriate surgical tip.

So, first I tried to insert a terumo guidewire into ureteral lumen. Although it was not successful, but in my opinion, it was worth to try.

Next step I took was to push the medial portion of the left ureterovesical junction using a ureteroscope and pull the access sheath with prudence.

By doing that, I was able to draw the sheath out of the body. Even though, there was mild degree of mucosal damage in the medial portion of the ureterovesical junction but the ureter was SAFE!!

Do you have any other option to suggest?

I would very much appreciated for your valuable tips.

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