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Grade 4 ureter injury with ureteral access sheath

August 18, 2019

I underwent my first case of full-thickness grade 4 ureteral injury with the use of ureteral access sheath (UAS) among my almost 2,000 cases of RIRS.




I fully understand that we may come along with this terrible situation because I am working for a teaching hospital with my trainees but we have to try our best to prevent this. We have to keep in mind some basic principles how to use UAS safely for minimizing UAS-related complications.


- Use a small diameter UAS (11/13Fr or smaller would be desirable).

- Pre-stenting would be recommended in some instances.

- Locate the level of target and use the shorter length of UAS. 

- Don't insert UAS THROUGH the ureter stone. 

- Check first whether your guidewire is really inserted into the renal pelvis or in the ureter above the ureter stone


And I try to prepare plan B, that means immediate conversion into antegrade approach with patients lied in modified supine position. We can resolve the problem with antegrade approach with flexible scope or mini-nephroscope to reach the target of ureteral stone. 

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