Transcystoscopic ureteral dilatation and ureteroscopy.

With the ureterorenoscope it is now possible to perform procedures under direct vision that previously had to be undertaken blindly or with the aid of fluoroscopy. The most common use of the ureterorenoscope is for removal of ureteral calculi, particularly those that are in the distal or middle one third of the ureter. The technique of ureteral dilatation and ureteroscopy of the lower ureter via the cystoscope sheath is particularly useful when repeated passes of the ureteroscope are necessary This method is extremely helpful in clearing the multiple fragments that comprise a ureteral “steinstrasse” following extracorporeal shockwave lithotripsy, but it is also useful for managing single stones. The technique is suitable for males only and certain limitations exist, but when applicable, the cystoscope sheath provides rapid, repeated access to the ureteral orifice and protection for the urethra. Our technique involves initial cystourethroscopy with a 21-F panendoscope. After completely inspecting the urethra and bladder, the appropriate ureteral orifice is cannulated with a 0.038-inch torque wire which is advanced beyond the calculus into the renal pelvis under fluoroscopic control. With the ureteral orifice and guide wire in view, the position of the cystoscope sheath is noted on the fluoroscopic monitor for future reference, and the cystoscope sheath is stabilized, providing a “straight shot” from the urethra1 meatus to the ureteral orifice. The cystoscope and bridge are then removed from the sheath, leaving the guide wire protruding. The ureteral orifice is then dilated in a coaxial fashion with sequentially larger semirigid dilators or with a balloon dilator. It is our practice to dilate the orifice and the ureter to the leve1 of the calculus. The 21-F panendoscope readily admits a 14-F dilator (Fig. 1A). These dilators as wel1 as the balloon dilators are passed more easily through the straight cystoscope sheath than through the curvaceous urethra where some loss of force occurs at each bend. After dilatation is completed, the ll.5F ureterorenoscope is passed through the cystoscope sheath adjacent to the guide wire which is left in place as a safety wire (Fig. 1B). Care