The Difficult Ureter: Stent and Come Back or Balloon Dilate and Proceed With Ureteroscopy? What Does the Evidence Say?

Abstract

ecent technical advancements mean flexible ureteroscopy is emerging as a serious competitor Rto percutaneous approaches even for larger intrarenal calculi. Retrograde intrarenal surgery procedures are likely to increase for the treatment of not only calculi but also other therapeutic upper tract procedures. Primary access up the ureter is not always possible with a failure rate of 8%-10%. This means that in 1 of every 10 procedures carried out, it is not possible to traverse the ureteric orifice or the access sheath or ureteroscope cannot be passed up with ease. What happens next is a relatively controversial area. A significant number would place a double-J stent to allow passive ureteric dilatation and reschedule the definitive procedure a few weeks later. Others would actively dilate the impassable segment of the ureter with semirigid dilators such as the 1-step Nottingham dilator or balloon-dilate the ureter and proceed with primary ureteroscopy. Proponents of the more conservative approach of stenting argue that balloon dilatation of the ureter, especially, carries significant risk of ureteric injury as a result of mechanical force or from ischemic damage and subsequent stricture formation later. We examine what evidence, if any, exists to support the theory that actively dilating the ureter especially with a balloon carries a significant risk and present the advantages and benefits of both approaches so that endourologists are able to make an informed decision. Evidence against balloon dilatation of the ureter to enable primary ureteroscopy in the published data is lacking. One recent study commented that balloon dilatation is associated with increased ureteral perforation with reference to the work by Pardalidis et al. They did indeed note 4 cases of perforation in their balloon dilatation group, but these were in fact attributed to the electrohydraulic lithotripsy probe used as opposed to the balloon dilatation.