Ureteral access strategies: pro-access sheath.

Routine use of the ureteral access sheath during flexible ureteroscopic procedures provides consistent, reliable, and unencumbered access to the upper tracts. The ureteral access sheath can be reliably and easily deployed if used properly and requires no special training. As such, it can be easily adopted into current urologic practice. Not only does the access sheath facilitate rapid, repeated, and atraumatic access to the upper tracts, but it also avoids back-loading over a superstiff guidewire, which may incur costly damage to the ureteroscope. The access sheath reduces overall costs and decreases operative times. Furthermore, application of a ureteral access sheath reduces the frustration associated with complex and some routine ureteroscopic procedures by optimizing irrigant flow to improve the surgeon's endoscopic vision while minimizing the intrarenal pressures that the kidney must tolerate. There is no evidence that the access sheath results in clinically significant ureteral ischemia, and extensive clinical use of the access sheath for long procedures has not resulted in increased stricture formation. Finally, the ureteral access sheath is useful for other procedures, such as PCNL, by improving visualization and minimizing the requirement for multiple percutaneous access sites. Winston Churchill said it best: "Give us the tools and we will finish the job." Industry has provided urologists with the tools in the form of advanced flexible ureteroscopes, the holmium laser, nitinol baskets, and the ureteral access sheath. Now it is up to urologists to finish the job.