Re: Kreshover et al.: Predictors for Negative Ureteroscopy in the Management of Upper Urinary Tract Stone Disease (Urology 2011;78:748-752)

b for upper ureteral stones with a high degree of clinical expertise. I do agree with the authors regarding the relative unsuitability of the male urinary tract for upper tract ureteroscopy. However, we have found that sometimes dilation of the intramural ureter can help, not only in the extraction of larger stone fragments, but also in patients with a rigid lower ureter. This is usually possible in the vast majority of young males, albeit a few patients will have nondilatable lower ureters. In patients with prominent adenoma, we usually proceed to direct ureteroscopy without the use of any cystoscopy sheath to facilitate the ascent of the scope to the upper ureter. However, we do not agree with the routine stenting of patients to avoid pneumatic fragmentation or multiple excursions of the ureteroscope because stenting overburdens patients both medically because they will have to undergo another procedure (no matter how simple it might be) and financially, especially in developing countries. We agree that these narrow ureteroscopes result in poorer vision owing to the decrease in water pressure. We have usually solved this by increasing the irrigant pressure using a blood pressure cuff or increasing further the height of the irrigant solution, when the lithoclast probe is in place. We also routinely place our patient in a steep Trendelenburg position to prevent upward calculus migration. Although we have not tried the contralateral tilt to direct the stones into the upper calix rather than the lower, it seems to be a very worthwhile idea to adopt. Not performing routine retrograde contrast studies is quite logical to not dislodge the stone. However, I would strongly insist on attempting to pass a floppy tip guidewire beyond the calculus and, if this fails, I would consider in that case performing a retrograde study or passing a guidewire under vision beside the stone. My rationale in that case would be that having a guidewire in the upper tract provides a safeguard to stenting and aborting the procedure in the case of any mishap. We believe that although the extractor-stone assembly increases the stone width, careful and gentle manipulation allows one to deliver the stone through the narrow terminal part of the ureter, avoiding the blindly directed pull on the Dormia basket. Finally, we strongly agree with the word of caution provided by the authors regarding the fact that one never knows with graduated ureteroscopes what is the exact site of tightness. We similarly stress that endoscopy does not require any degree of force and that the trick is in the smoothness of the procedure.