Entrapped Ureteral Access Sheath: An Unusual Problem

Flexible ureteroscopy is well-known and performed procedure by urologists, yet instrument related complications may suprise even experienced surgeons. In this study, we present a unique instrument related complication during flexible ureteroscopy. A 68 year old male patient with 1.9 cm left upper ureteral stone presented to us. With semi-rigid ureteroscope laser lithotripsy performed. Stone got retropulsed into lower pole of the kidney. The procedure was converted to retrograde intrarenal surgery. Within Porges-Coloplast Retrace® Ureteral Access Sheath 12 Fr and 35 cm (UAS) with Karl Storz Flex-X2 fiber-optic ureteroscope (fURS) stone fragmentation completed. After removal of fURS from the patient, UAS got tried to pull away but it got stuck into the patient. Hanging part of the UAS below the external meatus cut-off and the internal spiral part withdrew. But it didn’t come off. So pulling the residual piece of UAS from the orifice level tried with cystoscope and foreign body forceps. It didn’t work out and sheath got split to two pieces from the orifice level. After that another enterance to the bladder had performed with cystoscope and left orifice had incised. 8 mg dexamethasone had administerated to the patient and lidocaine including lubricant gel got injected inside and around the UAS. It didn’t come off. Decision made that ending the procedure after placing double-J stent, then after 3-4 weeks when the ureteral edema got regressed removal of the residual UAS. Four weeks later with cystoscope and foreing body forceps residual UAS got removed by two pieces. Ureteral edema can led entrapment UAS inside of the ureter. Most of the cases moderate traction and withdrawing the internal spiral part of UAS is enough to pull away. In cases that these solutions are insufficient, stenting and planning another endoscopic procedure after a few weeks may help avoiding unnecessary open surgery.