Operative Tricks

™ If the patient is placed in the Trendelenburg position (head lowered), mobilization of stone fragments into lower calices can be avoided because stone fragments will fall into upper calices, which are now the lowest point of the kidney.

™ Stones within the upper calices can be reached in some cases by semirigid URS, facilitating stone manipulation.

™ If direct insertion of a flexible ureteroscope is not possible, prior semirigid ureteroscopy 'optically' dilates orifice and ureter. This type of dilation is less traumatic than mechanical dilation and allows later flexible URS in most cases.

™ Lower caliceal stones are often easier to disintegrate after mobilization to the renal pelvis or an upper calyx. Baskets or a nitinol grasper can be helpful for stone mobilization.

™ If a calyx is not accessible with flexible URS, emptying of the renal collecting system with a syringe (use of a three-way switch on a working/irrigation channel) may facilitate the procedure.

™ If a stone basket sticks inside the ureter, the handle of the basket can be removed to get the scope out of the body (according to the user's guide of the basket manufacturer). Afterwards, the ureteroscope can be inserted again beside the basket wire. If disintegration of the fragments caught inside the basket does not relieve the basket, the wires can be cut carefully by a Ho:YAG laser. However, a safety wire should have been placed before and complete removal of all residual basket wires should be assured. A less risky but more time-consuming method is the application of SWL on the basket.

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