Does the Ureteral Access Sheath Reduce Infections in Previously Drained Sepsis Patients? UAS and Infection Rates Post Sepsis-Drainage

Does the Ureteral Access Sheath Reduce Infections in Previously Drained Sepsis Patients? 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UAS and Infection Rates Post Sepsis-Drainage Renato I. Navarro C., Lucas Dueñas, Nicolás Moreno, Enzo Castiglioni, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6900220/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Nov, 2025 Read the published version in World Journal of Urology → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Flexible ureteroscopy is the main treatment in upper tract urolithiasis. In cases of urinary tract infection associated to ureterolithiasis, drainage is required. Different authors prefer using a ureteral access sheath (UAS) to reduce complications. Our objective is to analyze the role of UAS in patients undergoing flexible ureteroscopy previously drained endoscopically for urosepsis. Methods Retrospective single-center study. We reviewed patients with urolithiasis associated with urosepsis requiring endoscopic drainage between 2017-2024. Only patients undergoing flexible ureteroscopy as final treatment were selected. We compared those using a UAS versus those who did not. Statistical analysis used Chi-square and Mann-Whitney tests. Results 77 patients met the inclusion criteria. The average age was 59 years, and the average stone size was 8.8 mm. UAS was used in 59.7% of patients. There were no differences in age, gender, stone size, stone location, comorbidities, and fever incidence on ER admission. We only report differences in previous ipsilateral ureteroscopy, with a higher incidence in the UAS group. In the UAS group, there were 13% complications at 3 months (Clavien Dindo>II), all infectious. In patients without UAS, a 12.9% complication rate was recorded. Only 1 patients had an infectious complication (non-febrile), and the rest were associated with pain due to residual stone. Regarding the percentage of SFR, there was no difference and there was no difference in the use of postoperative JJ-stent. Conclusions In our series, UAS doesn’t show a benefit in the rate of post-operative infections, though it could have a role in post-operative mechanical complications. sepsis ureter calculi ureteroscopy urinary catheterization Urinary Tract Infection INTRODUCTION Urosepsis, a urinary tract infection causing systemic inflammation and bacteremia, accounts for 30% of sepsis cases with 20–40% mortality, often due to obstructive urolithiasis ( 1 – 3 ). Initial management requires urinary drainage and antibiotics ( 4 – 6 ), followed by definitive stone treatment. For renal/upper ureteral stones < 2cm, flexible ureteroscopy is preferred due to lower morbidity, shorter hospitalization, and higher stone-free rates (SFR) ( 7 , 8 ). The ureteral access sheath (UAS), introduced in 1974 ( 10 ), facilitates ureteroscope passage, improving irrigation flow, reducing intrarenal pressure, and shortening surgery time ( 9 , 11 ). While UAS may protect the ureter and enhance visualization ( 9 , 11 ), its universal use remains debated. The use of this instrument has become so widespread that, according to a recent global survey, 45.83% of endourologists frequently utilize UAS for the management of ureteral stones, and 75.71% do so for renal stones ( 12 ). Nevertheless, it is not without complications; some reports have linked its use to ureteral injury in nearly half of the patients, although this risk may be reduced by the prior placement of a JJ stent, as noted by the authors ( 13 ) To our knowledge, no studies have compared sheath use in flexible ureteroscopy for patients with infected obstructing stones initially managed by stenting. Given the lack of direct evidence in this clinical scenario, this study evaluates UAS outcomes in this specific population. MATERIAL AND METHODS After approval by the ethics committee, a retrospective study was conducted at UC-Christus Clinic Hospital in Chile, reviewing all patients admitted between 2017 and 2024 with a diagnosis of urolithiasis complicated by urosepsis who required endoscopic drainage and subsequently underwent definitive stone treatment at our center. The analysis focused specifically on patients who underwent flexible ureteroscopy for final stone clearance. The study included only emergency department admissions meeting these criteria: obstructive ureteral stones with concurrent infection requiring urgent endoscopic drainage, followed by definitive flexible ureteroscopic management at our institution. Patients were considered infected if they presented with ≥ 2 systemic signs (fever/hypothermia, tachycardia, tachypnea, leukocytosis) along with CT-confirmed obstructive urolithiasis and positive urine culture before or during stent placement. Exclusion criteria comprised: Patients with indwelling ureteral stents, transfers from other institutions with pre-existing stents, pediatric cases, pregnant women, those with urological malformations, permanent catheter users, and cases where stenting was performed for non-stone related infections. For all included cases, we collected clinical history, admission laboratory values, and surgical details from both the initial drainage procedure and definitive ureteroscopy. Outcomes were compared between patients treated with versus without ureteral access sheaths (12-14Fr, at surgeon's discretion). We analyzed demographic data, complications (defined as ED visits within 3 months post-procedure), and stone-free rates (SFR) based on non-contrast CT scans (2mm slices) performed within 6 weeks postoperatively. SFR was graded as: Grade A (complete clearance), Grade B (≤ 2mm fragments), or Grade C (2.1-4mm fragments). For patients with larger stone burdens, stone volume reduction percentages were calculated by the research team, with equivocal findings reviewed by radiology specialists. Statistical analysis employed Mann-Whitney and Chi-square tests, with p < 0.05 considered significant. RESULTS From 77 eligible patients (41 women, 36 men; mean age 59 years), the mean stone size was 8.8 mm, (right-sized 41.5%, left-sized 52%, bilateral 6.5%). Cultures showed E.coli (65%), K.pneumoniae (16%), and E.faecalis (13%), the rest were other microorganisms from the Candida or Proteus family, among others. UAS was used in 59.7% (n=46). Both groups had similar baseline characteristics: mean age (60.5 vs 58.6 years), stone size (8.9 vs 8.7 mm) and volume (291 vs 265 mm³; all p>0.05). Time between stenting and definitive procedure and stone composition by FTIR spectroscopy were comparable with 78 and 74 % calcium oxalate, 13 and 16% Uric Acid and the remaining percentage with other compositions, mostly calcium phosphate. Both groups had similar rates of diabetes and hypertension (p>0.05). UAS patients had more prior ipsilateral ureteroscopies (28.3% vs 12.9%, p<0.05; Demographics and patient characteristics at ED presentation are in Table 1). In the group of patients in which UAS was used, 13% presented complications at 3-month follow-up, and all these complications were infectious in nature, with 2 patients who developed a febrile infection. In the patients in whom no access sheath was used, 12.9% (p>0.05) of complications were recorded at 3 months, only 1 patient consulted with an infectious complication (non-febrile UTI), the rest were mechanical complications, with the need for only 1 surgical reintervention due to residual lithotripsy. The list of complications is shown in Table 2. No intraoperative lesions were observed in any of the groups. In terms of the classic SFR (Grades A+B), no statistically significant difference was observed between the groups (89.1% vs 77.4%, p=0.068), though a clinically relevant trend favored UAS.. Stone volume reduction (87% vs 83%) and postoperative stenting decisions did not differ (p>0.05). The complete SFR distribution across all grade categories is presented in Table 3 DISCUSSION As we have reviewed, urosepsis secondary to urolithiasis is an entity associated with a high morbidity and mortality rate. Given its advantages compared to other interventions, endoscopic ureterolithotomy with flexible ureteroscopy is nowadays one of the most widely used techniques for the definitive management of lithiasis ( 14 , 15 ). To facilitate the passage of the flexible ureteroscope to the upper urinary tract, the use of the ureteral access sheath is becoming more and more common among urologists. However, the evidence supporting this practice in patients with a history of urosepsis for lithiasis is extrapolated from studies that do not distinguish this specific clinical scenario. This study is critical because no prior work has evaluated UAS use in patients presenting with urosepsis secondary to obstructive urolithiasis, a population with distinct pathophysiological features. Sepsis in this context involves exacerbated inflammatory responses, higher risks of reinfection, and increased postoperative complications (e.g., strictures, persistent bacteriuria). These factors may alter the risk-benefit balance of UAS deployment, yet current guidelines lack sepsis-specific recommendations. Our findings aim to bridge this gap, offering data to optimize decision-making in high-risk patients. Among the general advantages associated with the use of UAS reported in the literature are: facilitating rapid entry of the ureteroscope, shortening operative times, allowing multiple reinsertions of the ureteroscope, decreasing intrarenal pressure, prolonging the longevity of the instruments, reducing procedure costs and improving the stone-free rate ( 9 , 11 , 16 , 17 ). Some of these advantages, hypothetically, could be related to decrease infectious complications that could be relevant in our clinical scenario. However, some of these results are controversial, with some authors suggesting that the use of the access sheath could be associated with an increased risk of injury to the mucosal and muscular layers of the ureter, with a higher risk of infectious and mechanical complications ( 9 , 13 , 18 , 19 ). Other studies show that the use of UAS increases the direct costs associated with the purchase of instruments and that its use does not result in truly significant differences in stone-free rates ( 9 , 20 , 21 ). According to our results, the use of access sheath was not associated with a significant decrease in the number of overall complications at 3-month follow-up. However, when distinguishing between infectious and mechanical complications, the sheath group showed a higher rate of infections compared to the non-UAS group, with no mechanical complications reported. This could be secondary to a false sense of security on the part of the surgeons who may have used higher irrigation pressures, some associated risk of contamination by multiple accesses, or greater damage from sheath insertion at the ureteral mucosa level. As for mechanical complications, the use of the access sheath was associated with fewer postoperative pain consultations. Some studies relate this lower pain to the fact that the use of UAS and its different sizes would provide greater safety for the surgeon to leave the patient without a postoperative stent and this would be directly related to a lower need for postoperative analgesia; however, in our series, there was no difference in the use of stents ( 22 ). When comparing our results with the available evidence, we found important discrepancies between different authors. For example, Huang et al. in a meta-analysis on the usefulness of the ureteral access sheath that included 8 studies, with a total of 3,127 procedures, showed that the use of UAS had a higher incidence of general postoperative complications such as bleeding, fever, urinary tract infection, pain, pulmonary embolism, sepsis, among others (OR = 14.6, p = 0.02) ( 23 ). On the other hand, an even more recent systematic review failed to find conclusive results on the effect of the use of the ureteral access sheath on postoperative pain, risk of infectious complications, or risk of ureteral strictures ( 24 ). Concerning this issue, several authors such as Traxer et al. and De Coninck et al. state that the installation of the ureteral access sheath would generate damage to the ureteral mucosa ( 13 , 25 ). According to Huang et al., this damage would contribute to the appearance of persistent hematuria, renal colic-type pain, and ureteral stenosis, among other complications in the postoperative period ( 23 ). On the other side, different authors would argue that the use of UAS, by allowing better control of intrarenal pressures on the collecting system, would help to avoid pyelovenous and pyelolymphatic reflux, resulting in a lower risk of infectious complications or renal damage ( 9 , 16 ). Our results could contribute to this discussion, showing that in the scenario following urosepsis, UAS would be associated with greater infectious complications, not being compatible with the potential complications suggested by the previously mentioned authors, even though in general the patients consulted less for postoperative complications. These discrepancies can be related to the use of a previous ureteral stent in our group, secondary to the initial presentation. This makes this group of patients underwent to a flexible ureteroscopy with a wider ureter allowing a better drainage of irrigation and a decrease of pyelovenous reflux during the surgery. In reviewing the available evidence on the use of UAS and its impact on SFR, we found mixed results. Some retrospective studies, such as that of L'esperance et al. show significant differences in favor of UAS use in the treatment of renal lithiasis (79% vs. 67%, p = 0.042) ( 11 ). Others, such as that of Berquet G et al, show that in the treatment of upper urinary tract lithiasis with a flexible ureteroscope, the use of UAS would not be associated with statistically significant differences in SFR (86% vs. 87%, p = 0.89) ( 20 ). A recent systematic review by De Coninck et al. evidences this situation, with inconclusive results regarding the impact of ureteral access sheath use on stone-free rates ( 25 ) In this aspect, our results showed no significant differences between the two groups, and both alternatives could be considered equally effective. However here it is important to emphasize that there was a trend that would benefit the use of the ureteral access sheath, which may not be statistically significant due to the lack of a greater number of interventions (p = 0.07). This point can be related to the necessity to multiple access to retrieve stones fragments which is more feasible when a UAS is used, but the interpretation also varies based on the stone-free definition used. When analyzing these results, the limitations of this study must be considered. The small number of patients meeting inclusion criteria is likely due to it being conducted at a single center and within a specific clinical scenario. This concept should be explored on a larger scale in a multicenter study to corroborate our findings. Also the retrospective nature and surgeon-determined UAS use, with no pre-established criteria introduce a potential bias. We believe that continuing studies in this clinical scenario is crucial. According to our results and literature review, the systematic use of the ureteral access sheath in urolithiasis complicated by urosepsis does not appear justified, as it does not reduce major complications or increase the stone-free rate. However, a randomized clinical study will be necessary to confirm our findings, compare the current sizes and types of UAS, and explore other impacts the ureteral access sheath might have when performing flexible ureteroscopy in this patient type. Clinicians should carefully weigh UAS utilization, while beneficial in specific scenarios, its routine application may unnecessarily increase costs and environmental burdens without demonstrating clear clinical benefits for most cases.. CONCLUSIONS The use of ureteral access sheath at the time of flexible ureteroscopy in patients previously drained for urosepsis associated with urolithiasis is not associated with fewer complications or higher stone-free rates. The series presented did not show a benefit for the use of UAS in terms of postoperative infection rate, although it could have a role in reducing mechanical complications at 3-month follow-up. In light of these results, the use of the ureteral access sheath does not seem to be justified systematically in these patients. In any case, a prospective randomized clinical trial would be necessary to support our findings with a higher level of evidence. Declarations The authors declare they have no relevant financial or non-financial interests to disclose. No funding was received for conducting this study. This retrospective study was approved by the ethics committee of UC-Christus Clinic Hospital, Chile, and was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendment. Consent: Informed consent was obtained from all individual participants included in the study. The authors affirm that human research participants provided informed consent for the publication of their anonymized data. Data, Material and/or Code Availability: The data supporting the findings of this study are available from the corresponding author upon reasonable request. Authors’ Contribution: The authors' contributions to the manuscript were as follows: Renato I. Navarro: Data collection or management, Protocol/project development, Data analysis, Manuscript writing/editing. Lucas Dueñas: Data collection or management, Manuscript writing/editing. Nicolás Moreno: Data collection or management. Enzo Castiglioni: Data collection or management. Gastón M. Astroza: Protocol/project development. Author Contribution RN: Data collection or management, Protocol/project development, Data analysis, Manuscript writing/editing.LD: Data collection or management, Manuscript writing/editing.NM: Data collection or management.EC: Data collection or management.GA: Protocol/project development. References Rosser CJ, Bare RL, Meredith JW. Urinary tract infections in the critically ill patient with a urinary catheter. Am J Surg 1999;177(4):287-290. https://doi.org/10.1016/s0002-9610(99)00048-3 Wagenlehner FME, Pilatz A, Weidner W. Urosepsis - from the view of the Urologist. Int J Antimicrob Agents 2011;38 Suppl. https://doi.org/10.1016/j.ijantimicag.2011.09.007 Catalán M, Cerón I, Astroza G. Tratamiento antibiótico empírico de elección en pacientes con urosepsis secundaria a litiasis ureteral: Reporte de Sensibilidad local. Rev Med Chil 2017;145(6):755-759. https://doi.org/10.4067/s0034-98872017000600755 Preminger GM, Tiselius HG, Assimos DG, et al. 2007 guideline for the management of ureteral calculi. Eur Urol 2007;52(6):1610-1631. https://doi.org/10.1016/j.eururo.2007.09.039 Lu X, Zhou B, Hu D, Ding Y. Emergency decompression for patients with Ureteral Stones and SIRS: A prospective randomized clinical study. Ann Med 2023;55(1):965-972. https://doi.org/10.1080/07853890.2023.2169343 Uppot RN. Emergent nephrostomy tube placement for acute urinary obstruction. Tech Vasc Interv Radiol 2009;12(2):154-161. https://doi.org/10.1053/j.tvir.2009.08.010 Hyams ES, Monga M, Pearle MS, et al. A prospective, multi-institutional study of flexible ureteroscopy for proximal ureteral stones smaller than 2 cm. J Urol 2015;193(1):165-169. https://doi.org/10.1016/j.juro.2014.07.002 Torricelli FC, De S, Hinck B, Noble M, Monga M. Flexible ureteroscopy with a ureteral access sheath: When to stent? Urology 2014;83(2):278-281. https://doi.org/10.1016/j.urology.2013.10.002 Kaplan AG, Lipkin ME, Scales CD, Preminger GM. Use of ureteral access sheaths in ureteroscopy. Nat Rev Urol 2015;13(3):135-140. https://doi.org/10.1038/nrurol.2015.271 Takayasu H, Aso Y. Recent development for pyeloureteroscopy: guide tube method for its introduction into the ureter. J Urol 1974;112(2):176-178. https://doi.org/10.1016/s0022-5347(17)59675-9 L'Esperance JO, Ekeruo WO, Scales CD, et al. Effect of ureteral access sheath on stone-free rates in patients undergoing ureteroscopic management of renal calculi. Urology 2005;66(2):252-255. https://doi.org/10.1016/j.urology.2005.03.019 Zilberman DE, Lazarovich A, Winkler H, Kleinmann N. Practice patterns of ureteral access sheath during ureteroscopy for nephrolithiasis: a survey among endourologists worldwide. BMC Urol 2019;19(1):58. https://doi.org/10.1186/s12894-019-0489-x Traxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 2013;189(2):580-584. https://doi.org/10.1016/j.juro.2012.08.197 Goldsmith ZG, Oredein-McCoy O, Gerber L, et al. Emergent ureteric stent vs percutaneous nephrostomy for obstructive urolithiasis with sepsis: Patterns of use and outcomes from a 15-year experience. BJU Int 2013;112(2). https://doi.org/10.1111/bju.12161 Pietropaolo A, Hendry J, Kyriakides R, et al. Outcomes of elective ureteroscopy for ureteric stones in patients with prior urosepsis and emergency drainage: Prospective study over 5 yr from a tertiary endourology centre. Eur Urol Focus 2020;6(1):151-156. https://doi.org/10.1016/j.euf.2018.09.001 Auge BK, Pietrow PK, Lallas CD, et al. Ureteral access sheath provides protection against elevated renal pressures during routine flexible ureteroscopic stone manipulation. J Endourol 2004;18(1):33-36. https://doi.org/10.1089/089277904322836631 Pietrow PK, Auge BK, Delvecchio FC, et al. Techniques to maximize flexible ureteroscope longevity. Urology 2002;60(5):784-788. https://doi.org/10.1016/s0090-4295(02)01948-9 Manoj M, Rizkala E. Controversies in ureteroscopy: Wire, basket, and sheath. Indian J Urol 2013;29(3):244. https://doi.org/10.4103/0970-1591.117287 Traxer O, Wendt-Nordahl G, Sodha H, et al. Differences in renal stone treatment and outcomes for patients treated either with or without the support of a ureteral access sheath: The Clinical Research Office of the Endourological Society Ureteroscopy Global Study. World J Urol 2015;33(12):2137-2144. https://doi.org/10.1007/s00345-015-1582-8 Berquet G, Prunel P, Verhoest G, et al. The use of a ureteral access sheath does not improve stone-free rate after ureteroscopy for upper urinary tract stones. World J Urol 2013;32(1):229-232. https://doi.org/10.1007/s00345-013-1181-5 Gurbuz C, Atış G, Arikan O, et al. The cost analysis of flexible ureteroscopic lithotripsy in 302 cases. Urolithiasis 2014;42(2):155-158. https://doi.org/10.1007/s00240-013-0628-x Al-Kandari AM, Al-Hunayan A, ElShebiny Y, et al. Single-use ureteroscopes: Are we there yet? J Endourol 2022;36(3):296-301. https://doi.org/10.1089/end.2021.0515 Huang J, Zhao Z, AlSmadi JK, et al. Use of the ureteral access sheath during ureteroscopy: A systematic review and meta-analysis. PLoS One 2018;13(2): e0193600. https://doi.org/10.1371/journal.pone.0193600 De Coninck V, Somani B, Sener ET, et al. Ureteral access sheaths and its use in the future: A comprehensive update based on a literature review. J Clin Med 2022;11(17):5128. https://doi.org/10.3390/jcm11175128 De Coninck V, Keller EX, Somani B, et al. Complications of ureteroscopy: A complete overview. World J Urol 2020;38(9):2147-2166. https://doi.org/10.1007/s00345-019-03012-1 Tables Table 1 Demographic distribution and the characteristics of the patients at the time of consultation at the emergency department in both groups. UAS (59.7%) Control (40.3%) Total n 77 Age (mean) y.o 60.5 58.6 59 p>0.05 Gender (% male/female) 46/54 48/52 47/53 p>0.05 Stone size (mean) mm 8.9 8.7 8.8 p>0.05 Stone location (% proximal ureter/renal pelvis) 33/67 23/77 29/71 p>0.05 DM % 32 26 30 p>0.05 HBP % 48 41 44 p>0.05 Previous ureteroscopy % 28.3 12.9 22 p0.05 Fever incidence on ER admission % 80 87 83 p>0.05 Table 2 List of complications of each group. Complications Control UAS Total UTI (non febrile) 1 4 5 UTI (febrile) 0 2 2 Renal colic requiring ER consultation 2 0 2 Renal colic requiring surgical reintervention 1 0 1 Table 3: Distribution of stone-free rate (SFR) categories by treatment group, using modified SFR classification: Grade A: Absolute stone-free (0 mm), Grade B: Clinically insignificant fragments (≤2 mm), Grade C: Residual fragments (2.1–4 mm), Failure: Fragments >4 mm Group Category N(%) UAS N 46 Grade A 14 (30.4%) Grade B 27 (58.7%) Grade C 3 (6.5%) >4mm (Failure) 2 (4.3%) A+B 41 (89.1%) Control N 31 Grade A 12 (38.7%) Grade B 12 (38.7%) Grade C 3 (9.7%) >4mm (Failure) 4 (12.9%) A+B 24 (77.4%) Total N 77 Grade A 26 (33.8%) Grade B 39 (50.6%) Grade C 6 (7.8%) >4mm (Failure) 6 (7.8%) A+B 65 (84%) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Nov, 2025 Read the published version in World Journal of Urology → Version 1 posted Editorial decision: Revision requested 09 Sep, 2025 Reviews received at journal 04 Sep, 2025 Reviewers agreed at journal 21 Aug, 2025 Reviewers agreed at journal 21 Aug, 2025 Reviewers agreed at journal 21 Aug, 2025 Reviewers invited by journal 21 Aug, 2025 Editor assigned by journal 16 Jun, 2025 Submission checks completed at journal 16 Jun, 2025 First submitted to journal 15 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6900220","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":506064842,"identity":"14ff194f-1227-4f8f-aba9-9e56e6c8cc4d","order_by":0,"name":"Renato I. Navarro C.","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Renato","middleName":"I. Navarro","lastName":"C.","suffix":""},{"id":506064843,"identity":"af2aae0f-db24-4185-87fd-5392f714d9e5","order_by":1,"name":"Lucas Dueñas","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Lucas","middleName":"","lastName":"Dueñas","suffix":""},{"id":506064847,"identity":"92d5f193-cd64-486f-b26d-f371d4d70fb9","order_by":2,"name":"Nicolás Moreno","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Nicolás","middleName":"","lastName":"Moreno","suffix":""},{"id":506064849,"identity":"a6ec5076-ef70-460c-89f5-a5eefb2c459d","order_by":3,"name":"Enzo Castiglioni","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Enzo","middleName":"","lastName":"Castiglioni","suffix":""},{"id":506064851,"identity":"9c06e6d0-d50e-4a02-be1d-4322a0cbd04d","order_by":4,"name":"Gastón M Astroza","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYLCCBwxyPPwgRkIBsVoSGIx5JBtADAMStDAYHACxiNEi7374mERim4GM8fnViR8eGDDI84sdwK/F8ExaGkgLj9mNt5slgA4znDk7gYCWhhwzoJY/QC1nN4C0JBjcJqSl//03sC3GM85u/kGUFnmJHDawFgP+3m3E2WIg8czYIuGcAY/EDd5tFgkGEoT9It+f/PDGhzIDe/7+s5tv/qiwkeeXJmTLARhLAqxSAr9ysC0NMBb/AdyqRsEoGAWjYGQDAHjCQbOsJhO5AAAAAElFTkSuQmCC","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":true,"prefix":"","firstName":"Gastón","middleName":"M","lastName":"Astroza","suffix":""}],"badges":[],"createdAt":"2025-06-15 21:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6900220/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6900220/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00345-025-06108-z","type":"published","date":"2025-11-24T15:57:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97178313,"identity":"d170f795-76c9-447d-8012-4a0c4ef95be0","added_by":"auto","created_at":"2025-12-01 16:07:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":518400,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6900220/v1/53c1b3db-1d83-44ae-befe-72a7116e72d1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does the Ureteral Access Sheath Reduce Infections in Previously Drained Sepsis Patients? UAS and Infection Rates Post Sepsis-Drainage","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eUrosepsis, a urinary tract infection causing systemic inflammation and bacteremia, accounts for 30% of sepsis cases with 20\u0026ndash;40% mortality, often due to obstructive urolithiasis (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Initial management requires urinary drainage and antibiotics (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), followed by definitive stone treatment.\u003c/p\u003e\u003cp\u003eFor renal/upper ureteral stones\u0026thinsp;\u0026lt;\u0026thinsp;2cm, flexible ureteroscopy is preferred due to lower morbidity, shorter hospitalization, and higher stone-free rates (SFR) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The ureteral access sheath (UAS), introduced in 1974 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), facilitates ureteroscope passage, improving irrigation flow, reducing intrarenal pressure, and shortening surgery time (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). While UAS may protect the ureter and enhance visualization (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), its universal use remains debated.\u003c/p\u003e\u003cp\u003eThe use of this instrument has become so widespread that, according to a recent global survey, 45.83% of endourologists frequently utilize UAS for the management of ureteral stones, and 75.71% do so for renal stones (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Nevertheless, it is not without complications; some reports have linked its use to ureteral injury in nearly half of the patients, although this risk may be reduced by the prior placement of a JJ stent, as noted by the authors (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eTo our knowledge, no studies have compared sheath use in flexible ureteroscopy for patients with infected obstructing stones initially managed by stenting. Given the lack of direct evidence in this clinical scenario, this study evaluates UAS outcomes in this specific population.\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cp\u003e After approval by the ethics committee, a retrospective study was conducted at UC-Christus Clinic Hospital in Chile, reviewing all patients admitted between 2017 and 2024 with a diagnosis of urolithiasis complicated by urosepsis who required endoscopic drainage and subsequently underwent definitive stone treatment at our center. The analysis focused specifically on patients who underwent flexible ureteroscopy for final stone clearance.\u003c/p\u003e\u003cp\u003eThe study included only emergency department admissions meeting these criteria: obstructive ureteral stones with concurrent infection requiring urgent endoscopic drainage, followed by definitive flexible ureteroscopic management at our institution. Patients were considered infected if they presented with \u0026ge;\u0026thinsp;2 systemic signs (fever/hypothermia, tachycardia, tachypnea, leukocytosis) along with CT-confirmed obstructive urolithiasis and positive urine culture before or during stent placement.\u003c/p\u003e\u003cp\u003eExclusion criteria comprised: Patients with indwelling ureteral stents, transfers from other institutions with pre-existing stents, pediatric cases, pregnant women, those with urological malformations, permanent catheter users, and cases where stenting was performed for non-stone related infections.\u003c/p\u003e\u003cp\u003eFor all included cases, we collected clinical history, admission laboratory values, and surgical details from both the initial drainage procedure and definitive ureteroscopy. Outcomes were compared between patients treated with versus without ureteral access sheaths (12-14Fr, at surgeon's discretion). We analyzed demographic data, complications (defined as ED visits within 3 months post-procedure), and stone-free rates (SFR) based on non-contrast CT scans (2mm slices) performed within 6 weeks postoperatively. SFR was graded as: Grade A (complete clearance), Grade B (\u0026le;\u0026thinsp;2mm fragments), or Grade C (2.1-4mm fragments). For patients with larger stone burdens, stone volume reduction percentages were calculated by the research team, with equivocal findings reviewed by radiology specialists.\u003c/p\u003e\u003cp\u003eStatistical analysis employed Mann-Whitney and Chi-square tests, with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eFrom 77 eligible patients (41 women, 36 men; mean age 59 years), the mean stone size was 8.8 mm, (right-sized 41.5%, left-sized 52%, bilateral 6.5%). Cultures showed \u003cem\u003eE.coli\u003c/em\u003e (65%), \u003cem\u003eK.pneumoniae\u003c/em\u003e (16%), and \u003cem\u003eE.faecalis\u003c/em\u003e (13%), the rest were other microorganisms from the \u003cem\u003eCandida\u003c/em\u003e or \u003cem\u003eProteus\u003c/em\u003e family, among others.\u003c/p\u003e\n\u003cp\u003eUAS was used in 59.7% (n=46). Both groups had similar baseline characteristics: mean age (60.5 vs 58.6 years), stone size (8.9 vs 8.7 mm) and volume (291 vs 265 mm\u0026sup3;; all p\u0026gt;0.05). Time between stenting and definitive procedure and stone composition by FTIR spectroscopy were comparable with 78 and 74 % calcium oxalate, 13 and 16% Uric Acid and the remaining percentage with other compositions, mostly calcium phosphate.\u003c/p\u003e\n\u003cp\u003eBoth groups had similar rates of diabetes and hypertension (p\u0026gt;0.05). UAS patients had more prior ipsilateral ureteroscopies (28.3% vs 12.9%, p\u0026lt;0.05; Demographics and patient characteristics at ED presentation are in Table 1).\u003c/p\u003e\n\u003cp\u003eIn the group of patients in which UAS was used, 13% presented complications at 3-month follow-up, and all these complications were infectious in nature, with 2 patients who developed a febrile infection. In the patients in whom no access sheath was used, 12.9% (p\u0026gt;0.05) of complications were recorded at 3 months, only 1 patient consulted with an infectious complication (non-febrile UTI), the rest were mechanical complications, with the need for only 1 surgical reintervention due to residual lithotripsy. The list of complications is shown in Table 2. No intraoperative lesions were observed in any of the groups.\u003c/p\u003e\n\u003cp\u003eIn terms of the classic SFR (Grades A+B), no statistically significant difference was observed between the groups (89.1% vs 77.4%, p=0.068), though a clinically relevant trend favored UAS.. Stone volume reduction (87% vs 83%) and postoperative stenting decisions did not differ (p\u0026gt;0.05). The complete SFR distribution across all grade categories is presented in Table 3\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAs we have reviewed, urosepsis secondary to urolithiasis is an entity associated with a high morbidity and mortality rate. Given its advantages compared to other interventions, endoscopic ureterolithotomy with flexible ureteroscopy is nowadays one of the most widely used techniques for the definitive management of lithiasis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). To facilitate the passage of the flexible ureteroscope to the upper urinary tract, the use of the ureteral access sheath is becoming more and more common among urologists. However, the evidence supporting this practice in patients with a history of urosepsis for lithiasis is extrapolated from studies that do not distinguish this specific clinical scenario.\u003c/p\u003e\u003cp\u003eThis study is critical because no prior work has evaluated UAS use in patients presenting with urosepsis secondary to obstructive urolithiasis, a population with distinct pathophysiological features. Sepsis in this context involves exacerbated inflammatory responses, higher risks of reinfection, and increased postoperative complications (e.g., strictures, persistent bacteriuria). These factors may alter the risk-benefit balance of UAS deployment, yet current guidelines lack sepsis-specific recommendations. Our findings aim to bridge this gap, offering data to optimize decision-making in high-risk patients.\u003c/p\u003e\u003cp\u003eAmong the general advantages associated with the use of UAS reported in the literature are: facilitating rapid entry of the ureteroscope, shortening operative times, allowing multiple reinsertions of the ureteroscope, decreasing intrarenal pressure, prolonging the longevity of the instruments, reducing procedure costs and improving the stone-free rate (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Some of these advantages, hypothetically, could be related to decrease infectious complications that could be relevant in our clinical scenario. However, some of these results are controversial, with some authors suggesting that the use of the access sheath could be associated with an increased risk of injury to the mucosal and muscular layers of the ureter, with a higher risk of infectious and mechanical complications (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Other studies show that the use of UAS increases the direct costs associated with the purchase of instruments and that its use does not result in truly significant differences in stone-free rates (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccording to our results, the use of access sheath was not associated with a significant decrease in the number of overall complications at 3-month follow-up. However, when distinguishing between infectious and mechanical complications, the sheath group showed a higher rate of infections compared to the non-UAS group, with no mechanical complications reported. This could be secondary to a false sense of security on the part of the surgeons who may have used higher irrigation pressures, some associated risk of contamination by multiple accesses, or greater damage from sheath insertion at the ureteral mucosa level. As for mechanical complications, the use of the access sheath was associated with fewer postoperative pain consultations. Some studies relate this lower pain to the fact that the use of UAS and its different sizes would provide greater safety for the surgeon to leave the patient without a postoperative stent and this would be directly related to a lower need for postoperative analgesia; however, in our series, there was no difference in the use of stents (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhen comparing our results with the available evidence, we found important discrepancies between different authors. For example, Huang et al. in a meta-analysis on the usefulness of the ureteral access sheath that included 8 studies, with a total of 3,127 procedures, showed that the use of UAS had a higher incidence of general postoperative complications such as bleeding, fever, urinary tract infection, pain, pulmonary embolism, sepsis, among others (OR\u0026thinsp;=\u0026thinsp;14.6, p\u0026thinsp;=\u0026thinsp;0.02) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). On the other hand, an even more recent systematic review failed to find conclusive results on the effect of the use of the ureteral access sheath on postoperative pain, risk of infectious complications, or risk of ureteral strictures (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConcerning this issue, several authors such as Traxer et al. and De Coninck et al. state that the installation of the ureteral access sheath would generate damage to the ureteral mucosa (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). According to Huang et al., this damage would contribute to the appearance of persistent hematuria, renal colic-type pain, and ureteral stenosis, among other complications in the postoperative period (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). On the other side, different authors would argue that the use of UAS, by allowing better control of intrarenal pressures on the collecting system, would help to avoid pyelovenous and pyelolymphatic reflux, resulting in a lower risk of infectious complications or renal damage (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Our results could contribute to this discussion, showing that in the scenario following urosepsis, UAS would be associated with greater infectious complications, not being compatible with the potential complications suggested by the previously mentioned authors, even though in general the patients consulted less for postoperative complications. These discrepancies can be related to the use of a previous ureteral stent in our group, secondary to the initial presentation. This makes this group of patients underwent to a flexible ureteroscopy with a wider ureter allowing a better drainage of irrigation and a decrease of pyelovenous reflux during the surgery.\u003c/p\u003e\u003cp\u003eIn reviewing the available evidence on the use of UAS and its impact on SFR, we found mixed results. Some retrospective studies, such as that of L'esperance et al. show significant differences in favor of UAS use in the treatment of renal lithiasis (79% vs. 67%, p\u0026thinsp;=\u0026thinsp;0.042) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Others, such as that of Berquet G et al, show that in the treatment of upper urinary tract lithiasis with a flexible ureteroscope, the use of UAS would not be associated with statistically significant differences in SFR (86% vs. 87%, p\u0026thinsp;=\u0026thinsp;0.89) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). A recent systematic review by De Coninck et al. evidences this situation, with inconclusive results regarding the impact of ureteral access sheath use on stone-free rates (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eIn this aspect, our results showed no significant differences between the two groups, and both alternatives could be considered equally effective. However here it is important to emphasize that there was a trend that would benefit the use of the ureteral access sheath, which may not be statistically significant due to the lack of a greater number of interventions (p\u0026thinsp;=\u0026thinsp;0.07). This point can be related to the necessity to multiple access to retrieve stones fragments which is more feasible when a UAS is used, but the interpretation also varies based on the stone-free definition used.\u003c/p\u003e\u003cp\u003eWhen analyzing these results, the limitations of this study must be considered. The small number of patients meeting inclusion criteria is likely due to it being conducted at a single center and within a specific clinical scenario. This concept should be explored on a larger scale in a multicenter study to corroborate our findings. Also the retrospective nature and surgeon-determined UAS use, with no pre-established criteria introduce a potential bias.\u003c/p\u003e\u003cp\u003eWe believe that continuing studies in this clinical scenario is crucial. According to our results and literature review, the systematic use of the ureteral access sheath in urolithiasis complicated by urosepsis does not appear justified, as it does not reduce major complications or increase the stone-free rate. However, a randomized clinical study will be necessary to confirm our findings, compare the current sizes and types of UAS, and explore other impacts the ureteral access sheath might have when performing flexible ureteroscopy in this patient type.\u003c/p\u003e\u003cp\u003eClinicians should carefully weigh UAS utilization, while beneficial in specific scenarios, its routine application may unnecessarily increase costs and environmental burdens without demonstrating clear clinical benefits for most cases..\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe use of ureteral access sheath at the time of flexible ureteroscopy in patients previously drained for urosepsis associated with urolithiasis is not associated with fewer complications or higher stone-free rates. The series presented did not show a benefit for the use of UAS in terms of postoperative infection rate, although it could have a role in reducing mechanical complications at 3-month follow-up. In light of these results, the use of the ureteral access sheath does not seem to be justified systematically in these patients. In any case, a prospective randomized clinical trial would be necessary to support our findings with a higher level of evidence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare they have no relevant financial or non-financial interests to disclose. No funding was received for conducting this study. This retrospective study was approved by the ethics committee of UC-Christus Clinic Hospital, Chile, and was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendment. Consent: Informed consent was obtained from all individual participants included in the study. The authors affirm that human research participants provided informed consent for the publication of their anonymized data. Data, Material and/or Code Availability: The data supporting the findings of this study are available from the corresponding author upon reasonable request. Authors\u0026rsquo; Contribution: The authors\u0026apos; contributions to the manuscript were as follows:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eRenato I. Navarro: Data collection or management, Protocol/project development, Data analysis, Manuscript writing/editing.\u003c/li\u003e\n \u003cli\u003eLucas Due\u0026ntilde;as: Data collection or management, Manuscript writing/editing.\u003c/li\u003e\n \u003cli\u003eNicol\u0026aacute;s Moreno: Data collection or management.\u003c/li\u003e\n \u003cli\u003eEnzo Castiglioni: Data collection or management.\u003c/li\u003e\n \u003cli\u003eGast\u0026oacute;n M. Astroza: Protocol/project development.\u003c/li\u003e\n\u003c/ul\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRN: Data collection or management, Protocol/project development, Data analysis, Manuscript writing/editing.LD: Data collection or management, Manuscript writing/editing.NM: Data collection or management.EC: Data collection or management.GA: Protocol/project development.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRosser CJ, Bare RL, Meredith JW. Urinary tract infections in the critically ill patient with a urinary catheter. Am J Surg 1999;177(4):287-290. https://doi.org/10.1016/s0002-9610(99)00048-3\u003c/li\u003e\n\u003cli\u003eWagenlehner FME, Pilatz A, Weidner W. Urosepsis - from the view of the Urologist. Int J Antimicrob Agents 2011;38 Suppl. https://doi.org/10.1016/j.ijantimicag.2011.09.007\u003c/li\u003e\n\u003cli\u003eCatal\u0026aacute;n M, Cer\u0026oacute;n I, Astroza G. 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Effect of ureteral access sheath on stone-free rates in patients undergoing ureteroscopic management of renal calculi. Urology 2005;66(2):252-255. https://doi.org/10.1016/j.urology.2005.03.019\u003c/li\u003e\n\u003cli\u003eZilberman DE, Lazarovich A, Winkler H, Kleinmann N. Practice patterns of ureteral access sheath during ureteroscopy for nephrolithiasis: a survey among endourologists worldwide. BMC Urol 2019;19(1):58. https://doi.org/10.1186/s12894-019-0489-x\u003c/li\u003e\n\u003cli\u003eTraxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 2013;189(2):580-584. https://doi.org/10.1016/j.juro.2012.08.197\u003c/li\u003e\n\u003cli\u003eGoldsmith ZG, Oredein-McCoy O, Gerber L, et al. Emergent ureteric stent vs percutaneous nephrostomy for obstructive urolithiasis with sepsis: Patterns of use and outcomes from a 15-year experience. BJU Int 2013;112(2). https://doi.org/10.1111/bju.12161\u003c/li\u003e\n\u003cli\u003ePietropaolo A, Hendry J, Kyriakides R, et al. Outcomes of elective ureteroscopy for ureteric stones in patients with prior urosepsis and emergency drainage: Prospective study over 5 yr from a tertiary endourology centre. Eur Urol Focus 2020;6(1):151-156. https://doi.org/10.1016/j.euf.2018.09.001\u003c/li\u003e\n\u003cli\u003eAuge BK, Pietrow PK, Lallas CD, et al. Ureteral access sheath provides protection against elevated renal pressures during routine flexible ureteroscopic stone manipulation. J Endourol 2004;18(1):33-36. https://doi.org/10.1089/089277904322836631\u003c/li\u003e\n\u003cli\u003ePietrow PK, Auge BK, Delvecchio FC, et al. Techniques to maximize flexible ureteroscope longevity. Urology 2002;60(5):784-788. https://doi.org/10.1016/s0090-4295(02)01948-9\u003c/li\u003e\n\u003cli\u003eManoj M, Rizkala E. Controversies in ureteroscopy: Wire, basket, and sheath. Indian J Urol 2013;29(3):244. https://doi.org/10.4103/0970-1591.117287\u003c/li\u003e\n\u003cli\u003eTraxer O, Wendt-Nordahl G, Sodha H, et al. Differences in renal stone treatment and outcomes for patients treated either with or without the support of a ureteral access sheath: The Clinical Research Office of the Endourological Society Ureteroscopy Global Study. World J Urol 2015;33(12):2137-2144. https://doi.org/10.1007/s00345-015-1582-8\u003c/li\u003e\n\u003cli\u003eBerquet G, Prunel P, Verhoest G, et al. The use of a ureteral access sheath does not improve stone-free rate after ureteroscopy for upper urinary tract stones. World J Urol 2013;32(1):229-232. https://doi.org/10.1007/s00345-013-1181-5\u003c/li\u003e\n\u003cli\u003eGurbuz C, Atış G, Arikan O, et al. The cost analysis of flexible ureteroscopic lithotripsy in 302 cases. Urolithiasis 2014;42(2):155-158. https://doi.org/10.1007/s00240-013-0628-x\u003c/li\u003e\n\u003cli\u003eAl-Kandari AM, Al-Hunayan A, ElShebiny Y, et al. Single-use ureteroscopes: Are we there yet? J Endourol 2022;36(3):296-301. https://doi.org/10.1089/end.2021.0515\u003c/li\u003e\n\u003cli\u003eHuang J, Zhao Z, AlSmadi JK, et al. Use of the ureteral access sheath during ureteroscopy: A systematic review and meta-analysis. PLoS One 2018;13(2): e0193600. https://doi.org/10.1371/journal.pone.0193600\u003c/li\u003e\n\u003cli\u003eDe Coninck V, Somani B, Sener ET, et al. Ureteral access sheaths and its use in the future: A comprehensive update based on a literature review. J Clin Med 2022;11(17):5128. https://doi.org/10.3390/jcm11175128\u003c/li\u003e\n\u003cli\u003eDe Coninck V, Keller EX, Somani B, et al. Complications of ureteroscopy: A complete overview. World J Urol 2020;38(9):2147-2166. https://doi.org/10.1007/s00345-019-03012-1\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Demographic distribution and the characteristics of the patients at the time of consultation \u0026nbsp; at the emergency department in both groups.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUAS (59.7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (40.3%) \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal n 77\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (mean) y.o\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e60.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e58.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e59\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ep\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender (% male/female)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e46/54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e48/52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e47/53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ep\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStone size (mean) mm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e8.8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ep\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStone location (% proximal ureter/renal pelvis)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e33/67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e23/77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e29/71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ep\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ep\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHBP %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ep\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious ureteroscopy %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026lt;0.05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRP value on ER admission (mean; mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ep\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFever incidence on ER admission %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ep\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2 List of complications of each group.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eUAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eUTI (non febrile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eUTI (febrile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eRenal colic requiring ER consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eRenal colic requiring surgical reintervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3: Distribution of stone-free rate (SFR) categories by treatment group, using modified SFR classification: Grade A: Absolute stone-free (0 mm), Grade B: Clinically insignificant fragments (\u0026le;2 mm), Grade C: Residual fragments (2.1\u0026ndash;4 mm), Failure: Fragments \u0026gt;4 mm\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eUAS\u003c/p\u003e\n \u003cp\u003eN 46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrade A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e14 (30.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrade B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e27 (58.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrade C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e3 (6.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026gt;4mm (Failure)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e2 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eA+B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e41 (89.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003eN 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrade A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e12 (38.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrade B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e12 (38.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrade C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e3 (9.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026gt;4mm (Failure)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e4 (12.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eA+B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e24 (77.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003eN 77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrade A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e26 (33.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrade B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e39 (50.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrade C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e6 (7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026gt;4mm (Failure)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e6 (7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eA+B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e65 (84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"sepsis, ureter calculi, ureteroscopy, urinary catheterization, Urinary Tract Infection","lastPublishedDoi":"10.21203/rs.3.rs-6900220/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6900220/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFlexible ureteroscopy is the main treatment in upper tract urolithiasis. In cases of urinary tract infection associated to ureterolithiasis, drainage is required. Different authors prefer using a ureteral access sheath (UAS) to reduce complications. Our objective is to analyze the role of UAS in patients undergoing flexible ureteroscopy previously drained endoscopically for urosepsis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRetrospective single-center study. We reviewed patients with urolithiasis associated with urosepsis requiring endoscopic drainage between 2017-2024. Only patients undergoing flexible ureteroscopy as final treatment were selected. We compared those using a UAS versus those who did not. Statistical analysis used Chi-square and Mann-Whitney tests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e77 patients met the inclusion criteria. The average age was 59 years, and the average stone size was 8.8 mm. UAS was used in 59.7% of patients. There were no differences in age, gender, stone size, stone location, comorbidities, and fever incidence on ER admission. We only report differences in previous ipsilateral ureteroscopy, with a higher incidence in the UAS group.\u003c/p\u003e\n\u003cp\u003eIn the UAS group, there were 13% complications at 3 months (Clavien Dindo\u0026gt;II), all infectious. In patients without UAS, a 12.9% complication rate was recorded. Only 1 patients had an infectious complication (non-febrile), and the rest were associated with pain due to residual stone.\u003c/p\u003e\n\u003cp\u003eRegarding the percentage of SFR, there was no difference and there was no difference in the use of postoperative JJ-stent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our series, UAS doesn’t show a benefit in the rate of post-operative infections, though it could have a role in post-operative mechanical complications.\u003c/p\u003e","manuscriptTitle":"Does the Ureteral Access Sheath Reduce Infections in Previously Drained Sepsis Patients? UAS and Infection Rates Post Sepsis-Drainage","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-29 18:19:50","doi":"10.21203/rs.3.rs-6900220/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-09T10:09:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-04T13:46:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25246525805452610683747481816965103489","date":"2025-08-22T00:51:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216565368308400384309531790383328907926","date":"2025-08-21T16:34:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168339425560334002542941379319334938360","date":"2025-08-21T16:27:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-21T16:22:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T17:03:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-16T13:06:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2025-06-15T21:26:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b48ed333-2add-4f9a-b182-aa4c5972077f","owner":[],"postedDate":"August 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:00:49+00:00","versionOfRecord":{"articleIdentity":"rs-6900220","link":"https://doi.org/10.1007/s00345-025-06108-z","journal":{"identity":"world-journal-of-urology","isVorOnly":false,"title":"World Journal of Urology"},"publishedOn":"2025-11-24 15:57:21","publishedOnDateReadable":"November 24th, 2025"},"versionCreatedAt":"2025-08-29 18:19:50","video":"","vorDoi":"10.1007/s00345-025-06108-z","vorDoiUrl":"https://doi.org/10.1007/s00345-025-06108-z","workflowStages":[]},"version":"v1","identity":"rs-6900220","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6900220","identity":"rs-6900220","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}