Ureteral access sheath or percutaneous nephrostomy during flexible ureteroscopy: which is better?

Studies in literature discussed the drawbacks of the ureteral access sheath use in flexible ureteroscopy and in the same time mentioned the benefits of ureteral access sheath in decreasing the incidence of urosepsis and better stone free rate. In the current study we aim to compare between percutaneous nephrostomy tube (PCN) insertion before flexible ureteroscopy and conventional ureteral access sheath (UAS) flexible ureteroscopy in terms of safety, efficacy and perioperative outcomes. In all, 100 Patients aged 20 to 67 years with upper ureteric stones and mild hydronephrosis or renal pelvic stones less than 20 mm with mild hydronephrosis were randomized into 2 groups; patients undergoing PCN insertion before flexible ureteroscopy, and patients undergoing the conventional UAS flexible ureteroscopy. Patients with active urinary tract infection, patients with urinary diversions or malformations and patients with uncontrolled coagulable status were excluded from the study. Perioperative data were recorded. This study was conducted on 50 PCN group and 50 UAS group. Age varied from 20.0 to 67.0 years. Males consisted more than half of study groups, 52% of PCN group and 66% of UAS group. Weak significant difference was found in need for ureteral pre-operative stenting between groups (8% with PCN vs. 22% with UAS, p 0.04995). There was no significant difference between two groups in intra-operative complications (mucosal injury, failed operation, perforation, false passage and conversion to other procedure), but there was significant difference in bleeding between the groups (6% with PCN vs. 22% with UAS, p = 0.021). There was no significant difference between two groups in post-operative complications (infection, fever, pain, hematuria, other complications, stone free rate, readmission and stent duration), but there was significant decrease in operative time (48.85 ± 13.861 in PCN group versus 56.82 ± 14.61 in UAS group, p = 0.0003). We conclude that PCN insertion before flexible ureteroscopy provides a safe technique with comparable outcomes to UAS use.