Access sheath

Cystoscopic access sheath

• Modern rigid cystourethroscopes consist of a sheath, obturator, bridge,

and telescopes.
• The telescopic lens is placed through the sheath by attaching a bridge
to the sheath.
• The bridge allows both passage of the telescope and access to the
working channel of the sheath for passage of accessory instruments.
• A deflector system (Albarran lever) can be placed through the sheath
to allow passage and controlled deflection of catheters through the
working channel.
• The irrigant fluid is connected to the sheath, and the fiberoptic light
source connects directly to the telescope.
• Obturators can be placed through the sheath to provide a smooth, blunt tip
for easy passage.
• Obturators through which a telescope can be passed (visual obturators)
provide a method of easy direct visual passage of the endoscope.
• The size of cystourethroscopes is usually given using the French scale and
refers to the outside circumference of the instrument in millimeters.
• Instruments of different sizes are available to accommodate pediatric
patients (No. 8 to 12 Fr) and adults (No. 16 to 25 Fr).
• In general, the choice of an endoscope with respect to size should be
the same as for catheter size—the smallest outer circumference that
will accomplish the task.
• If diagnostic cystourethroscopy is being performed, a small
instrument (No. 16 to 17 Fr) is adequate.
• If a larger working channel is needed for accessory equipment (e.g.,
biopsy device), a larger endoscope is chosen
• Most cystoscopes use straight, direct-viewing telescopes.

• Access to the instrumentation channel is via angled ports

inferior to the telescope .

• This system works well with flexible accessories, but precludes

the use of removable rigid accessories such as stone graspers or
forceps.

• To allow for easy entry and removal of rigid accessories, many

rigid ureteroscopes and nephroscopes use a right-angle or offset-
oblique ocular configuration so that the urologist can have direct
access to the instrumentation port for the passage of rigid
accessories without impairing the view of the scope
• This is especially important for rigid nephroscopy in which the
placement of large-caliber ultrasonic lithotripsy probes, stone graspers,
and endopyelotomy knives requires a straight-line access to the
instrumentation channel.

• With increasing use of video cameras, which have become smaller and
less cumbersome, this is becoming less an issue. In the future, as the
trend continues toward digital and electronic imaging, the need for a
viewable ocular lens will not be there.
Resectoscope

• The resectoscope is fundamental to modern urological

endoscopy.
• It is similar to the cystourethroscope, with a sheath and
obturator, except that the sheath has an insulated beak.
• The working part consists of a mount for the electrode with a
handle to enable the electrodes to be moved back and forward.
Continuous flow resectoscope

• The standard resectoscope has been modified by an extra

irrigation channel which enables continuous irrigation of the
bladder.
• This gives improved visibility, especially during resection of
hemorrhagic lesions.
• Other advantage is that it is possible to work with a bladder
partially deflated and under lower pressure, lessening the
amount of extravasation.
• The disadvantage is the extra thickness of sheath in relation to
the cutting loop electrode.
• Resectoscope is available from size 10F upwards.
• 12F for paediatrics urology, 24F for adults with small urethra,
26F for continuous flow resectoscope and 27F for large urethra.
Care of the instruments
• The endoscopic sheath also requires special handling to avoid
bending or denting of the shaft .

• The sheath is inspected for rough edges or metal burrs and

the inner channels and working and irrigation ports are cleaned
with soft brushes and rinsed thoroughly.

• Stopcocks are opened, cleaned with soft brushes and mild

detergent, and rinsed well.

• The obturator should be inspected for smoothness and

efficiency of the locking mechanism.

• Stopcocks and movable parts of the rigid endoscope are

lubricated as needed with instrument milk to ensure smooth
movement of these parts.
Ureteral Access Sheath

• This accessory was originally developed in the 1970s to

facilitate insertion of the flexible ureteroscope ( Takayasu and
Aso, 1974 ) and has been shown to decrease renal pressures
during ureteroscopy.

• Ureteral access sheaths (UASs) come in sizes ranging from 9

to 18 Fr and are inserted with a tapered dilating obturator over
a guide wire.

• UASs can provide ureteral dilation because of the tapered tip,

and there has been report of less postoperative pain following
ureteroscopy utilizing a UAS for dilation compared with
balloon dilation .
• Today’s access sheaths consist of a two-piece hydrophilic,
lubricious outer sheath and inner introducer which is removed after
advancement over the guidewire.

• Sheaths come in various lengths (20–55 cm) and diameters (10–

16 Fr) depending on patient size and gender.

• The access sheath acts as a dilator and a conduit that prevents

buckling of the flexible ureteroscope within the bladder.

• With these devices, the flexible ureteroscope is not inserted over a

guidewire, but is advanced directly up the lumen of the access
sheath.

• At the end of the procedure, the access sheath can facilitate the
insertion of a ureteral stent if necessary
• As an open conduit into the kidney, the UAS allows irrigation
to flow in through the endoscope and back out of the kidney,
thus preventing high renal pressures.

• Shorter operating room times and greater cost savings have

been demonstrated when UASs are utilized in conjunction with
ureteroscopy.

• The shortened surgical times are thought to be due to the ease

of repeated insertion of the flexible ureteroscope and thus
facilitation of basketing to remove stone fragments from the
kidney, which would otherwise require intracorporeal
lithotripsy into small enough fragments to pass spontaneously
• Part of the overall decrease in costs was due to a decreased
incidence of ureteroscope damage.

• As the ureteroscope is not in direct contact with a potentially

tight ureter undergoing axial forces during insertion, the
endoscope appears to sustain less damage over time and can be
used in more cases before servicing is required.

• Previous concerns that UASs may cause ureteral ischemia and

necrosis resulting in a ureteral stricture have been unfounded,
as the stricture incidence has been demonstrated to be the same
as that with ureteroscopy alone (∼1.4%)
• Flexible ureteroscopy is better facilitated by UASs than
semirigid ureteroscopy.

• UASs do not appear to be useful in semirigid ureteroscopic

management of distal ureteral stones.

• The use of UASs has been extended to simultaneous

ureteroscopic access during percutaneous nephrolithotomy and
extracorporeal shockwave lithotripsy (SWL) for large stone
burdens in patients surgically unfit for percutaneous
nephrolithotomy .
• In summary, use of UASs during flexible ureteroscopy shortens
operating times, reduces renal pelvic pressures, and can limit
endoscope damage.