Large impacted proximal ureteric calculi with unsuccessful stenting remains a challenging task for endourologists. A retrograde approach would be the most common approach. However, a narrow field of vision with mucosal oedema can result in a technically challenging and prolonged procedure, with possibility of staging. In this video, we aim to demonstrate a novel technique of utilizing a flexible and navigable ureteric access sheath (FANS) in an antegrade fashion for lithotripsy in such cases.

We present a 51-year-old gentleman whose CT imaging revealed a 1198mm3 proximal ureteric stone at the level of L3-4 . As initial attempts at retrograde and percutaneous antegrade advancement of guidewires past the impacted proximal ureteric stone were unsuccessful, an 8Fr percutaneous nephrostomy tube was inserted. The Storz miniaturised percutaneous nephrolithotomy (PCNL) 15/16F single-step dilator and sheath were used for tract dilation. Due to the position of the calculus, the rigid Storz MIP "M" mini 12F nephroscope was not able to visualise the calculus despite maximal torque. A Reborn 12/14F 40 cm FANS sheath together with the Innovex Euscope 8.7Fr Flexible ureteroscope was used to steer the access sheath using a ureteroscope deflection technique to the proximal edge of the stone. Lithotripsy was then performed using the pulsed Thulium:YAG laser while suction was employed.

At the of surgery, there were no residual calculi radiologically or endoscopically. A Silicone 7F 26cm ureteric stent was placed and a tubeless exit strategy was adopted. The patient was discharged within 24hours on post operative day 1 with no complications.

The novel use of the FANS allowed directed placement of the flexible tip at the level of stone, with numerous benefits including better visibility, suction of dust fragments and thus contributing to a stone free outcome in a shorter operative time due to less fragments being dispersed into the rest of the pelvi-calyceal system . Additionally, suction and the difference in diameters between the ureteroscope, FANS and the mini PCNL sheath facilitate low intrarenal pressures. Future directions could include development of shorter FANS specifically for percutaneous access, and integration with the percutaneous access sheath.