Figure 1.

Wire problems (in bladder) for access sheath insertion. 1a. A straight safety wire is present, but the working wire, over which the access sheath is being passed, is substantially coiled in the bladder. Further advancement of the sheath will not only fail to access the ureter, but is likely to result in displacement of the working wire to the bladder. 1b. The access sheath has been withdrawn to the urethra. 1c. The working guide wire has been withdrawn slightly, such that the coiled loop is of smaller diameter. 1d. The working wire is now straight, and the tip of the access sheath has been moved along it towards the left ureteric orifice. 1e. Keeping the image intensifier over the lower third of the ureter, the access sheath can be advanced under fluoroscopic control to ensure there is no “buckling” in this part of the ureter. 1f. Once the lower third has been successfully traversed, the image intensifier can be moved to the proximal ureter to allow precise positioning of the tip of the sheath in the upper ureter.