required ureteral stent placement, thereby eliminating theneed for additional anesthesia in 60% of the patient cohort.Although personally I choose not to actively dilate the ure-teral orifice due to the proven association with postoperativecomplications, including ureterovesical stricture, the au-thors observed the ability to decrease the number of anes-thetic procedures by active dilation.

Also, the introduction of smaller ureteroscopes has en-hanced the ability of the pediatric endoscopist to treat upperurinary tract calculi in retrograde fashion. Traditionallyflexible ureteroscopy has been the preferred technique toevaluate and treat proximal to the iliac vessels. We havepreviously reported the safety, advantages and high successrate (83%) of retrograde proximal rigid ureteroscopy andpyeloscopy for proximal ureteral and renal pelvis calculi aswell as diagnostic ureteropyeloscopy in prepubertal children(reference 12 in article). Although rigid ureteroscopes haveobvious limitations compared to flexible ureteroscopes totreat upper tract stones, I tend to use the former endoscopeswhen possible. The current authors used a 6.9Fr flexibleureteroscope in a relatively large number of children unableto successfully undergo the initial procedure, presumablydue to ureteral anatomy. An option that the authors do notdiscuss in the article is the use of a wire, which usually

allows the anatomy to be more clearly delineated, providingguidance and passage of the ureteroscope. The authorsshould be acknowledged for further advancing retrogradeureteroscopy in the upper urinary tract in children.

Jeffrey S. PalmerCenter for Pediatric Urology

Glickman Urological and Kidney InstituteCleveland ClinicCleveland, Ohio

REPLY BY AUTHORS

Our technique includes a safety wire and a working wire todelineate anatomy and facilitate passage of the uretero-scope. We believe our results show that dilating the ureteralorifice is a safe and effective means of accessing the upperurinary tract in prepubertal children, facilitating highstone-free rates with flexible ureteroscopy. Although therecontinues to be concern that active dilation of the pediatricureteral orifice will cause stricture, to date we have encoun-tered only 1 ureteral stricture in a prepubertal patient whohad a stent placed before ureteroscopy (reference 1 in arti-cle).

PRIOR URETERAL STENT PLACEMENT AND UPPER URINARY TRACT ACCESS1864