Death of the Safety Guidewire

The placement of a safety guidewire (SGW) during retrograde ureteroscopy or percutaneous nephrolithotomy is recommended because of many years in textbooks and European Association of Urology/American Association of Urology guidelines. ^1,2 However, this recommendation is only based on expert opinion, a low level of evidence. The purpose of its use is that it can ensure access to the collecting system and facilitate the placement of a stent in case of ureteral or collecting system injury such as ureteral perforation or excessive bleeding. Some authors reported the feasibility of performing ureteroscopy without the use of SGW and the absence of major intraoperative complications. In this study, the authors argue that the use of an SGW may be counterproductive. Although their results are based on data of the literature, we want to address some comments.

First of all, we agree that the studies reporting ureteroscopy without SGW did not have any major intraoperative complications; however, Somani et al. reported recently in 11,885 patients that the risks of ureteral perforation and bleeding are still 1.05% and 1.41%, respectively. ³ Even if this kind of complications is rare, having an SWG in place when it occurs allows the insertion of a ureteral stent. As it is known that surgeon inexperience is associated with higher complication rates, the management of these complications could be easier with the presence of the SGW. That is why we teach to residents and fellows to insert an SGW at the beginning of an ureteroscopy procedure.

Another comment is on the use of ureteral access sheath (UAS). The authors mention that the development of UAS obviates the need for the SGW. However, an UAS is not a guidewire and does not warranty the absence of complication. Often placed in the proximal ureter, reported to be the portion of the ureter at greatest risk for avulsion because of the least muscular tissue support, the placement of UAS does not protect against this risk and the perforation of the portion of the ureter between the UAS and the renal pelvis. However, instead of placing two guidewires that may be time consuming, some newly designed UASs use only one guidewire, meaning the working guidewire turns into SGW. ⁴

Also, Eandi and Ulvik found that the SGW significantly increased the amount of force required to introduce the ureteroscope. However, the endoscopes used in these studies were larger than the new generation of fiberoptic or digital ureteroscopes having a maximum outer diameter of 8.5F. Thus, the use of the SGW should not interfere anymore with insertion of the ureteroscope.

Although the postoperative placement of ureteral stent after uncomplicated ureteroscopy for stone disease is still debated, it has been reported in large series that ∼80% of urologists place a ureteral stent after ureteroscopy. ³ Thus, having an SGW in place allows direct insertion of the ureteral stent instead of placing a guidewire and subsequently the stent at the end of the procedure.

Finally, what is the morbidity of the SWG? No report has been published; however, it may be insignificant.

To conclude, the SWG is like the seat belt. It may be useful only once in your life and at this time you will not regret to always use it.