Fluoroscopy guidance is mandatory for safety reasons and fluoroscopy time should be as minimal as possible (e.g. by reducing continuous screening).

General anesthesia is preferred in comparison with regional anesthesia in order to perform rigid URS as the patient is relaxed and not in pain due to the black flow.

Insertion of a hydrophilic safety guidewire into the ureteral orifice and up the kidney under fluoroscopic control is the first step for a successful URS.

Retrograde contrast studies although advisable in all case, could be avoided in experienced surgeons that recognize normal advancement and curling of the safety wire.

Usually, the first (safety) guidewire is advanced through an open access ureteral catheter, which is introduced with the cystoscope. This step could be avoided in experienced hands in case the first wire is placed through the ureteroscope from the very beginning (provided that the bladder is emptied).

The placement of a second (working) wire can ease the insertion of the rigid ureteroscope in the intramural part of the ureter. The insertion of the wire(s) could straiten a ureter with kinking. The ureteroscope can be advanced between the two wires (railway technique) without pushing in case of resistance (i.e. narrow ureter).

The use of a double lumen ureteral catheter can enable retrograde contrast studies and the placement of the second wire.