We present our experience with the use of the ureteral access sheath for the management of small impacted lower third ureteral stones, in comparison with more standard techniques. Ninety-eight consecutive patients, aged 18-73 years (mean 48.5), with small (diameter < or = 10 mm) impacted lower third ureteral stones (< 5 mm in 56, and 5-10 mm in 42 patients) were randomly managed with either a 12/14F coaxial ureteral dilator/sheath and a 7.5F flexible ureteroscope (group A; 48 patients), or with balloon dilatation and the 7.5F flexible ureteroscope (group B; 50 patients). In both groups, stones were grasped and extracted with a basket, and when necessary they were disintegrated with a 1.9F electrohydraulic lithotripsy (EHL) probe. Postoperatively, excretory urography was performed at 1 month and patients were followed-up for 1 year. The mean operative time was 45.5 min in group A, and 58.5 min in group B (P<0.05). EHL was performed in 16 (33.3%) patients of group A, and in 12 (24%) patients of group B. In group B, balloon dilatation was performed in 28 (56%) patients. Ureteral perforation was revealed in 4 (8%) patients of group B. The follow-up imaging tests showed stone-free status in 46 (95.8%) patients of group A and in all (100%) patients of group B. No long-term complications were recorded. Endoscopic management of small impacted lower third ureteral stones with the ureteral access sheath is a quicker and safer procedure, in comparison with the more standard approach, bearing comparable efficacy.