Aim <p>To discuss an alternative approach for cannulating the vesico-ureteric Junction (VUJ) in the case of an unusual ureteric opening.</p> Methods <p>Data were collected retrospectively from the electronic patient record system. A 6-month-old girl presented a primary obstructive megaureter. She was planned for high pressure balloon dilatation of the VUJ. During the procedure, it was difficult to cannulate the VUJ because the VUJ was facing away from the surgeon’s vision (towards the dome of the bladder). Various techniques to maneuver the guide wire across the VUJ were unsuccessful. As an alternative approach, a 14 Fr Abbocath^® was put into the bladder by suprapubic route under the cystoscopic vision and in-line access to the VUJ was achieved successfully and 0.0014 guide wire was inserted into the ureteric orifice. The guide wire was then retrieved through the urethra using the cystoscope and standard VUJ cutting balloon dilation was done after that.</p> Results <p>The suprapubic access allowed for inline access to the unusually placed VUJ and allowed for successful cannulation. Follow-up USS showed improvement in distal ureter and pelvicalyceal dilation.</p> Conclusion <p>A suprapubic needle approach helped successfully manage a complex case of megaureter highlighting its potential for difficult ureteric access.</p>