Retrograde Ureteral Stent Research Articles

Likelihood of retrograde double-J stenting according to ureteral obstructing pathology

To evaluate the likelihood of retrograde double-J stenting in urgent ureteral drainage according to obstructing pathology. From July 2002 to January 2003, 43 consecutive patients with ureteral obstruction who needed urgent decompression were evaluated at our institution, where we performed a total of 47 procedures. Emergency was defined as ureteral obstruction associated with infection, obstructive acute renal failure, or refractory pain. Ureteral obstruction was defined as intrinsic and extrinsic based on etiology and evaluated by ultrasound. Patients submitted to previous double-J stenting were excluded. Failures in retrograde ureteral stenting were treated with percutaneous nephrostomy. Results were analyzed with Fisher's exact test and regression analysis. Failure in retrograde ureteral stenting occurred in 9% (2/22) and 52% (13/25) of the attempts in patients with intrinsic and extrinsic obstruction respectively (p < 0.001). Failures in stenting extrinsic obstructions occurred due to lack of identification of the ureteral meatus in 77% and impossibility of catheter progression in 23% (p < 0.05). All attempts of retrograde catheter insertion failed in obstructions caused by prostate or bladder pathologies (6/6). Inability to identify the ureteral meatus was the cause of all failures. Retrograde double-J stenting has a low probability of success in extrinsic ureteral obstruction caused by prostate or bladder disease. Such cases might be best managed with percutaneous nephrostomy.

Retrograde stenting for obstruction of the renal transplant ureter

Objectives To present our experience with retrograde stent placement and stent exchange for transplant ureteral obstruction. Methods A review of our renal transplant database was performed to identify all renal transplant patients who underwent attempted retrograde ureteral stenting for allograft ureteral obstruction or attempted allograft ureteral stent exchange between May 1992 and April 2004. A retrospective review was performed. Results Forty patients underwent 52 attempted retrograde ureteral stent placements, and 11 patients underwent a total of 27 attempted stent exchanges. In patients with ureteral obstruction, the most common clinical signs and symptoms were nausea, vomiting, diarrhea, abdominal pain, fever, decreased urine output, edema, and an elevated serum creatinine. Of the 52 cases of allograft ureteral obstruction and attempted retrograde ureteral stent placement, 28 (53.8%) were managed successfully with retrograde ureteral stenting. Of the 27 attempted stent exchange procedures, a successful exchange was accomplished in 23 cases (85.2%). Conclusions Cystoscopy with retrograde allograft stent placement is a reasonable first approach to the management of transplant ureteral obstruction and is successful in more than one half of cases.

How painful are shockwave lithotripsy and endoscopic procedures performed at outpatient urology clinics?

Our aim was to investigate the subjective pain felt by patients during shockwave lithotripsy (SWL) and endoscopic procedures such as cystoscopy, retrograde ureteral stenting, retrograde pyelography (RGP), and ureteroscopic lithotripsy performed in an outpatient clinic, and to identify how severe pain during such procedures is. We estimated subjective pain in 984 patients after SWL (186), cystoscopy (489), retrograde ureteral stenting (127), RGP (97), and ureteroscopic lithotripsy (85) performed by a single expert in an outpatient clinic using a prospective questionnaire with a ten point visual analog scale between January 2001 and December 2003. There was no premedication in any procedure except ureteroscopic lithotripsy for which an intramuscular injection of analgesics (pethidine HCl 50 mg) was used. The pain scale score in SWL was 6.62+/-2.27, the highest among the procedures (P<0.05). Pain scores for endoscopies were 4.48+/-2.07 in retrograde ureteral stenting, 3.81+/-2.06 in ureteroscopic lithotripsy, 3.72+/-1.75 in RGP, and 3.08+/-1.95 in cystoscopy. In this study, we observed that patients feel most pain in SWL without anesthesia, and that pain during ureteroscopic lithotripsy under local anesthesia is not high, compared with other endoscopic procedures.

Retrograde or antegrade double-pigtail stent placement for malignant ureteric obstruction?

To determine the optimum approach for double-pigtail stent placement in malignant ureteric obstruction. Retrograde stent placement was attempted in a consecutive series of patients presenting with malignant ureteric obstruction. If retrograde stent placement was unsuccessful, percutaneous nephrostomy was performed immediately followed by elective antegrade stent placement. Identical digital C-arm fluoroscopy for image-guidance and conditions for anaesthesia and analgesia were employed for both retrograde and antegrade procedures. Identical 8 Fr (20-26 cm) double-pigtail hydrophilic coated stents were used for each approach. Retrograde placement was attempted in 50 ureters in 30 patients {19 male, 11 female, average age 61.4 yr (range 29-90 yr)} over a 24-month period. The success rate for retrograde ureteric stent placement was 50% (n = 25/50). Technical failures were due to failure to identify the ureteric orifice (n = 22), failure to cross the stricture (n = 1), failure to pass the stent (n = 1) and failure to pass a 4 Fr catheter (n = 1). Antegrade placement was attempted in 25 ureters with a success rate of 96% (n = 24/25). Failure in the one case was due to inability to cross an upper third stricture secondary to pyeloureteritis cystica. It is suggested that retrograde route should be the initial approach if imaging shows no involvement of ureteric orifice (UO), when nephrostomy is technically very difficult or in cases of solitary kidney. The antegrade route is preferred if imaging shows tumour occlusion of the UO or if there is a tight stricture very close to the uretero-vesical junction (UVJ) making purchase within the ureter difficult for crossing the stricture.

Retroperitoneoscopic Live Donor Nephrectomy (RPLDN): Establishment and Initial Experience of RPLDN at a Single Center

We tried to establish the technique of retroperitoneoscopic live donor nephrectomy (RPLDN). Between July 2001 and March 2004, 135 renal transplant donors underwent RPLDN. Low (average: 7 mmHg) CO2 gas pressure was employed during the procedure. All procedures were performed through a three-port retroperitoneal approach without opening the peritoneal cavity. The hand-assisted technique was not used. One hundred and twenty-seven cases were of left and eight cases were of right nephrectomy. Donor nephrectomy was carried out successfully in all patients. In one donor, the procedure was changed to open donor nephrectomy because of severe adhesion around the renal vein due to previous surgery. No serious complications, such as massive bleeding or bowel injury were encountered. Return of bowel function took 0.7 days on average. Post-operative hospital stay was 4.9 days on average, and return to work was 12 days on average. Ureteral complications occurred in 2 patients and were treated with temporally retrograde ureteral stenting. Average serum creatinine levels were 1.5 mg/dL, 1.3 mg/dL and 1.3 mg/dL at 3, 7 and 14 days after transplantation, respectively. No patients required hemodialysis after transplantation due to acute tubular necrosis. RPLDN could be an option for laparoscopic live donor nephrectomy.

Ultrasonography‐guided bladder resection to aid retrograde ureteric stent placement

Ultrasonography‐guided bladder resection to aid retrograde ureteric stent placement

Combined antegrade and retrograde ureteral stenting: the rendezvous technique

Ureteral stenting is a routine procedure in endourology. To increase the success rate in difficult cases, it may be helpful to use the rendezvous technique, a combined antegrade and retrograde approach. We performed 16 urological rendezvous in 11 patients with ureteral strictures or urologic lesions. The combined approach was successful in all patients, without morbidity or mortality. In our experience the rendezvous technique increased the success rate of antegrade ureteral stenting from 78.6 to 88.09% ( p>0.05). This procedure is a valid option in case of failure of conventional ureteral stenting.

Fistulas of the lower urinary tract: percutaneous approaches for the management of a difficult clinical entity.

Fistulas of the lower urinary tract are uncommon conditions that may occur spontaneously or after therapy in patients with various pelvic abnormalities. When present, these fistulas are associated with urine leakage, which is often socially distressing and disabling. Unfortunately, factors that lead to the formation of genitourinary fistulas often increase their complexity or preclude surgical repair. A high failure rate is associated with surgical repair, and many patients are not optimal surgical candidates. For such patients, a percutaneous treatment approach is highly desirable. Percutaneous ureteral occlusion combined with insertion of a functioning nephrostomy tube allows complete diversion of urine in those patients in whom nephrostomy alone does not provide adequate relief. Many approaches to percutaneous ureteral occlusion have been used with variable success, including coils and gelatin sponge, isobutyl-2-cyanoacrylate, detachable balloons, radiofrequency electrocautery, ureteral clipping, and solid and soft polymer agents. Furthermore, percutaneous or retrograde ureteral stents may be used to preserve antegrade urine flow, and surgical options are also available. It is essential that the interventional radiologist involved in the care of these patients be familiar with these different techniques as well as with the limitations, pitfalls, and possible complications of their use.

15-YEAR EXPERIENCE WITH THE MANAGEMENT OF EXTRINSIC URETERAL OBSTRUCTION WITH INDWELLING URETERAL STENTS

We assessed the success of retrograde placement of indwelling ureteral stents in the management of ureteral obstruction due to extrinsic compression. Between July 1987 and December 2002 adequate followup was available for 101 patients who underwent primary retrograde ureteral stenting for extrinsic ureteral obstruction. Mean age at presentation was 61.4 years (range 33 to 90). Chart review was performed on all patients for primary diagnosis, symptomatology, degree of hydronephrosis, creatinine levels (baseline, treatment and posttreatment), location of compression, size and number of stents used, progression to percutaneous nephrostomy tube (PNT), stent failure, days to stent failure, post-stent therapy and status at last followup. Mean length of followup was 11 months (range 1 to 127). In 101 patients 138 ureteral units (UU) were stented. Total stent failure occurred in 41 (40.6%) patients and 58 (42.0%) UU. A total of 40 (29.0%) UU required PNTs at a mean of 40.3 days (range 0 to 330) with 18 PNTs placed in less than 1 week. Cases of stent failure that did not undergo PNT placement included 18 (13.0%) UU at a mean of 52.4 days (range 3 to 128). A total of 90 (89.1%) patients had metastatic cancer at stenting with 32.2% dead at 5.8 months (range 1 to 32). Univariate and multivariate analyses identified cancer diagnosis, baseline creatinine greater than 1.3 mg/dl and post-stent systemic treatment as predictors of stent failure. Proximal location of compression and treatment creatinine greater than 3.11 mg/dl were marginal predictors of failure on univariate analysis, while proximal location of obstruction was also marginally significant on multivariate analysis. No predictors were identified for early stent failure (less than 1 week). At almost 1 year followup stent failure due to extrinsic compression occurred in nearly half of treated patients. Analysis of data revealed a diagnosis of cancer, baseline mild renal insufficiency and metastatic disease requiring chemotherapy or radiation as predictors of stent failure. Managing extrinsic compression by retrograde stenting continues to be a practical but guarded decision and should be tailored to each patient.

Major complications after percutaneous nephrostomy—lessons from a department audit

AIM: To audit the performance of our percutaneous nephrostomy service by comparing the major complication rate with the standards recommended by the Society of Cardiovascular and Interventional Radiology and the American College of Radiology: major haemorrhage in <4%, and septic shock in <4%. Secondary aims were to identify common sources of errors for quality improvement measures. METHODS: Major complications sustained between January 1997–December 2002 were identified. All cases had been carried out by the interventional radiology service of a large teaching hospital with the assistance of a nurse and radiographer, under fluoroscopic and ultrasound guidance using a Seldinger technique. Existing department protocols specified pre-procedure antibiotics for suspected infected cases and normal coagulation studies. From records and review of case notes pertinent clinical/procedural details and eventual outcome were assessed. The following were particularly noted: adherence to protocols, clinical status at time of procedure, delay in referral, complication sustained, signs of infection or coagulopathy, timing of procedure (in versus out of hours), level of operator and technical faults. RESULTS: Ten of 318 (3.1%) cases sustained a major complication: five had sepsis alone, two haemorrhage (one with sepsis as well) and three patients had a major pelvic injury (one with sepsis as well). Thus the major sepsis and haemorrhage rates were 2.2 and 0.6%, and were within the recommended threshold limits but proportionately more complications occurred out of hours: six of 105 (5.7%) versus four of 312 (1.8%; p=0.087). Sepsis was the most serious complication and may have contributed to the death of two patients. On individual case analysis, failed instrumentation with delay to definitive renal drainage was a common factor with sepsis; but the following were contributory factors in one or more cases: omitted antibiotics (in three of 10; two became septic), technical factors in four cases [medial renal puncture ( n=1), damage due to fascial dilator ( n=1) or peelaway sheath ( n=2)] and delay in diagnosis/therapy (of 1–8 days, in six of 10 cases of whom four out of six became septic). One pelvic injury required surgical correction (contributory factor—faulty use of peelaway sheath). Patients with haemorrhage settled with prolonged tube drainage alone. CONCLUSION: An adequately staffed percutaneous nephrostomy service can perform within published clinical standards. Best practice factors identified were: attention to agreed protocols and algorithms, pre-procedure antibiotics, careful renal puncture and care with use of dilators/peelaway sheaths, but the paramount finding was that sepsis was the most serious complication, contributing to death (two of 10 in this study) or a significant increase in the level of care required. The risk is greatest after failed instrumentation (retrograde ureteral stent or percutaneous nephrostomy insertion) and particularly if there is a further delay before establishment of renal drainage. A close working relationship between interventional radiologists and urologists is crucial.

The Management of Ureteric Obstruction Secondary to Malignant Pelvic Disease

AIM: Management of upper-tract obstruction secondary to a malignant pelvic process is a difficult problem and is best dealt with by a multi-disciplinary team. In the present audit, we address the question: is staged antegrade stenting better than retrograde ureteric stenting? MATERIALS AND METHODS: We reviewed our present management of upper-tract obstruction secondary to malignant pelvic disease in 65 patients treated over a period of 2 years. Fifty-eight patients had urological cancer and seven patients had non-urological cancers; 70% of all cases had renal impairment. Twenty-four of 65 patients had an attempt at endoscopic retrograde ureteric stenting as a primary method of decompression while percutaneous nephrostomy followed by antegrade ureteric stenting was performed in 41/65 patients. RESULTS: Endoscopic retrograde stenting had a success rate of 21% whereas two-stage antegrade stenting was successful in 98% of patients. The antegrade approach had minimal morbidity. CONCLUSION: Obstruction of the pelvic ureter secondary to any pelvic malignancy is best managed by two-stage antegrade ureteric stenting. This approach has a high success rate with minimal morbidity, and should be preferred to an endoscopic approach. This highlights the important role of an interventional uroradiologist in the management of these patients. Chitale, S. V. et al. (2002). Clinical Radiology57, 1118–1121.

Ureteral Stenting Via an Ileal Conduit Using a Gastroscope

We describe a technique that facilitates retrograde ureteral cannulation and stenting in patients with an ileal conduit. A standard flexible gastroscope is inserted into the ileal conduit. Guide wires are passed into the ureters under direct vision. Stents are inserted over the guide wires with the aid of the image intensifier. The technique was used repeatedly in 1 patient with a complex history who had ureteral strictures. The procedure is technically easy and it was successful on each occasion. A fiber optic gastroscope may have advantages over conventional urological instrumentation for inserting ureteral stents in patients with an ileal conduit. This novel, simple technique is less invasive than percutaneous stenting and easier than fluoroscopic cannulation of the ureters. It is readily repeated.

PREDICTING THE SUCCESS OF RETROGRADE STENTING FOR MANAGING URETERAL OBSTRUCTION

Retrograde ureteral stenting is often considered the first line option for relieving ureteral obstruction when temporary drainage is indicated. Several retrospective studies have implied that in cases of extrinsic obstruction retrograde ureteral stenting may fail and, therefore, percutaneous nephrostomy drainage is required. We examined the efficacy of retrograde ureteral stenting for resolving ureteral obstruction and identified clinical and radiological parameters predicting failure. Enrolled in our prospective study were 92 consecutive patients with ureteral obstruction, which was bilateral in 8. Retrograde ureteral stenting was attempted in all cases by the urologist on call. When stent insertion failed, drainage was achieved by percutaneous nephrostomy. Patients were followed at 3-week intervals for 3 months. Each followup visit included a medical interview, blood evaluation, urine culture and ultrasound. Stent malfunction was defined as continuous flank pain manifesting as recurrent episodes of acute renal colic, 1 or more episodes of pyelonephritis, persistent hydronephrosis or elevated creatinine. Preoperative data and outcomes were compared in cases of intrinsic and extrinsic obstruction. Univariate and multivariate analysis was done to identify predictors of the failure of ureteral stent insertion and long-term function. The etiology of obstruction was intrinsic in 61% of patients and extrinsic in 39%. Extrinsic obstruction, which was associated with a greater degree of hydronephrosis, was located more distal. Retrograde ureteral stenting was successful in 94% and 73% of patients with intrinsic and extrinsic obstruction, respectively. At the 3-month followup stent function was maintained in all patients with intrinsic obstruction but in only 56.4% with extrinsic obstruction. On multivariate logistic regression the type of obstruction, level of obstruction and degree of hydronephrosis were the only predictors of stent function at 3 months. Stent diameter and preoperative creatinine had no predictive value. Retrograde ureteral stenting is a good solution for most acutely obstructed ureters. In patients with extrinsic ureteral obstruction a more distal level of obstruction and higher degree of hydronephrosis are associated with a greater likelihood of stent failure. These patients may be better served by percutaneous drainage.

Outpatient ureteric procedures: a new method for retrograde ureteropyelography and ureteric stent placement.

To evaluate a new method for retrograde ureteropyelography and retrograde ureteric stent placement. Procedures were undertaken using a flexible cystoscope and digital C-arm fluoroscopy in outpatients under sedoanalgesia. The flexible cystoscope was used to identify the ureteric orifice and a straight 0.9 mm hydrophilic guidewire inserted and passed into the renal pelvis under fluoroscopic guidance. A 4 F general-purpose catheter was then passed over the wire and ureteropyelography performed. To place the stent the hydrophilic guidewire was exchanged for an ultra-stiff wire, over which the stent was passed directly. Over a 47-month period, 723 procedures were carried out in 472 patients. The clinical indications were ureteric obstruction in 229 (32%), stone disease in 165 (23%), unexplained hydronephrosis in 150 (21%), haematuria in 94 (13%) and others in 85 (12%). Of the 723 procedures, 643 (89%) were technically successful. Failure was most commonly caused by failure to cannulate the ureteric orifice (51, 7%). Just over half the procedures (366, 51%) involved stent placement or replacement. Immediate complications occurred in 17 patients (3%). Of those who were questioned, 94% (282 of 300) reported the procedure to be acceptable. Retrograde ureterography and ureteric stent placement may be satisfactorily undertaken with the patient under sedoanalgesia on an outpatient basis. This technique can reduce costs, hospital admissions, general anaesthetic use, demands on theatre time and complication rates.

Ureteral stent placement in hydronephrosis during pregnancy

In this study we describe 22 cases of retrograde ureteral stent placement in pregnant women with therapy-resistant flank pain due to hydronephrosis. Eleven were primiparous and one patient expected twins. Eight of 22 patients presented symptoms of pyelonephritis. In 21 cases the hydronephrosis was located on the right and in 4 cases it was bilateral. Maximal lower calix diameter was 12 mm (range 9-22 mm). With the exception of two cases, sonographically controlled stent placement was performed under local anesthesia without sedation. All patients were painfree within 6 days and were given prophylactic low doses of antibiotic until the day of delivery. Renal function remained within the normal limits. Double-J stent displacement occurred in 3 patients - of which one underwent nephrostomy. Postnatal examination demonstrated urolithiasis in 4 of 19 patients. This study provides evidence for effectiveness of retrograde ureteral Double-J stent placement as a therapeutic option in cases of severe symptomatic hydronephrosis during pregnancy with a low morbidity rate.

Combined percutaneous antegrade and cystoscopic retrograde ureteral stent placement: an alternative technique in cases of ureteral discontinuity

We describe an alternative method of double J stent placement for ureteral transection following the failure of traditional antegrade and retrograde approaches. Cystoscopically, a guidewire was placed across the distal ureteral segment and was advanced into a urinoma cavity at the level of the transected ureter. Subsequently, an antegrade approach was used to place a gooseneck snare through the proximal ureteral segment into the urinoma cavity. The guidewire was grasped with the snare and pulled through the percutaneous access site. A double J ureteral stent was then placed using the typical antegrade method.

New technique of ureteral stent placement for impacted ureteral calculus: the glidewire loop technique

Impacted ureteral stones pose a challenge during retrograde ureteral stenting. Multiple attempts to bypass the obstruction with conventional guide wires often fail and may result in perforation of the ureter. We describe a new, simple approach to overcome this common problem by utilizing a retrograde glidewire loop technique. The technique described allows safe and successful bypassing and stenting of ureteral obstruction.

Technical report: Fluoroscopically guided retrograde ureteric stent retrieval and replacement using a guide catheter directed snare

Technical report: Fluoroscopically guided retrograde ureteric stent retrieval and replacement using a guide catheter directed snare

Ureteral stenting using a combined antegrade/retrograde procedure. A technique for difficult cases.

Ureteral stenting is a procedure of daily routine. There are however cases in which cystoscopic placement of a stent fails despite various technical aids. Percutaneous nephrostomy is usually performed in those patients. In some cases however it is no reasonable alternative. For these special cases we used a combined antegrade/retrograde technique consisting in antegrade guide wire insertion followed by retrograde ureteral stenting. In 8 of 12 cases it was finally possible to insert a ureteral stent with this method. To our mind this technique should be applied when other attempts of stenting have failed and percutaneous nephrostomy is no reasonable alternative.

Palliative percutaneous and endoscopic urinary diversion for malignant ureteral obstruction

We performed a retrospective analysis of 22 patients with malignant ureteral obstruction who underwent palliative urinary diversion by retrograde ureteral stenting or nephrostomy tube placement. The average duration of survival after diversion was 526 days and was unrelated to tumor type, patient's age or sex, renal function, or indications for diversion. As a group, patients without previous hormonal or chemotherapy survived longer. Morbidity related to the urinary diversion was low. The majority of patients (77%) were discharged from the hospital, and this group spent 86 percent of their survival time at home. We conclude that modern palliative urinary diversion can be performed with low morbidity and can result in long-term survival and improved quality of life. Predictions or assumptions concerning survival of individual patients should be made with caution.