Retrograde radiological retrieval and replacement of double-J ureteric stents

Efficacy of the direct grasping technique using pean forceps under fluoroscopy to replace ureteral stents in women

Purpose : To evaluate the efficacy of the direct grasping technique using pean forceps under fluoroscopic guidance for ureteral stent replacement in women. Methods : Between April 2018 and September 2020, 28 female patients underwent ureteral stent replacements at our facility, and 184 stent replacement procedures were performed. A total of 127 stents were replaced using pean forceps under fluoroscopic guidance (pean forceps group), and 57 stents were replaced using the cystoscope (cystoscopy group). Clinical characteristics and surgical outcomes were compared between the groups. Results : All stents were successfully replaced. There was a statistically significant difference in the procedure time between the two groups (median [interquartile range], pean forceps group : 10.8 [8.2-13.9] minutes vs. cystoscopy group : 15.8 [11.1-20.9] minutes, P < 0.001). There were no intraoperative complications in either group and no difference in the incidence of postoperative complications (pean forceps group : 1.6% vs. cystoscopy group : 1.8%, P = 1.000). Fluoroscopy time was longer in the pean forceps group, although this difference was not statistically significant (pean forceps group : 38.9 [22.6-60.1] seconds vs. cystoscopy group : 33.0 [20.0-48.9] seconds, P = 0.0558). Conclusion : The direct grasping technique using pean forceps under fluoroscopy may be a beneficial alternative to cystoscopy for ureteral stent replacement in women. J. Med. Invest. 68 : 326-329, August, 2021.

Radiological retrograde ureteric stent exchange in women: a single-centre review

AIM

To evaluate the safety and efficacy of modified wire loop technique for retrograde stent exchange.

MATERIALS AND METHODS

All patients were from the KK Women and Children's Hospital where there is no on-site urology service. Patients were identified retrospectively from the institutional radiological information system (RIS) database. In total, 270 stents were removed and 238 replaced for 79 patients between January 2012 to December 2016. Success rates for stent removal and exchange as well as skin dose and fluoroscopy time were assessed.

RESULTS

Stent exchange was successful in 234/238 (98%) of cases. Failure was due to loss of access (one case), inability to snare stent due to distorted anatomy (two cases), and extensive encrustation of stent (one case). In 252/270 (93%) cases, stent was removed using modified snare while in 18 (7%) cases, other snare devices were used. Average fluoroscopy time per stent for stent exchange was 573 seconds and average skin dose was 12,494 DAP/mGy•cm².

CONCLUSION

Fluoroscopy-guided retrograde ureteric stent exchange using the modified snare loop technique is effective, quick, and can be performed easily with equipment used in daily intervention practice. It may also be coupled with ureteroplasty, which may help the patient achieve eventual stent-free status.

A prospective and randomized comparison of rigid ureteroscopic to flexible cystoscopic retrieval of ureteral stents

Background

Flexible cystoscopy has become an accepted alternative for stent retrieval. However, it is associated with higher cost. Some reports have described experiences of using rigid ureteroscope to retrieve ureteral stents. We compared rigid ureteroscopic to flexible cystoscopic retrieval of ureteral stents in a prospective and randomized clinical trial.

Methods

Three hundred patients treated with ureteral stents between July 2012 and July 2013 were accrued in this study. These patients were divided into two groups using the random number table method. Group A, with 162 patients, had stents removed with a flexible cystoscope and Group B, with 138 patients, had stents removed with a rigid ureteroscope. All procedures were performed under topical anesthesia by the same urologist. Patients in each group were compared in terms of preoperative, perioperative, and postoperative data. Postoperative data were collected using telephone interview on the postoperative day two. The postoperative questionnaire used included three items: hematuria, irritable bladder symptoms, and pain scores.

Results

All the stents were retrieved successfully. No statistical differences were noted between the two groups in terms of gender, age, laterality and duration of the stents, operative time, postoperative hematuria, irritable bladder symptoms, and pain scores. The per-use cost of instrument was much higher for the flexible cystoscopic group, RMB 723.1 versus 214.3 (USD 107.9 versus 28.2), P < 0.05.

Conclusion

Ureteral stent retrieval using rigid ureteroscope under topical anesthesia is as safe and effective as flexible cystoscope but with a much lower cost to patients.

Trial registration

This study was registered with Chinese Clinical Trial Registry on March 27, 2017 (retrospective registration) with a trial registration number of ChiCTR-IOR-17010986.

Facilitate Stent Removal: Magnetic DJ Stent

A 23-year-old male patient was performed semirigid ureterorenoscopy and laser lithotripsy with placement magnetic DJ stent because of right urethral stone. Removal of the magnetic DJ stent does not need a second procedure such as cystoscopy for the patients. This technique is easy to learn and should be considered as suitable for use on an outpatient basis.

Clinical significance of ureteral stent removal by flexible cystoscopy on pain and satisfaction in young males: a prospective randomised control trial

The cystoscopic removal of ureteral stents causes discomfort and pain, especially in young male patients. We aimed to evaluate the usefulness of ureteral stent removal by flexible cystoscopy on pain and satisfaction in young males. In total, 104 patients undergoing ureteroscopic removal of stones with indwelling of ureteral stent (May 2013-July 2015) were randomised to receive a ureteral stent removal by either rigid cystoscopy (group 1) or flexible cystoscopy (group 2). Visual analogue scale (VAS) pain score and satisfaction scale score were assessed immediately after stent removal. All patients were males and the mean age was 22.72 ± 2.49 years. Group 2 showed significantly lower VAS pain score (p < 0.001) and higher satisfaction scale score (p < 0.001) than group 1. Ureteral stent removal by flexible cystoscopy may offer advantages on pain and satisfaction to young male patients.

Manual Replacement of Double J Stent Without Fluoroscopy (Double j stent replacement)

It is not always possible to replace a ureteric stent with a new one due to the fact that tumoral effect increases in ureter with time. We present our experience of manual replacement of double J stent without fluoroscopy. The data from 23 female patients who underwent double J stent replacement with a total of 110 times was retrospectively analyzed. The steps of technique are as follows: take out distal end of the double J stent through urethra to external urethral meatus cystoscopically, insert a 0.035-inch guide wire through double J stent to the renal pelvis or intra pelvicaliceal system, take out old double J stent over guide wire, slide new stent over guide wire and at external meatus level take out guide wire while gently sliding distal end of double J stent over guide wire into urethra. The mean age was 58.39 ± 9.21 years. Cervical, endometrial, and ovarian cancer were diagnosed in 16, 4, and 3 patients respectively. The mean follow-up and indwelling period were 13.8 ± 5.2, 3.8 ± 0.6 months, respectively. Increased pelvicaliceal dilatation, serum creatinine level, or renal parenchymal loss was not observed. Replacement of double J stents with this technique is easy and can be used successfully in distal ureteral obstructions.

Pain and satisfaction during rigid cystoscopic ureteral stent removal: a preliminary study

BACKGROUND

Cystoscopy evokes discomfort and pain, especially in males. The cystoscopic retrograde approach is standard in the removal of ureteral stents. However the satisfaction and degree of pain during the procedure according to the use of several pain controlling methods are unclear.

METHODS

This is a cross-sectional survey of 60 patients who underwent cystoscopic ureteral stent removal under intravenous analgesics (group 1, n = 20), midazolam induction (group 2, n = 20), and propofol (group 3, n = 20). Procedural pain and post-procedure satisfaction were determined, and cost differences between the approaches were clarified.

RESULTS

Group 2 and 3 showed significantly less pain than group 1 (P < 0.001) and significantly higher satisfaction rate than group 1 (P < 0.001). Comparison of groups 2 and 3 revealed showed significantly less pain and higher satisfaction rate in group 3 (P < 0.001 for both). In Group 1, 17 (85.0%) patients wanted other treatment modalities, compared to eight group 2 patients (40.0%) and no group 3 patients.

CONCLUSIONS

Considering the potential pain and dissatisfaction of rigid cystoscopic ureteral stent removal, procedures utilizing moderate sedation with midazolam or general anesthesia using propofol without muscle relaxation should be considered.

TRIAL REGISTRATION

KCT0001260.

A preliminary study of the variability in location of the ureteral orifices with bladder filling by fluoroscopic guidance: the gender difference

BACKGROUND AND PURPOSE

To determine landmarks for stent positioning in both ureteral orifices (UOs) and the gender differences in their location in men and women.

PATIENTS AND METHODS

The location of the UO and the bladder neck (BN) was measured fluoroscopically by the intravesical distal location of an open-ended catheter marked with radiopaque materials. We compared the location in men (n = 12) and women (n = 12) with a full bladder (hydrostatic pressure of 50 cmH2O) or an empty bladder.

RESULTS

The mean distances from BN to UO in men and women were significantly different both in an empty bladder (2.5 ± 0.4 and 2.1 ± 0.3 cm, respectively) and in a full bladder (2.9 ± 1.0 and 2.3 ± 0.6 cm, respectively). The location of UO was changed by bladder filling in women but not in men. In women, most UOs were found superior to the symphysis pubis (SP) in empty bladder (66.6 %). Most of this location was observed at behind the upper boarder of SP in full bladder of women (75 %). The BN of women was located at the lower level in basal state compared to men. Also, the location of BN was markedly changed by bladder fulling in women (p = 0.04) but not in men.

CONCLUSIONS

Significant gender differences were observed in the location of UO and BN. Clinicians should keep in mind the anatomical differences between men and women during fluoroscopic-guided procedure.

Retrieval of proximally migrated double J ureteric stents in children using goose neck snare

Purpose:

Proximal migration of the ureteric double J stent is a rare but known complication. We describe three cases where a minimally invasive technique for retrieval of displaced double J stents using Amplatz^™ goose-neck snare was successful.

Materials and Methods:

A retrospective review of patients with displaced double J stent was carried out, in whom cystoscopy guided retrieval of double J stent was attempted with the help of Amplatz goose-neck snare under radiological control.

Results:

All three patients were under the age of 3 years. Two patients had migrated double J stent following pyeloplasty and in one patient the double J stent was displaced during a retrograde insertion of double J stent. In all cases, retrieval of displaced double J stent was successfully achieved using Amplatz goose-neck snare. There were no postoperative complications.

Conclusion:

Our method of retrieval of stent from renal pelvis is simple, safe and minimally invasive. This technique is a useful and safe alternative option for retrieval of proximally migrated double J stents in children.

Percutaneous antegrade ureteric stent removal using a rigid alligator forceps

To evaluate the safety and efficacy of percutaneous antegrade ureteric stent removal using a rigid alligator forceps. Twenty patients were included in our study. Indications for ureteric stent insertion included stone disease (n = 7), malignancy (n = 8) and transplant anastomotic strictures (n = 5). Stent retrieval was carried out for proximal stent placement/migration in seven patients and encrustation in the remaining 13. Twenty-two stents were successfully retrieved in 20 patients. There was one technical failure (5%). There were no major complications. We had four minor complications, which included nephrostomy site pain (n = 2), periprocedural sepsis (n = 1) and a small urinoma (n = 1). All patients settled with conservative management. Percutaneous radiologically guided antegrade ureteric stent removal with an alligator forceps is safe and effective, particularly when initial surgical removal has failed.

Fluoroscopically guided retrograde replacement of ureteral stents

PURPOSE

We assessed the feasibility of fluoroscopically guided transurethral replacement of ureteral stents as an alternative to cystoscopy.

MATERIALS AND METHODS

Over the last year, we replaced 27 double-J ureteral stents in 20 patients (10 men and 10 women; mean age 67.7 years, range 43-83); 15/20 patients had a native kidney, 3/20 had a transplanted kidney and 2/20 had a ureteroileal conduit. The procedures were performed in the angiography suite with the patient under sedation. All stents were grasped with a gooseneck snare under fluoroscopic control, and the distal end was withdrawn just outside the urethra; then a wire was advanced through the stent lumen and positioned in the renal pelvis. The stent was then removed and replaced with a new double-J stent.

RESULTS

The procedures were successful in 26/27 cases. We observed 7 cases of mild haematuria that resolved spontaneously. During follow-up (1-16 months, mean 6.7), stent obstruction occurred in 4 cases, requiring an additional retrograde replacement.

CONCLUSIONS

Transurethral fluoroscopically guided retrograde replacement of dysfunctioning ureteral stents is an effective and safe alternative to cystoscopy.

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

OBJECTIVE

To evaluate a new method for retrograde ureteropyelography and retrograde ureteric stent placement.

PATIENTS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.