Ureteral stent placement without postprocedural nephrostomy tube: experience in 41 patients

Imaging-Guided De Novo Retrograde Ureteral Access and Stent Placement without Cystoscopy in Women

PURPOSE

To evaluate the feasibility of a new technique for imaging-guided de novo retrograde ureteral double J (DJ) stent placement without cystoscopy in women.

MATERIALS AND METHODS

Eighty-four women referred for ureteral stent placement between April 2019 and January 2022 were included. In all the patients, the initial attempt for stent placement was performed in a retrograde fashion. Successful ureteral catheterization and DJ stent placement were considered as technical success. The fluoroscopy time required to catheterize the ureter and that for the entire procedure were recorded. Factors affecting the technical success rate and fluoroscopy time were examined.

RESULTS

A total of 108 ureteral stent placement procedures in 84 women, with a mean age of 57.5 years (range, 19-85 years), were performed. The most common underlying pathologies were cervical (n = 33, 31%) and ovarian (n = 32, 30%) carcinomas. The most commonly involved segments of the ureter were the lower half (n = 44, 40%) and trigone (n = 39, 36%). The technical success rate was 81.5%, and it reached 93% in the case of lower-half ureteral obstruction. Distorted trigonal anatomy caused by external compression of the bladder wall by a mass was associated with a higher rate of technical failure (90.6% vs 47.8%; P < .001). The use of ultrasound guidance to guide the sheath to the ureteral orifice allowed for a significant decrease in the fluoroscopy time for ureteral catheterization (4.6 minutes ± 3.91 vs 2.26 minutes ± 2.32; P = .003) and that for the entire procedure (9.42 minutes ± 4.95 vs 5.93 minutes ± 4.06; P = .001).

CONCLUSIONS

Imaging-guided de novo retrograde ureteral catheterization and stent placement can be successfully performed in a high percentage of patients within a reasonable fluoroscopy time without the need for cystoscopy in women.

To tube or not to tube? Utilising a tubeless antegrade ureteric stenting system in a tertiary referral hospital

INTRODUCTION

To assess the benefits and complications of developing a practice of single-stage primary ureteral stenting in a university hospital.

METHODS

A practice change developed from the traditional practice of multi-stage stenting to single-episode stent placement. To evaluate this change of practice, we retrospectively analysed data of 70 patients who underwent primary tubeless antegrade ureteric stenting and compared this group to the previous 54 patients who had a covering nephrostomy.

RESULTS

There was an overall success rate of 91.3% (85/93 stents having had tubeless antegrade stenting). There were no major and 33 minor complications. The comparative group of 54 patients whose stents had a covering nephrostomy had a median length of stay of 13.2 days compared to 7.4 days for the tubeless group.

CONCLUSION

Single-stage primary ureteric stenting is a safe practice to employ and has universal benefits for both the patient and the health service.

Primary and Secondary Percutaneous Ureteral Stent Placement: Comparison of Stent Patency and Clinical Outcome

OBJECTIVES

To compare early double J ureteral stent (DJUS) dysfunction rate and long-term patency between two percutaneous ureteral stent placement methods: single-stage (primary) or two-stage (secondary) procedures.

METHODS

A total of 250 (176 primary and 74 secondary) DJUS placements performed on interventional unit were retrospectively reviewed between February 2008 and March 2014. Early DJUS dysfunction was defined as no passage of contrast media into the urinary bladder in 2-3 days after placement. Long-term patency was considered if the ureteral stent functioned for 3 months (time point for a first routine DJUS change). Amount of blood retained in the collecting system was scored on nephrostogram immediately after DJUS placement with three levels of score.

RESULTS

The overall early DJUS dysfunction rate and long-term patency rate were 30.8 and 96.7%. The early DJUS dysfunction rates were similar in primary and secondary DJUS placements (30.7 and 31.1%, P = 0.950). The long-term patency rates were similar in primary and secondary groups (96.2 and 97.9%, P = 0.928). The amount of blood retained in the collecting system between primary and secondary groups was not significantly different. The early DJUS dysfunction rate significantly increased with increasing blood retention.

CONCLUSIONS

The early DJUS dysfunction rates and long-term patency are similar in primary and secondary DJUS placement. However, the early DJUS dysfunction rate can be increased by increasing the blood retention in the collecting system.

Nephroureteral stents: principles and techniques

Nephroureteral stents including antegrade, retrograde, or internal (double-J) stents are routinely placed by interventional radiologists. The purpose of this review is to provide a detailed and comprehensive description of indications, contraindications, technique, and various technical challenges of these procedures. Also pre- and postprocedure management of patients will be discussed including routine follow-up and dealing with potential complications.

Pediatric urologic interventional radiology

Interventional radiologists are playing an increasingly important role in pediatric urologic intervention, working closely with the pediatric urologist. Interventional radiologists are frequently asked to establish percutaneous access to the renal collecting system prior to nephrolithotomy. Additionally, procedures such as percutaneous nephrostomy, ureteral stent placement and exchange, and renal parenchymal biopsy are frequently encountered requests. This article will review these common procedures and highlight techniques and pathology that are unique to the pediatric population.

Endourologic management of malignant ureteral obstruction: indications, results, and quality-of-life issues

Obstruction of the upper urinary tract is a problem commonly faced by practicing urologists. The constant evolution in endourology has effectively facilitated minimally invasive management of upper-tract obstruction. In a case in which malignancy is the cause of obstruction, however, the situation significantly changes. Questions arise regarding the need for relieving the obstruction, the means to accomplish this, and the benefits and drawbacks of each technique regarding both their efficacy and their impact on the patients well-being and the crucial issue of quality of life in the face of malignancy.

One-stage tubeless antegrade ureteric stenting: a safe and cost-effective option?

INTRODUCTION

Antegrade insertion of ureteric stent has become an established mode of management of upper tract obstruction secondary to ureteric pathology. It is conventionally performed as a two-stage procedure for various reasons but, more recently, a one-stage approach has been adopted.

PATIENTS AND METHODS

We discuss our experience of primary one-stage insertion of antegrade ureteric stent as a safe and cost-effective option for the management of these difficult cases in this retrospective observational case cohort study of patients referred to a radiology department for decompression of obstructed upper tracts. Data were retrieved from case notes and a radiology database for patients undergoing one-stage and two-stage antegrade stenting. It was followed by telephone survey of regional centres about the prevalent local practice for antegrade stenting. Outcome measures like hospital stay, procedural costs, requirement of analgesia/antimicrobials and complication rates were compared for the two approaches.

RESULTS

a one-stage approach was found to be suitable in most cases with many advantages over the two-stage approach with comparable or better outcomes at lower costs. Some of the limitations of the study were retrospective data collection, more than one radiologist performing stenting procedures and non-availability of interventional radiologist falsely raising the incidence of two-stage procedures.

CONCLUSIONS

In the absence of any clinical contra-indications and subject to availability of an interventional radiologist's support, one-stage antegrade stenting could easily be adopted as a routine approach for the management of benign or malignant ureteric obstruction.

Steerable antegrade stenting: a new trick of the trade

INTRODUCTION

Whereas a retrograde attempt to insert an indwelling stent is performed in lithotomy position, usually renal access is gained in a prone position. To overcome the time loss of patient repositioning, a renal puncture can be performed in a modified lithotomy position with torqued truncus and slightly elevated flank. There is a two-fold advantage of this position: transurethral and transrenal access can be obtained using a combined approach. In the present study, this simple technique is used to position a floppy guide wire through a modified needle directly through the renal pelvis into the ureter.

MATERIALS AND METHODS

The kidney is punctured in the modified lithotomy position under sonographic control using an initial three-part puncture needle. A floppy tip guide-wire is inserted into the collecting system via the needle after retrieving the stylet. The retracted needle is bent at the tip while the guide-wire is secured in the needle and the collecting system. The use of the floppy tip guide-wire helps to insert the curved needle back into the kidney pelvis, which becomes the precise guidance for the now steerable wire. The desired steerable stent is positioned under radiographic control in a retrograde fashion over the endoscopically harbored tip of the guide-wire. Two patient cohorts (newly described method and conventional method) were compared.

RESULTS

The presented steering procedure saves 16.5 mean minutes compared to the conventional antegrade stenting and 79.5 Euros compared to the control group.

CONCLUSION

The described combined antegrade-retrograde stent placement through a bent three-part puncture needle results in both clinical superiority (OR time, success rate) and financial benefits.

Is the routine check nephrostogram following percutaneous antegrade ureteric stent placement necessary?

Our aim was to review our experience with percutaneous antegrade ureteric stent (PAUS) placement and to determine if the routinely conducted check nephrostogram on the day following ureteric stent placement was necessary. Retrospective review of patients who had undergone PAUS placement between January 2004 and December 2005 was performed. There were 83 subjects (36 males, 47 females), with a mean age of 59.9 years (range, 22-94 years). Average follow-up duration was 7.1 months (range, 1-24 months). The most common indications for PAUS placement were ureteric obstruction due to metastatic disease (n = 56) and urinary calculi (n = 34). Technical success was 93.2% (96/103 attempts), with no major immediate procedure-related complications or mortalities. The Bard 7Fr Urosoft DJ Stent was used in more than 95% of the cases. Eighty-one of 89 (91.0%) check nephrostograms demonstrated a patent ureteric stent with resultant safety catheter removal. Three check nephrostograms revealed distal stent migration requiring repositioning by a goose-snare, while five others showed stent occlusion necessitating permanent external drainage by nephrostomy drainage catheter reinsertion. Following PAUS placement, the serum creatinine level improved or stabilized in 82% of patients. The serum creatinine outcome difference between the groups with benign and malignant indications for PAUS placement was not statistically significant (p = 0.145) but resolution of hydronephrosis was significantly better (p = 0.008) in patients with benign indications. Percutaneous antegrade ureteric stent placement is a safe and effective means of relief for ureteric obstruction. The check nephrostogram following ureteric stent placement was unnecessary in the majority of patients.

Direct primary or secondary percutaneous ureteral stenting: what is the most compliant option in patients with malignant ureteral obstructions?

The objective of this study was to analyze three ureteral stenting techniques in patients with malignant ureteral obstructions, considering the indications, techniques, procedural costs, and complications. In the period between June 2003 and June 2006, 45 patients with bilateral malignant ureteral obstructions were evaluated (24 males, 21 females; average age, 68.3; range, 42-87). All of the patients were treated with ureteral stenting: 30 (mild strictures) with direct stenting (insertion of the stent without predilation), 30 (moderate/severe strictures) with primary stenting (insertion of the stent after predilation in a one-stage procedure), and 30 (mild/moderate/severe strictures with infection) with secondary stenting (insertion of the stent after predilation and 2-3 days after nephrostomy). The incidence of complications and procedural costs were compared by a statistical analysis. The primary technical success rate was 98.89%. We did not observe any major complications. The minor complication rate was 11.1%. The incidence of complications for the various techniques was not statistically significantly. The statistical analysis of costs demonstrated that the average cost of secondary stenting (637 euros; SD, 115 euros) was significantly higher than that of procedures which involved direct or primary stenting (560 euros; SD, 108 euros). We conclude that one-step stenting (direct or primary) is a valid option to secondary stenting in correctly selected patients, owing to the fact that when the procedure is performed by expert interventional radiologists there are high technical success rates, low complication rates, and a reduction in costs.

Percutaneous nephrostomy and antegrade ureteral stenting: technique-indications-complications

In this review the technique, indication for and complications of percutaneous nephrostomy (PCN) and antegrade ureter stent insertion are described. In the majority of the cases PCN is performed to relieve urinary obstruction, which can be of benign or malignant nature. Another indication for PCN is for treatment of urinary fistulas. PCN can be performed under ultrasound and/or fluoroscopic guidance, with a success rate of more than 90%. The complication rate is approximately 10% for major and minor complications together and 4-5% for major complications only. Percutaneous antegrade double-J stent insertion usually is performed if retrograde ureter stenting has not been successful. However, especially in malignant obstructions, the success rate for antegrade stenting is higher than for retrograde transvesical double-J stent insertion. In the case of severe infection and bleeding after PCN JJ-stent insertion may be contraindicated so long as there is no sufficient concomitant drainage via a PCN . Lower urinary tract dysfunction should be excluded before stent placement. The complication rate is 2-4%. Consequent stent surveillance with regular stent exchange is mandatory.

Percutaneous Treatment of the Obstructive Uropathy

Purpose

to analyse the technical aspects, the patient's selection criteria, and some useful tactics to reduce the complications of percutaneous nephrostomy and of other interventional procedures to temporarily treat obstructive uropathy (OU), such as double J stent insertion, dilatation of the stricture using high-pressure balloon catheters, removal of renal or ureteral calculi, fistulas treatment.

Materials and Methods

a fluoroscopy table and an ultrasonographic guidance are key elements. Two techniques are employed, either the Seldinger type (wire-guided catheters) or the trocar needle type. Sole contraindication: uncorrectable severe coagulopathy. Most important risk factors are: dendritic calculus, non corrected high blood pressure, obesity, small size kidney, severe scoliosis.

Results

high technical success of the procedure in case of dilated collecting systems (98%); it is minor without dilatation (85%).

Conclusion

percutaneous nephrostomy is indicated in 87% of obstructive uropathy cases. It represents the basic technique allowing other interventional procedures to treat obstructive uropathy; it should be performed by most radiologists following an adequate training with technique and materials.