Fluoroscopic Guidance of Retrograde Exchange of Ureteral Stents in Women

The optimal stent pusher position to achieve successful ureteral stent insertion under fluoroscopic guidance

Objective

To examine factors to predict the optimal stent pusher position when inserting ureteral stents under fluoroscopy.

Methods

We retrospectively reviewed 327 patients who underwent ureteral stent insertion. We considered the pubic bone as a useful anatomical landmark to insert ureteral stents under fluoroscopic guidance. Thus, we categorized patients into three groups (proximal, middle, and distal groups) according to the position of the radiopaque tip of the push catheter when inserting the ureteral stent. Success was defined as a completely curled ureteral stent tail. We compared stent insertion success rates among the three groups. A multivariate analysis was performed to identify the factors affecting stent insertion success.

Results

In men, 36 (63.2%) cases were deemed successful in the proximal group compared with 40 (80.0%) cases in the middle group and 12 (20.7%) cases in the distal group (p<0.001). In women, 26 (45.6%) cases were deemed successful in the proximal group compared with 54 (98.2%) cases in the middle group and 38 (76.0%) cases in the distal group (p<0.001). With the multivariate analysis, the stent pusher position was the most significant factor influencing successful stent insertion (men: odds ratio 6.00, 95% confidence interval 2.66-13.51, p<0.001; women: odds ratio 37.80, 95% confidence interval 4.94-289.22, p<0.001).

Conclusion

The position of the stent pusher affects stent insertion success. The middle of the pubic symphysis is the optimal position for the radiopaque tip of the pusher when inserting ureteral stents under fluoroscopic guidance.

Percutaneous snare-retrieval of intracardiac thrombus under fluoroscopic and transesophageal echocardiography guidance: case report and systematic review

Intracardiac foreign bodies (IFB) are rare clinical conditions. There are now several reports on the percutaneous retrieval of IFB under fluoroscopy. However, some IFB are not radiopaque, and retrieval requires combined fluoroscopic and ultrasound guidance. We report the case of a bedridden 23-year-old male patient with T-lymphoblastic lymphoma treated with long-term chemotherapy. Ultrasound examination diagnosed a huge thrombus in the right atrium near the opening of the inferior vena cava which affected the patency of his PICC line. Ten days of anticoagulant therapy did not modify the thrombus size. Open heart surgery was not feasible because of the patient clinical condition. Snare-capture of the non-opaque thrombus was done from the femoral vein under fluoroscopic and ultrasound guidance with excellent outcomes. We also present a systematic review of IFB. We found out that percutaneous removal of IFBs is a safe and effective procedure. The youngest patient who received percutaneous IFB retrieval was 10 days old and weighed only 800 g, while the oldest patient was 70 years old. Port catheters (43.5%) and PICC lines (42.3%) were the most commonly found IFBs. Snare catheters and forceps were the most commonly used instruments.

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.

Removal and repositioning of urinary tract implants by use of an endovascular snare system in dogs and cats (2013-2019)

OBJECTIVE

To report the fluoroscopic removal or repositioning of urinary tract implants in dogs and cats by use of an endovascular snare system (ESS) and to report procedural usefulness and complications in dogs and cats.

ANIMALS

3 cats and 14 dogs.

PROCEDURES

A medical records review was performed to identify dogs and cats that underwent removal or repositioning of urinary tract foreign bodies or implants by use of an ESS with fluoroscopic guidance at a veterinary teaching hospital from 2013 to 2019.

RESULTS

Dogs had a median weight of 25 kg (55 lb) with a range of 3.5 to 60.6 kg (7.7 to 133.3 lb), and cats had a median weight of 5 kg (11 lb) with a range of 4.2 to 5.4 kg (9.2 to 11.9 lb). By use of an ESS, 12 patients (2 cats and 10 dogs) underwent transurethral retrieval of retained vesicourethral implants or ureteral stents, 2 dogs underwent transurethral ureteral stent repositioning, 1 cat and 2 dogs underwent transnephric retrieval of ureteral stents, and 1 dog underwent cystoscopic-assisted transureteral ureteral stent retrieval. All procedures were successfully performed, and there were no associated procedural complications.

CONCLUSIONS AND CLINICAL RELEVANCE

Retained vesicourethral implants or ureteral stents were successfully retrieved by use of an ESS in dogs and cats transurethrally or with an open or percutaneous transnephric approach and fluoroscopic guidance. These techniques should be considered as an alternative or adjunct to more invasive methods for implant retrieval or manipulation.

Retrograde ureteric stent exchange in the female oncology patient by interventional radiology: the experience of a single tertiary referral centre

BACKGROUND

Double-J stents are used to treat ureteric outflow obstruction. Deployed in antegrade or retrograde fashion, they relieve ureteric obstruction in several conditions including ureteric calculi, strictures and malignancy. Traditionally exchanged in an operating theatre (OT) under general anaesthetic (GA), more recently described is the technique of using fluoroscopic guidance under sedation.

AIMS

To assess the efficacy and safety of retrograde double-J stent exchange in an interventional radiology (IR) setting in a tertiary oncology referral centre over a 7-year period.

METHODS

Clinical data on 460 double-J stent exchanges in 126 female patients was acquired from the hospital electronic patient record. Four fellowship-trained interventional radiologists performed the procedures. A standard approach was used in conjunction with conscious sedation using midazolam and fentanyl. Use of the technique with certain anatomical variations is also described.

RESULTS

Technical success rate was 96%. The main reasons for failure included failure to snare the stent (1.8%) and patient discomfort (1.1%). The overall complication rate was 5%: 5 category 1 (minor) and 18 category 3 outcomes, with the latter group requiring further intervention. Average screening time was 9.65 min and the average radiation dose was 2018.24 mGy/m2. We also demonstrate the successful use of this method in patients with unusual anatomy and ileal conduits.

CONCLUSION

Fluoroscopic-guided retrograde double-J stent exchange is a safe and effective procedure that can be performed with a high degree of success using equipment and techniques used in daily IR practice. This approach precludes the need for GA, reduces OT utilisation and is well tolerated in a patient group for whom this procedure is typically palliative.

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.

Use of a magnetic double J stent in pediatric patients: A case-control study at two Canadian pediatric centers

BACKGROUND

Ureteral stents with magnetic tips (Blackstar©) were recently approved for use in Canada. To our knowledge this is the first published evidence of their use in pediatric patients. Traditionally, pediatric stent insertion and removal are performed under general anesthetic. Magnetic stents have three main benefits in pediatric patients; cost savings, decreased OR time and reduced general anesthetic exposure.

METHODS

This study was a proof of concept pilot, ran from May 2017-May 2018 to demonstrate the safety and efficacy of magnetic stents in pediatric patients. Patients undergoing ureteroscopy, ureteric re-implantation, and pyeloplasty with simultaneous magnetic stent insertion. Forty (40) patients had regular double J stents removed under anesthesia and served as control cases, and 40 patients had a magnetic double J at initial surgery at two different sites, CHU de Quebec and Alberta Children's Hospital.

RESULTS

Overall, 39 magnetic stents were successfully retrieved without general anesthetic, representing a retrieval failure rate of only 2.5%.

CONCLUSION

As demonstrated in our research, magnetic stents represent a safe and equally effective alternative to traditional stents, especially in a pediatric patient. This is because, at worst, if retrieval of the magnetic stent fails, traditional cystoscopic removal can be performed, so nothing is lost.

STUDY TYPE

Case-control study.

LEVEL OF EVIDENCE

Level III.

Trans-Urethral Ureteral Stent Replacement Technique (TRUST): 10-Year Experience in 1168 Patients

OBJECTIVES

To affirm technical success, clinical success and safety of fluoroscopically guided transurethral replacement of double-J (DJ) ureteral stents.

METHODS

From January 2005 to December 2015, in a follow-up period ranging from 9 to 73 months, we replaced 6167 DJ ureteral stents in 3221 procedures in 1168 patients. All the procedures were performed in the angiography suite under fluoroscopic control.

RESULTS

Technical success was achieved in 97.5% of the procedures. In eighty procedures, cystoscopic approach was necessary; time from previous procedure and side were significantly associated with technical success. Clinical success was reached in 95.7% of the procedures and was significantly lower in urological and gynaecological tumours (when compared to fibrosis and other causes) and in bilateral stents. No major complications were reported. In 90 cases, self-limiting transient minor haematuria occurred and in 160 procedures urinary tract infection responding to antibiotics were registered. Overall procedure time was 27 min. Mean fluoroscopic time was 6 min and 45 s. Mean radiation dose of the procedure was 38.40 Gy cm².

CONCLUSIONS

In patients that need routine replacement of DJ ureteral stent, transurethral fluoroscopically guided method may be the first choice; only in few cases of technical failure, cystoscopy may be considered.

Fluoroscopy Guided Transurethral Placement of Ureteral Metallic Stents

Ureteral stent exchange is usually performed under both fluoroscopic and cystoscopic guidance. We experienced two cases with retrograde placement of metallic ureteral stent via urethra under fluoroscopic guidance. When patients with double-J ureteral stent (DJUS)have symptom and want to change DJUS to metallic stent, fluoroscopic guided transurethral placement of ureteral metallic stent is a good option as alternative of cystoscopic procedure or percutaneous procedure through percutaneous nephrostomy tract.

Fluoroscopically guided transurethral removal and/or replacement of ureteric stents in women

BACKGROUND

Traditionally double J ureteric stents have been removed and replaced via cystoscopy. Fluoroscopically guided procedures for the removal/replacement of stents using endovascular snare devices have previously been described as a successful alternative.

PURPOSE

To evaluate the technical and clinical success of fluoroscopically guided transurethral removal and/or replacement of ureteric stents in women. To assess radiation dose and screening time associated with this approach.

MATERIAL AND METHODS

A 31-month retrospective review of all ureteric stent removals and/or replacements under fluoroscopic guidance performed in a university hospital radiology department.

RESULTS

One hundred and fourteen procedures were performed in 83 patients. Thirty ureteric stents were removed and 84 ureteric stents were replaced. The majority of patients required stents for urinary tract obstruction secondary to malignancy (78.3%). Overall technical and clinical success rates (defined respectively as satisfactory removal/replacement and drainage of the collecting system) of 98.2% were attained. Mean screening time was 13.9 min (range, 1.0-67.6 min). Effective radiation dose was in the range of 0.69-132 mSv with a mean of 11.18 mSv equating to the dose of a contrast-enhanced computed tomography abdomen/pelvis.

CONCLUSION

Transurethral ureteric stent removal and replacement under fluoroscopic guidance is highly successful, well tolerated by patients with acceptable radiation exposure, and can obviate the need for cystoscopic retrieval.

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.

Retrograde fluoroscopy-guided trans-urethral exchange of ureteral stents: Comparison of direct grasping vs. modified snare

BACKGROUND

Several different techniques including guide-wire lasso, simple snare, modified snare (MS) and direct grasping (DG), are available for retrograde ureteral stent retrieval and exchange. Choice among them is not always easy and depends on many different factors, including the local level of expertise.

OBJECTIVE

To compare the MS and DG during retrograde exchange of double-J ureteral stent under fluoroscopic guidance.

SETTINGS AND DESIGN

66 patients (36 men and 30 women; mean age 66.6 years) needing retrograde ureteral stent exchange were included. All stents were previously placed through an anterograde way.

MATERIALS AND METHODS

Time needed to grasp each single stent was recorded as well as the complications.

STATISTICAL ANALYSIS

Fisher's test was used to compare procedural time in both groups; P < 0.05 was considered significant.

RESULTS

102 stents were exchanged. Mean time was 4.46 min for DG and 7.81 min for MS (P = 0.029). No significant complications were encountered.

CONCLUSIONS

Compared to the MS, the DG is easier, quicker, and less expensive.

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.

Ureteral stent retrieval using the crochet hook technique in females

Introduction

We developed a method for ureteral stent removal in female patients that requires no cystoscopy or fluoroscopic guidance using a crochet hook. In addition, we also investigated the success rate, complications and pain associated with this procedure.

Methods

A total of 40 female patients (56 stents) underwent the removal of ureteral stents. All procedures were carried out with the patients either under anesthesia, conscious sedation, or analgesic suppositories as deemed appropriate for each procedure including Shock Wave Lithotripsy (SWL), Ureteroscopy (URS), Percutaneous Nephrolithotomy (PCNL), and ureteral stent removal. At the time of these procedures, fluoroscopy and/or cystoscopy were prepared, but they were not used unless we failed to successfully remove the ureteral stent using the crochet hook. In addition, matched controls (comprising 50 stents) which were removed by standard ureteral stent removal using cystoscopy were used for comparison purposes.

Results

A total of 47 of the 56 stents (83.9%) were successfully removed. In addition, 47 of 52 (90.4%) were successfully removed except for two migrated stents and two heavily encrusted stents which could not be removed using cystoscopy. Ureteral stent removal using the crochet hook technique was unsuccessful in nine patients, including two encrustations and two migrations. Concerning pain, ureteral stent removal using the crochet hook technique showed a lower visual analogue pain scale (VAPS) score than for the standard technique using cystoscopy.

Conclusions

Ureteral stent removal using a crochet hook is considered to be easy, safe, and cost effective. This technique is also easy to learn and is therefore considered to be suitable for use on an outpatient basis.

Antegrade retrieval of ureteral stents through an 8-French percutaneous nephrostomy route

OBJECTIVE

The purpose of this study was to describe the technique of antegrade retrieval of ureteral stents under fluoroscopic guidance through an 8-French nephrostomy.

MATERIALS AND METHODS

During an 8-year period, we retrieved 26 ureteral stents from 24 patients who were not candidates for retrograde removal or had other conditions precluding use of a retrograde approach. A loop snare or grasping forceps was used to retrieve a ureteral stent in the renal pelvis or calyx or upper ureter through an 8-French vascular sheath with a safety wire in place. A snare catheter advanced into the bladder for retrieval of the bladder end was used in patients in whom retrieval with both a loop snare and a grasping forceps failed.

RESULTS

All 26 ureteral stents were successfully retrieved by the antegrade approach. Ten stents were retrieved with a snare alone and nine with a forceps alone. Five stents were retrieved successfully with a forceps after initial failures with snare catheters. Two stents were retrieved with snare catheters advanced into the bladder. The major complication of nephrostomy wound infection occurred in a patient with a urinary tract infection who underwent a one-stage procedure. All minor complications, including pelvic perforation in one patient and blood clot in the renal pelvis in four patients, resolved spontaneously without adverse sequelae.

CONCLUSION

Antegrade percutaneous retrieval of a ureteral stent through an 8-French nephrostomy is safe and effective and has a high degree of technical success. It can be used as a routine interventional practice in radiology.