Marshall L. Stoller, Maxwell V. Meng-Urinary Stone Disease
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484 Lam and Gupta
If the ureter will not accommodate both ureteral stent and ureteroscope, a parallel 4.7 Fr
ureteral stent can be placed and ureteroscopy can be reattempted after sufficient passive
dilation has taken place. If this fails, or there is a large proximal stone burden, the patient
can be placed in the prone position and a percutaneous approach may be attempted with
removal of the stone burden and, if necessary, simultaneous antegrade ureteroscopy.
Typically, a mid-posterior calyx is selected. If these approaches fail, laparoscopic or
open surgery can be considered. An IVU demonstrates a malfunctioning stent with
associated bladder and renal stones in a patient who failed to follow-up for over a year
(Fig. 4 A,B). Following cystolitholapaxy, the retained stent was exchanged for a new
stent and PCNL was performed at a later session to remove the remaining stone-burden.
Fig. 3. Bladder component of stent encrustation. (A) Cystoscopic view of a retained indwelling
ureteral stent with a large bladder stone encompassing the distal coil. (B) Fragment of encrustation.
Chapter 25 / Ureteral Stents 485
Fig. 4. IVU. (A) Scout film of a retained ureteral stent with renal and bladder stones. (B) Delay
film showing a hydronephrotic and obstructed right renal unit with a persistent nephrogram and
normal left renal unit.
486 Lam and Gupta
It is important to monitor for a possible post-obstructive diuresis following exchange to
a functional stent.
Prevention would be one way of avoiding the problem of retained stents, especially
in poorly compliant patients. Some investigators have recommended a stent registry to
keep track of indwelling stents placed in patients. Others have used a computerized
tracking program, which significantly lowered the incidence of overdue indwelling
ureteral stents from 12.5 to 1.2% over a 1-yr period (129). Another option is to leave
a distal traction suture attached and left at the urethral meatus after the stent is placed.
This will remind the patient that a foreign body is in the urinary system and permit
retrieval of the stent without cystoscopy. Straight ureteral stents connected to a urethral
catheter have been used in poorly compliant patients. All straight-stent treated patients
returned for follow-up, whereas only 45% of double-J stent treated returned for follow-
up (130). The development of biodegradable stents may also eliminate the need for stent
removal.
A rare but described complication is the knotting of an indwelling ureteral stent. Most
of these knots involve the proximal coiled end, necessitating difficult methods for
extraction (131). Previous reports have attributed knot formation to excessive length of
the stent with one end abutting the wall of a dilated renal pelvis and then passing through
the open loop (132). Stent configuration, such as Double-J or multicoil, and flexibility
may also be contributing factors (131,132).
In vivo ureteral stent fracture has been reported to have an incidence of <1%; however,
the consequences of fracture are severe (133). Depending on the biomaterial, the elon-
gation capacity of a stent decreases as a result of the urinary environment as well as the
stresses and strains to which it is subjected in active patients. Stent fragmentation will
have serious implications for the patient, as broken stent fragments may migrate either
downward into the bladder or, more seriously, upwards toward the renal pelvis. Broken
pieces from fractured stents have been removed by cystoscopy, ureteroscopy, percuta-
neous nephroscopy, or open surgery (133,134).
False Passage/Erosion
Mucosal tears of the ureter are common, especially with ureteral dilation or on intro-
duction of the beak of a scope. Submucosal passage and/or perforation with a
ureteroscope, wire or stent can be dangerous, causing devascularization of the ureter.
Subsequently this may cause stricture or, worse, necrosis of the ureter. Most injuries are
minor and can be managed conservatively with a stent and postoperative antibiotics
(135). Microscopic hematuria is not uncommon with all ureteral stents (9). Gross hema-
turia is rare and may indicate that the proximal or distal stent tip is eroding into the
surrounding tissues (6). Ureteral erosion can occur and lead to a periureteral collection
or fistula formation (136). These cases require surgical intervention. More frequent stent
changes may minimize such complications.
PEARLS/TRICKS
Accurate and atraumatic stent placement is greatly enhanced by proper ureteral access
using a guidewire under fluoroscopic guidance. Guidewires straighten the course to the
ureter and secure the luminal path for low-friction passage of a stent, balloon dilator, or
ureteroscope. Different types of guidewires have been developed, each designed with
unique structural properties to help accomplish specific tasks. An appropriate guidewire
Chapter 25 / Ureteral Stents 487
should be selected based on patient anatomy, suspected pathology, and planned proce-
dure. Guidewires are described by material of composition, size (diameter and length),
tip design, surface coating, core (moveable or nonmovable), and shaft rigidity. Guide-
wires may be composed of stainless steel or nitinol. Stainless steel wires may be round-
or flat-shaped. Round-shaped wires have standard stiffness, whereas flat-shaped wires
allow for a thicker, stiffer core without increased diameter. Nitinol-based wires are kink-
resistant and can be designed with a stiffer core or a stripped core. Standard guidewires
range in diameter from 0.018 to 0.038 inch and available lengths vary from 145 to 180
cm. The distal 3 cm of all guidewires are designed to be soft and flexible to minimize
trauma to the ureteral wall during passage. Various tip designs and shapes have been
developed to facilitate passage through tortuous ureteral anatomy or ureteral strictures.
Tip configurations may be straight, angled, or “J” configuration. Straight and angled
guidewires are also available with an 8-cm flexible tip. Shaft rigidity depends on the core
materials. Guidewires may be coated with polytetrafluoroethylene (PTFE, Teflon),
which improves advancement of more rigid devices; a lubricious covering, used for soft
devices; or a hydrogel, which permits near frictionless passage.
A standard 145-cm long, 0.038-inch, PTFE-coated guidewire can be used to secure
ureteral access in the majority of cases. Stiff wires are excellent safety and working wires
that are less likely to accidentally displace than flexible wires. The Boston Scientific/
Microvasive Amplatz Super Stiff is useful for percutaneous procedures and large cath-
eter or endopyelotomy stent placement. For passing tortuous anatomy, stones, strictures,
and narrowed ureteral orifices, the authors prefer the Boston Scientific/Microvasive
Glidewire, which is constructed with a central core of nitinol alloy surrounded by poly-
urethane and covered with hydrophilic polymer. Guidewires must be kept wet during
usage for frictionless performance.
To access a J-shaped ureter, as in patients with prostatic enlargement, or for a ureter
obstructed by an impacted stone, an angled guidewire can help steer past the critical
point. Alternatively, a hydrophilic guidewire can be used in such situations. For this, an
open-ended ureteral stent is first introduced through the cystoscope to intubate the ure-
teral orifice. The selected guidewire is passed through the stent, which acts as a conduit
that introduces the wire into the ureter. In extremely tortuous ureters, the combination
of a 5-Fr angiographic Cobra catheter and an angle-tipped glidewire with a torque device
attached to the distal end allow negotiation of even 360° loops. Eventually, when the
renal pelvis is reached, the glidewire should be immediately exchanged for an extra or
super stiff wire that will be used for final stent placement. In all cases of difficult access,
a cystoscope placed at the ureteral orifice allows all the torque of the wire or catheter to
be directed into the ureter and not into the bladder. In cases of impacted stones, position-
ing an open catheter via a cystocope directly under the stone followed by instillation of
water or saline or lidocaine jelly can help create enough space around the stone to allow
a glidewire to be insinuated past the stone. If this still fails, ureteroscopy can be per-
formed along a guidewire up to the stone and manual irrigation can be used to dislodge
the stone enough to place a glidewire. If a guidewire goes past the stone, but a stent will
not, a small 4.7-Fr stent can be attempted or a dual lumen catheter can be placed over the
guidewire and then the stone flushed or a second wire placed through the second lumen.
If a stent still can not be placed, a 4 Fr angiographic catheter can be placed for temporary
drainage. In the worst case scenario, the guidewire can be left in place and the patient
turned prone for a PCN, or if the situation does not call for immediate drainage, the
guidewire can be placed into a Council catheter to keep it sterile and the patient brought
488 Lam and Gupta
back to the cystoscopy suite the following day after the ureter has had a chance to
passively dilate.
FUTURE DIRECTIONS
As minimally invasive endourologic and laparoscopic techniques continue to flour-
ish, ureteral stents will continue to play a major role in urology. Novel biodegradable
materials and more biocompatible polymers continue to be developed that allow for
temporary ureteral drainage without the need for subsequent cystoscopic removal.
Advances in surface coating technologies, along with the use of biodegradable materials
will result in novel drug-delivery systems. By incorporating various drugs and medica-
tions such as growth factors, antiinflammatory agents, and chemotherapeutic drugs, new
therapeutic strategies for the treatment of ureteral stricture disease and possibly geni-
tourinary malignancy may be offered. More comfortable stent designs will continue to
be developed to decrease morbidity associated with indwelling ureteral stents. Further
understanding of the basic physiochemical nature of urinary tract encrustation will ulti-
mately reduce the problem of biomaterial-related encrustation. Advances in other
subspecialties, such as endoluminal paving in cardiology stenting, may offer insights
into segmental ureteral stenting by limiting treatment to a localized segment of ureter.
Finally, research into ureteral replacement techniques may redefine the role of ureteral
stents in urology.
SUMMARY
Indwelling ureteral stents offer urologists an enormous arsenal against a host of uro-
logic diseases. There is no ideal stent, so it is important that the surgeon be familiar with
the various indications for usage, selection, modes of insertion, and potential for com-
plications. With this information, the surgeon will optimize the efficacy and safety of
ureteral stents in the care of patients.
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