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A Simplified Placement Richard
a common interventional in stent materials and
rates and improved
recent delivery systems or coaxial stent-pusher
[1 -3]. The most ,
set and positioning
the need for a of suture
Technique A percutaneous nephrostomy is performed first by using a favorable caliceal approach to allow easy access to the ureter.
be taken to use a large loop of wire to stitch the side holes
If the urine is grossly bloody or infected, in order to prevent occlusion of the ureteral stent, antegrade stenting is deferred until drainage from the nephrostomy tube is clear. Antibiotics
and avoid kinking the wire. After the stent is lubricated with mineral oil, the stent-wire combination is advanced by hand into the peel-away sheath, and the stiff wire is pushed by hand until the distal pigtail with its slightly protruding wire exits the sheath within the bladder. The pusher supplied with the urologic stent kit is placed within the sheath over the guidewire to the internal straightened proximal tip of the stent.
are administered to patients who have signs of infection. Once a rigid guidewire such as a 0.038-in. (0.97-mm) Tefloncoated Lunderquist-Ring torque guidewire or a 0.038-in. Amplatz superstiff guidewire (Cook, Bloomington, IN) is manipulated into the bladder,
long with coaxial
an 1 1-French
sheath then is partially
20, 1990. 3330
pusher is held against the internal stent. If additional stent is needed within the bladder, the pusher is advanced while the guidewire is held. Once the distal end of the stent is coiled properly within the bladder, the pusher is held against the
advanced over the guidewire into the bladder, and the introducer and guidewire are removed. An 8.5-French urologic retrograde ureteral soft silicone or stiffer Silitek Uropass stent (Surgitek, Racine, WI) of appro-
priate length is selected by bending an extra guidewire or marking a catheter at appropriate distal and proximal sites fluoroscopically within the sheath. The stent is placed over the 0.038-in. guidewire (Fig. 1) as follows: The tips of the soft silicone stent, if used, are cut off with a scalpel blade because the soft silicone stent ends are closed. The stiff end of the 0.038-in. guidewire is used to pierce the side holes of the proximal stent by first passing the guidewire through the distal (bladder) pigtail end hole. For the silicone stent, the wire carefully is stitched out and then back in on one side of two contiguous proximal side holes and then is passed back out through the most proximal side hole at the beginning curve of the proximal (renal) pigtail on the side opposite to the stitch. The stiffer Uropass stent has less friction with larger side holes and requires an additional stitch through more distal side holes opposite the more proximal side stitch. Care must
procedure. led to longer
use either peel-away sheaths [1 4] combinations . We recently
uroradiologic design have
We describe our approach, which uses retrograde ureteral stents that are readily available in multiple lengths from any hospital urology department.
Percutaneous become Advances
to R. Krauthamer.
the final position the
into the pusher, must
and the guidewire
the proximal and steadily
the stent. The guidewire then can be readvanced within the peel-away sheath into the collecting system, allowing placeDownloaded from www.ajronline.org by 184.108.40.206 on 10/09/15 from IP address 220.127.116.11. Copyright ARRS. For personal use only; all rights reserved
of a temporary
tube until the urine clears.
The nephrostomy tube is removed after an antegrade pyelogram shows the stent is patent. With this method, we have placed eight ureteral stents successfully and without difficulty in a variety of benign and malignant conditions.
Previous reports have described the use of peel-away sheaths and coaxial stent-pusher combinations for placement of ureteral stents, but both methods require the use of a suture
can be difficult
and can tear the
stent wall, become entangled in the proximal coil, or wedge the proximal stent in the ureter [1 3]. The Amplatz ureteral stent set (Cook) does not require a suture loop, but it does require a readily available supply of stents in different lengths, and the final coiled position is not seen before the guidewire ,
and stiffer, larger-lumen Uropass stent (small arrow) proximal pigtail coils with single side stitch (large arrowhead) for soft silicone stent and double side stitch (small arrowheads) for Uropass side hole at beginning of pigtail.
stent to ensure that the stent does not retract;
the collecting of a nephros-
of the stent
advancement necessary. renal pelvis
friction exists between
and the guidewire
the smaller retraction
of the stent for final positioning is possible if Dilute contrast material can be injected into the at this time via the peel-away
vessel dilator after temporarily
the use of an
assistant. During retraction of the sheath, the proximal stent coil reforms because the guidewire exits the proximal side
hole (Fig. 1). Also, enough
on an available
is removed further and left just within to allow easy subsequent placement
through the proximal side holes, instead of an end hole, eliminates the need for a suture loop and relies on urologic ureteral stents. These are more readily available in our institution and come in various lengths. The use of a peel-away sheath eliminates buckling and friction of the softer silicone stents. The coiling of the proximal stent with the guidewire still in position and the ability to retract the stent by pulling the guidewire makes final positioning of the stent technically simple. In addition, the possibility of retracting the stent into the renal parenchyma is eliminated. In summary, we think that our simplified method for placing an antegrade ureteral stent is easily learned and eliminates the need for a suture loop and
1 . Rozenblit G, Tarasov E, Srur MF, Neithamer CD, Sumers EH, Sos TA. Druy ureteral stent set: clinical experience in 25 patients. Radiology 1986;160:737-740 2. Mitty HA, Dan SJ, Train JS. Antegrade ureteral stents: technical and catheter related problems with polyethylene and polyurethane. Radiology
1987;165:439-443 3. Mitty HA, Rackson ME, Dan SJ, Train JS. Experience with a new ureteral stent made of a biocompatible polymer. Radiology 1988;168:557-559 4. Lee WJ, Rich M. Universal introducer: a simplified approach to antegrade ureteral stent insertion. AJR 1986;147:830-831