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763

Technical

A Simplified Placement Richard

patency

for Antegrade

placement

of antegrade

a common interventional in stent materials and

rates and improved

recent delivery systems or coaxial stent-pusher

adopted

a simplified

radiologic

ureteral

patient tolerance

stents

has

[1 -3]. The most ,

that eliminates

set and positioning

the need for a of suture

loops.

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

introducer

peel-away

(Medi-tech,

sheath

Watertown,

45 cm

MA) is

The peel-away

October

Department

AJR 156:763-764,

9, 1990;

of Radiology,

April

accepted

after revision

Torrance

Memorial

1991 0361-803x/91/1564-0763

November

Medical

Center,

sheath then is partially

withdrawn

20, 1990. 3330

0 American

Lomita Roentgen

while the

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-

1

Stent

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 [3]. We recently

technique stent

ureteral

uroradiologic design have

We describe our approach, which uses retrograde ureteral stents that are readily available in multiple lengths from any hospital urology department.

Received

Ureteral

Krauthamer1

Percutaneous become Advances

Method

Note

Blvd.,

Torrance,

Ray Society

CA 90505.

Address

reprint

requests

to R. Krauthamer.

KRAUTHAMER

764

April 1991

AJR:156,

Once against

slowly wire

the final position the

stent

side

into the pusher, must

is obtained,

hole,

be retracted

the pusher

and the guidewire

freeing slowly

the proximal and steadily

is held

is retracted

stent

coil. The

to avoid

kinking

the stent. The guidewire then can be readvanced within the peel-away sheath into the collecting system, allowing placeDownloaded from www.ajronline.org by 1.34.45.138 on 10/09/15 from IP address 1.34.45.138. Copyright ARRS. For personal use only; all rights reserved

ment

of a temporary

nephrostomy

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.

Discussion

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

loop, which

can be difficult

to remove

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 ,

is removed.

Fig. 1.-Photograph

shows

soft

8.5-French

silicone

stent

(large

arrow)

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.

Note

guidewire

exiting

reliance

stent to ensure that the stent does not retract;

the peel-away

sheath system

the collecting of a nephros-

REFERENCES

tomy

tube.

This

maneuver

usually

requires

side

holes

of the stent

advancement necessary. renal pelvis

5-French

friction exists between

and the guidewire

that

the smaller retraction

or

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

of placing

a 0.038-in.

guidewire

supply

of prefabricated

radiologic

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

method

on an available

stent sets.

is removed further and left just within to allow easy subsequent placement

Our

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

sheath

removing

by using

the pusher.

a

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