THE ,)Ol RNAL OF UROLOG,

Vol. 115 . .Janu, ·

Copyright© [976 by The Williams & Wilkins Co.

Printed in U.,-...·

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EXPERIENCE WITH INDWELLING URETERAL STENT CATHETERS ROBERT P. GIBBONS, ROY J. CORREA, JR., KENNETH B. CUMMINGS

AND

J. TATE MASON

From the Division of Urology, The Virginia Mason Medical Center, Seattle, Washington

ABSTRACT

A new indwelling ureteral stent to provide long-term ureteral drainage is described. This radiopaque stent is manufactured of non-reactive, non-collapsible tubing and is designed to resist downward expulsion and upward migration. Internal stent diversion offers several advantages in managing patients whose ureters are obstructed by malignancy. 1) Endoscopic placement of the ureteral stent is associated with less morbidity and mortality than supravesical diversion. 2) Unilateral ureteral obstruction can be corrected at the time of diagnosis, thus ensuring that later supravesical diversion will not be necessary. 3) If time proves that the urinary diversion is no longer desirable in terms of quality of life, the stent can be removed. The use of indwelling ureteral catheters to provide long-term drainage of obstructed or damaged urinary tracts has been well documented. 1 -• However, the use of these stents in clinical practice has been limited because of the difficulty, inconvenience and inconsistent results of self-fabrication. The experience with these homemade stents demonstrated that downward expulsion, upward migration, radiolucency and compression of the soft silastic tubing were frequent problems. A stent design has evolved which has eliminated or significantly reduced all of the aforementioned problems (fig. 1). This stent is available in 7F and 9F sizes, and 15 and 23 cm. lengths.*

tively the stent may be removed by extracting the stent with a stone basket or passing a small Fogarty catheter up the stent lumen and inflating the balloon. The protruding wings are quite flexible at body temperature allowing nearly painless removal of the stent with local anesthesia. RESULTS

The following observations are based on our experience with the present and prior indwelling ureteral stents in 22 patients (26 ureters) for up to 44 months. 4 Because of mechanical

TECHNIQUE

The stent is endoscopically placed as if passing a retrograde ureteral catheter. Considerable time will be saved if the obstructed ureter is initially dilated with successively larger ra.diopa.que wings to prevent ureteral catheters or dilators before attempting to place the tip ejection by peristalsis soft and flexible stent (fig. 2). If a ureteral catheter the size of ~ and gravity the stent to be used cannot be passed, a smaller catheter is left in place for 48 to 72 hours to soften the obstruction. The ureter silastic coated can then usually be dilated sufficiently to accept the stent. spring coil The stent can be inserted with either the 24F panendoscope or cystoscope. The largest caliber stent that will pass the obstruction should be used. After preliminary dilation of the obstructed ureter a 4F ureteral catheter with a wire stylet is placed through the rubber nipple of the endoscope and advanced approximately 25 cm. (fig. 3). Sterile mineral oil is injected into the lumen of the stent (fig. 4, A) and the stent is passed onto the ureteral catheter guide (fig. 4, B). The endoscope, guide and stent are placed into the sheath (fig. 5) and the stent is advanced up the ureter in a retrograde manner until its distal flange is in contact with the ureteral orifice (fig. 6). Additional resistance to downward expulsion can be obFrG. 1. Features of radiopaque ureteral stent include non-reactive, tained by removing 1 or 2 protrusions of the distal flange and non-collapsible tubing with design to resist downward expulsion and placing the remaining flange into the submucosal ureter above upward migration. the ureteral orifice (fig. 7). This also creates a non-refluxing unit but may result in reduced protection against upward factors a stent could not be passed in an additional 5 patients migration. The wire stylet is then removed (fig. 8, A), leaving thought to be candidates for this type of diversion. Ureteral the 4F ureteral catheter limp enough so that it can be slowly obstruction secondary to cancer was present in 17 cases. The removed without dislodging the stent (fig. 8, B). Any final average age of these patients was 60 years (range 41 to 87 years). Four patients had ureteral obstruction secondary to adjustments can be made with the flexible forceps (fig. 8, C). The stent can be removed by securing a hold on one of the benign disease and 1 patient had a renal pelvic-cutaneous arms of the distal flange with the grasping forceps. Alterna- fistula secondary to a gunshot wound (see table). Obstruction. The proper placement of a stent served to Accepted for publication June 13, 1975. immediately relieve the ureteral obstruction in 20 of 21 Read at annual meeting of American Urological Association, Miami patients. One uremic patient with advanced chronic hyBeach, Florida, May 11-15, 1975. * Heyer-Schulte Corp., 600 Pine Ave., Goleta, California 93017. droureteronephrosis secondary to idiopathic retroperitoneal

.,

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INDWELLING URETERAL STENT CATHETERS

FIG. 4. A, lubricate stent by injecting sterile mineral nil into its lumen. B, pass stent onto ureteral catheter guide.

FIG. 2. Before stent is placed obstructed ureter should be dilated with successively larger ureteral dilators or catheters up to size of stent to be used.

stenl 4F uretercl catheter v,'itl~1 v:ire stylet r:_ipple of Vv'urking elernent of C\stnsco;Y?.



l

'

Stent and ureteral calheter gdide ar2 now reedy sheath. 24F •

n1Lrqe1u.cs0. into

t~~

be

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GIBBONS AND ASSOCIATES

renal function, x-ray appearance or microscopic changes in renal tissue obtained at autopsy to reflux. Hematuria . Gross hematuria occurred in 1 patient who had been placed on anticoagulant therapy for a cerebrovascular thrombosis. The hematuria ceased when the anticoagulants were discontinued. Asymptomatic microhematuria is a common finding. DISCUSSION

The successful placement of an indwelling stent to correct ureteral obstruction or fistula offers several advantages, especially in a poor-risk patient. There is no incision, appliance or external catheter. The presence of the stent does not interfere with subsequent management and its relative simplicity decreases morbidity and hosp ital costs . The stent herein described has corrected the deficiencies inherent when plain silicone rubber tubing is used for this purpose . The stent is radiopaque along its entire length, non-collapsible and designed to resist downward expulsion and upward migration. Do.! ard expulsion with this stent has b~ problem only when t e o e obstruction lie above tfielevelo ftfie outstretched wings, t ·s there is no coinpressi~ or the w! ! ! g ~mst. · Patient selection is important. The indications for placing a stent into a patient whose ureters are obstructed by cancer are essentially the same as the indications for a nephrostomy. 6 • 7 Basically, these are patients who either have treatable metastatic cancer or who are free of pain but symptomatic from

g

FIG. 6. Stent is advanced up ureter in retrograde manner until distal flange is in contact with ureteral orifice.

fibrosis had no immediate improvement and ultimately required a nephrostomy tube. Infection . Antibiotics are not used prophylactically. If infection is present specific antibiotics are used at the time the stent is placed and discontinued after 2 weeks . Four patients had a urinary tract infection (pyelonephritis 2, cystitis 2) with an indwelling stent in place. In all 4 patients the infection cleared after a specific antibiotic determined by sensitivity testing was given. A 6-week course is given for pyelonephritis and a 2-week course for cystitis. In addition, the urine is acidified and increased fluids are encouraged to reduce sludging of the debris secondary to infection. The x-ray appearance of ureteritis cystica was seen in 1 patient after a urinary tract infection but this cleared with time. Little tissue reaction to the stent was noted in 1 patient who had a functioning stent for 44 months prior to death from an aortic graft-duodenal fistula (fig. 9). Encrustation. Nong~ stents became calcified. Obstruction from mucoid debris occurred in 4 patients who were unable to maintain a fluid intake of greater than 1,500 cc per day. A stent so obstructed can be quickly and easily changed. Reflux. Reflux occurs when the stent is in its usual osition (fig . 8,C). ~ave not been able to attn ute any chan~ in

FIG. 7. A , usual location of distal flange adjacent to ureteral orifice.

B, alternative non-refluxing position with 2 distal flanges removed and remaining 2 flanges placed within intramural ureter.

Diagnoses in 22 patients treated with a ureteral stent No. Pts. Ureteral obstruction: Malignant-17 pts. Cervix Bladder Rectum Ovary Endometrium Ureter Kidney Stomach Lymphoma Benign retroperitoneal fibrosis-4 pts. Secondary aorta-iliac graft Idiopathic Ureteral fi stula: Renal pelvic-cutaneous secondary to gunshot wound

4

3 3

2

2 2

INDWELLING URETERAL STE'.\JT CATHETERS

25

/

FIG. 8. A, once stent is positioned remove wire stylet from ureteral catheter. B, slowly remove ureterai catheter guide. If stent tends to become dislodged you may need to place larger stent or hold stent in place with grasping forceps or deflecting mechanism of cystoscope. C, proper placement of indwelling ureteral stent.

Fm. 9. Ureteral stent was in for 44 months in 62-year-old man (Marmar reaction. H & E, from x 40. Bl focal loss of epithelium lymphocyte H & E, reduced from x 100. 1

in area of nJ.axin1urn

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GIBBONS AND ASSOCIATES

azotemia. • Of our 17 patients with ureters obstructed by cancer, 15 (88 per cent) left the hospital and lived more than 2 months. Nine of these patients were uremic prior to placing the stent. There have been no operative complications or deaths from the endoscopic placement of these stents. Grabstald and McPhee reported that in 170 consecutive cancer patients with ureters obstructed or damaged by treatment in whom nephrostomy was performed, 43 per cent did not leave the hospital alive and 3 per cent died as a direct result of the operation. 6 Brin and associates reported that in 47 patients with advanced pelvic malignancies who underwent palliative urinary diversion, 41 per cent never left the hospital. 7 These results illustrate the difference in morbidity between a supravesical diversion and an internal ureteral stent, which can often be placed with local anesthesia in these ill patients. TJw_..1najm.i-ty...o.£-pati~nts- i-H-wh0-m_we were unable to_p.ass a stent were those we had followed w· ut attemp_ting_cfuce.rsion unfi ot ureters became o stn!£ted_fr.un1-..c_fill£fil.___\Y_e__nmy en to place a stent into any_uie.te.r_o_bstrncted by neoplasm at i-agnosis. An additional significant advantage of the stent over any other supravesical diversion is that it is .rea.iiJ,Y reversible_, The .-+:o

tlieune=o--

indications to perform a diversion are not always cert ain. If time determines that the stent diversion was not a wise decision, the stent can be easily removed.

REFERENCES

1. Zimskind, P. D., Fetter, T. R. and Wilkerson, J. L.: Clinical use of

2. 3. 4. 5. 6. 7.

long-term indwelling silicone rubber ureteral splints inserted cystoscopically. J. Urol., 97: 840, 1967. Marmar, J. L.: The management of ureter al obstruction with silicone rubber splint catheters. J . Urol. , 104: 386, 1970. Orikasa, S., Tsuji, I., S iba, T . and Ohashi, N .: A new technique for transurethral insertion of a sil icone rubber tube into an obstructed ureter. J. Urol., llO: 184, 1973. Gibbons, R. P., Mason, J . T. and Correa, R. J ., Jr.: Experience with indwelling silicone rubber ureteral catheters. J . Urol., lll: 594, 1974. Pais, V. M., Spellman, R. M. , Stiles, R. E. and Mahoney, S. A.: Internal ureter al splints. Urology, 5: 32, 1975. Grabstald, H . a nd McPhee, M .: Nep hrostomy and t he cancer patient . South. Med. J., 66: 217, 1973. Brin, E. N., Schiff, M ., Jr. and Weiss, R. M .: Palliative urinary diversion for pelvic malignancy. J. Urol. , 113: 619, 1975 .

Experience with indwelling ureteral stent catheters.

A new indwelling ureteral stent to provide long-term ureteral drainage is described. This radiopaque stent is manufactured of non-reactive, non-collap...
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