PROXIMAL
STENT DISPLACEMENT
COMPLICATION
M. DWAYNE GERALD MARK
COLLIER,
R. JERKINS,
H. NORMAN
OF PIGTAIL
NOE,
S. SOLOWAY,
From the Department Center for the Health
AS
URETERAL
STENT
M.D. M.D.
M.D. M.D. of Urology, University of Tennessee Sciences, Memphis, Tennessee
ABSTRACT - The indwelling ureteral stent recently introduced by Cook offers relative ease of placement with a self-curling end which prenents migration down the ureter. We have seen 4 cases of proximal migration of these stents. The reasons for this event are described. Our experience suggests the placement of a suture in the distal portion of the catheter to allow retrieval of the catheter should migration occur.
The indwelling ureteral stent has become an increasingly useful tool for the urologist in the management of ureteral obstruction or fistula. l-2 The two commercially available indwelling stents are the Cook indwelling pigtail stent and the Gibbons ureteral catheter. The reported complications of the Gibbons catheter are calyceal stone formation, catheter encrustation, inadequate catheter length, and distal migration. 3 To our knowledge, complications with the Cook stent have not been reported. We have encountered several instances of loss of the stent up the ureter at the time of placement or subsequent proximal migration after initial satisfactory placement. The causes of this problem as well as a simple solution are presented. Case Reports
Case 1 A thirty-one-year-old white woman underwent a left Foley Y-V-pyeloplasty for ureteropelvic junction obstruction. In the postoperative period, the patient continued to have moderate left flank pain. An excretory urogram (IVP) demonstrated caliectasis which was essentially unchanged from the preoperative appear-
372
ance. In an attempt to determine if the patient’s pain was related to continued ureteropelvic obstruction, a 27-cm. Cook stent was placed three months postoperatively. Placement of the stent was accurate cystoscopically and confirmed by x-ray film (Fig. 1A). Several days later persistent pain in the left lower quadrant and gross hematuria developed. A plain film of the abdomen suggested proximal migration of the catheter (Fig. 1B). Two weeks after insertion, cystoscopy confirmed that the distal end of the stent had retracted proximally. The stent was removed by passing two 5-F ureteral catheters up the ureter, twisting the catheters to engage the stent, and removing the catheters and stent. The patient is asymptomatic nine months postpyeloplasty.
Case 2 A twenty-one-year-old white woman underwent a right upper third ureterolithotomy on June 22, 1977. Because of persistent drainage from the right flank, a ureteral catheter was inserted on the eighth postoperative day but became dislodged, and copious drainage from the flank continued. On the fourteenth postoperative day, the right upper ureter was explored, a
UROLOGY
/ APRIL 1979 / VOLUME
XIII.
NUMBER 4
FIGURE 1. Case 1. {A) Cook ureter-al stent in left ureter, of curl to note relationship hemsxlip at let;el of renal peltiis. (B) Stent has migrated pror imally in collecting systern.
FIGURE 2. Case 2. (A) Cook catheter stenting right ureter; note incomplete curl of pigtail. (B) Stent has migrated proximally as result of increase in curl of proximal end.
Silastic stent placed, and the ureterotomy closed. Marked improvement led to the removal of the stent; however, the drainage recurred. A Cook catheter (24 cm. length) was readily inserted. At the time of placement, the distal end of the catheter was protruding from the ureteral orifice, and x-ray film of the kidney, ureters, and bladder (KUB) confirmed accurate placement (Fig. 2A). The patient was discharged with much improvement in the flank drainage. Twelve days later the drainage returned. A KUB revealed an increase in the coil at, the tip of the catheter (Fig. 2B). At cystoscopy no catheter was apparent at the ureteral orifice. Because of the retracted catheter and the persistent flank drainage, the right flank was reexplored. The pigtail catheter was removed and
UROLOGY
/ APRIL 1979 i
VOLUME
XIII,
NUMBER 4
the ureteral defect repaired using an intubated ureterotomy. After removal of the ureteral stent and nephrostomy tube, the patient has been dry* Case 3 The patient was a twenty-nine-year-old black woman in whom a right retroperitoneal abscess developed related to common bile duct obstruction and a previous choledochoduodenostomy. After drainage of the abscess via the flank, a right renal pelvicutaneous fistula resulted from pressure necrosis by a sump drain tube lying in the retroperitoneum. A 24-cm. Cook stent was inserted and was observed to retract past the ureteral orifice as the wire guide was removed. Efforts to retrieve the stent cystoscopically were
373
futile, and the patient continued to drain large amounts of urine via the flank. Because of the patient’s septic course, a right nephrectomy and drainage of residual abscess were performed four days later. The patient eventually recovered after undergoing multiple abdominal procedures related to intra-abdominal abscesses and common duct obstruction from biliary calculi. Case 4 A seventy-five-year-old man underwent an upper-third ureterolithotomy in a solitary kidney at another institution. The patient was transferred one month postoperatively after insertion of ureteral catheters on two occasions failed to stop flank urinary drainage. A 24-cm. Cook stent with a 5-cm. Prolene 4-O suture tag was placed (Fig. 3). The distal end of the catheter retracted into the ureteral orifice at the time of placement, leaving the suture protruding from the orifice. The stent was not replaced, as a longer stent was not immediately available. Flank drainage immediately subsided, and the Cook catheter was cystoscopically retrieved one month later by grasping the suture tag with a foreign body forceps. The patient has had no further urinary difficulties.
ter is then removed leaving the tip of the wire in the renal pelvis. The stent followed by a “pusher” catheter is threaded over the wire guide, with the pusher used to advance the stent until the flanged end is about 3 cm. from the ureteral orifice. Withdrawal of the wire guide allows the proximal tip to curl in the renal pelvis. This curling usually draws the distal flanged end another 1 or 2 cm. toward the ureteral orifice. A critical step is the proper selection of a stent of proper length. Too short a stent may likely migrate up the ureter; too long a stent will irritate the trigone and cause pain and hematuria. Retrograde pyelography in conjunction with measurements from the ureteral catheter markings should provide a guide to selection of the correct length. The appropriate catheter length should be based on the distance from the ureteral orifice
Comment Stent dislocation proximally can not only be troublesome but also may result in additional surgery if the stent cannot be retrieved endoscopically. Cystoscopic retrieval of a stent whose distal end lies within the ureter is neither easy nor certain, and was possible in only one of our cases prior to use of the suture tag. The Cook stent is a radiopaque polyethlene 5-F catheter with a proximal pigtail curl and a small flange on the distal (bladder) end. The catheter has multiple perforations for drainage. The pigtail is designed to be placed in the renal pelvis or dilated calyx, preventing migration of the stent down the ureter. A long, 6-F ureteral catheter, wire guide, and pusher catheter required for insertion are supplied with the stent. The Cook stent is available in l-cm. increments from 24 through 30 cm. The length of the catheter is measured from the distal flange to the base of the proximal curl. The initial step involved in placement of the stent requires insertion of the long 6-F ureteral catheter to the renal pelvis. Retrograde pyelography may be used to determine the ureteral length. A flexible guide wire is then passed inside the ureteral catheter to the renal pelvis. The ureteral cathe-
374
Ureretal Opening
FIGURE
Obsewe
3. Cook ureter-al stent in correct location. monofilament nylon suture in distal end.
UROLOGY
/ APRIL 1979 / VOLUME
XIII,
NUMBER 4
to the uppermost portion of the renal collection system. Underestimation of the length may result in proximal migration of the catheter. Therefore, one should err on the long side. We believe proximal stent migration may occasionally occur even after careful estimation of the appropriate length. The stent tip may “catch” on or in an infundibulum and, as the curl forms, the stent may retract up the ureter more than had been predicted. We believe this occurred in Case 2. Bending and twisting of the torso and renal excursion with respiration may cause the flange tip to retract up the orifice. Once retracted, the stiff catheter would likely abut the ureterovesical junction at such an angle that the tip would not likely spontaneously drop back into the bladder. Thus proper stent placement initially may not prevent subsequent stent migration, as in Case 1. Finally, the indication for the Cook stent may be so urgent that placement of the stent will be undertaken when a full selection of stent lengths is not available. This was a faction in 2 of our cases. To permit easy stent retrieval, should proximal migration occur, we advocate placement of
UROLOGY
I
APRIL 1979
/
VOLUME XIII,
NUMBER 4
a 4 to 6-cm., 4-O monofilament suture through the flange of the stent (Fig. 3). One suggestion already received by the manufacturers of the Cook stent is to incorporate a small “eye” in the flange of the catheter through which a suture could be placed. So far this has not been routinely incorporated into the production of the pigtail catheter. In spite of the technical problems which can be associated with the indwelling pigtail stent, it remains a valuable instrument in the treatment of ureteral obstruction and/or ureteral fistula. P.O. Box 63635 806 Madison Avenue Memphis, Tennessee 38163 (DR. SOLOWAY) References 1. Pais VM, Spelhnan RM, Stiles RE, and Mahoney SA: Internal ureteral splints, Urology 5: 22 (1975). 2. Gibbons RP, Correa RJ, Cummings KB, and Mason JT: Experience with indwelling ureteral stent catheters, J. Urol. 115: 22 (1976). 3. Schneider RD, Depauw AP, Montie JE, and Thompson IM: Problems associated with Gibbons ureteral catheters, Urology 8: 243 (1976).
375
STENT DISPLACEMENT
COMPLICATION
M. DWAYNE GERALD MARK
COLLIER,
R. JERKINS,
H. NORMAN
OF PIGTAIL
NOE,
S. SOLOWAY,
From the Department Center for the Health
AS
URETERAL
STENT
M.D. M.D.
M.D. M.D. of Urology, University of Tennessee Sciences, Memphis, Tennessee
ABSTRACT - The indwelling ureteral stent recently introduced by Cook offers relative ease of placement with a self-curling end which prenents migration down the ureter. We have seen 4 cases of proximal migration of these stents. The reasons for this event are described. Our experience suggests the placement of a suture in the distal portion of the catheter to allow retrieval of the catheter should migration occur.
The indwelling ureteral stent has become an increasingly useful tool for the urologist in the management of ureteral obstruction or fistula. l-2 The two commercially available indwelling stents are the Cook indwelling pigtail stent and the Gibbons ureteral catheter. The reported complications of the Gibbons catheter are calyceal stone formation, catheter encrustation, inadequate catheter length, and distal migration. 3 To our knowledge, complications with the Cook stent have not been reported. We have encountered several instances of loss of the stent up the ureter at the time of placement or subsequent proximal migration after initial satisfactory placement. The causes of this problem as well as a simple solution are presented. Case Reports
Case 1 A thirty-one-year-old white woman underwent a left Foley Y-V-pyeloplasty for ureteropelvic junction obstruction. In the postoperative period, the patient continued to have moderate left flank pain. An excretory urogram (IVP) demonstrated caliectasis which was essentially unchanged from the preoperative appear-
372
ance. In an attempt to determine if the patient’s pain was related to continued ureteropelvic obstruction, a 27-cm. Cook stent was placed three months postoperatively. Placement of the stent was accurate cystoscopically and confirmed by x-ray film (Fig. 1A). Several days later persistent pain in the left lower quadrant and gross hematuria developed. A plain film of the abdomen suggested proximal migration of the catheter (Fig. 1B). Two weeks after insertion, cystoscopy confirmed that the distal end of the stent had retracted proximally. The stent was removed by passing two 5-F ureteral catheters up the ureter, twisting the catheters to engage the stent, and removing the catheters and stent. The patient is asymptomatic nine months postpyeloplasty.
Case 2 A twenty-one-year-old white woman underwent a right upper third ureterolithotomy on June 22, 1977. Because of persistent drainage from the right flank, a ureteral catheter was inserted on the eighth postoperative day but became dislodged, and copious drainage from the flank continued. On the fourteenth postoperative day, the right upper ureter was explored, a
UROLOGY
/ APRIL 1979 / VOLUME
XIII.
NUMBER 4
FIGURE 1. Case 1. {A) Cook ureter-al stent in left ureter, of curl to note relationship hemsxlip at let;el of renal peltiis. (B) Stent has migrated pror imally in collecting systern.
FIGURE 2. Case 2. (A) Cook catheter stenting right ureter; note incomplete curl of pigtail. (B) Stent has migrated proximally as result of increase in curl of proximal end.
Silastic stent placed, and the ureterotomy closed. Marked improvement led to the removal of the stent; however, the drainage recurred. A Cook catheter (24 cm. length) was readily inserted. At the time of placement, the distal end of the catheter was protruding from the ureteral orifice, and x-ray film of the kidney, ureters, and bladder (KUB) confirmed accurate placement (Fig. 2A). The patient was discharged with much improvement in the flank drainage. Twelve days later the drainage returned. A KUB revealed an increase in the coil at, the tip of the catheter (Fig. 2B). At cystoscopy no catheter was apparent at the ureteral orifice. Because of the retracted catheter and the persistent flank drainage, the right flank was reexplored. The pigtail catheter was removed and
UROLOGY
/ APRIL 1979 i
VOLUME
XIII,
NUMBER 4
the ureteral defect repaired using an intubated ureterotomy. After removal of the ureteral stent and nephrostomy tube, the patient has been dry* Case 3 The patient was a twenty-nine-year-old black woman in whom a right retroperitoneal abscess developed related to common bile duct obstruction and a previous choledochoduodenostomy. After drainage of the abscess via the flank, a right renal pelvicutaneous fistula resulted from pressure necrosis by a sump drain tube lying in the retroperitoneum. A 24-cm. Cook stent was inserted and was observed to retract past the ureteral orifice as the wire guide was removed. Efforts to retrieve the stent cystoscopically were
373
futile, and the patient continued to drain large amounts of urine via the flank. Because of the patient’s septic course, a right nephrectomy and drainage of residual abscess were performed four days later. The patient eventually recovered after undergoing multiple abdominal procedures related to intra-abdominal abscesses and common duct obstruction from biliary calculi. Case 4 A seventy-five-year-old man underwent an upper-third ureterolithotomy in a solitary kidney at another institution. The patient was transferred one month postoperatively after insertion of ureteral catheters on two occasions failed to stop flank urinary drainage. A 24-cm. Cook stent with a 5-cm. Prolene 4-O suture tag was placed (Fig. 3). The distal end of the catheter retracted into the ureteral orifice at the time of placement, leaving the suture protruding from the orifice. The stent was not replaced, as a longer stent was not immediately available. Flank drainage immediately subsided, and the Cook catheter was cystoscopically retrieved one month later by grasping the suture tag with a foreign body forceps. The patient has had no further urinary difficulties.
ter is then removed leaving the tip of the wire in the renal pelvis. The stent followed by a “pusher” catheter is threaded over the wire guide, with the pusher used to advance the stent until the flanged end is about 3 cm. from the ureteral orifice. Withdrawal of the wire guide allows the proximal tip to curl in the renal pelvis. This curling usually draws the distal flanged end another 1 or 2 cm. toward the ureteral orifice. A critical step is the proper selection of a stent of proper length. Too short a stent may likely migrate up the ureter; too long a stent will irritate the trigone and cause pain and hematuria. Retrograde pyelography in conjunction with measurements from the ureteral catheter markings should provide a guide to selection of the correct length. The appropriate catheter length should be based on the distance from the ureteral orifice
Comment Stent dislocation proximally can not only be troublesome but also may result in additional surgery if the stent cannot be retrieved endoscopically. Cystoscopic retrieval of a stent whose distal end lies within the ureter is neither easy nor certain, and was possible in only one of our cases prior to use of the suture tag. The Cook stent is a radiopaque polyethlene 5-F catheter with a proximal pigtail curl and a small flange on the distal (bladder) end. The catheter has multiple perforations for drainage. The pigtail is designed to be placed in the renal pelvis or dilated calyx, preventing migration of the stent down the ureter. A long, 6-F ureteral catheter, wire guide, and pusher catheter required for insertion are supplied with the stent. The Cook stent is available in l-cm. increments from 24 through 30 cm. The length of the catheter is measured from the distal flange to the base of the proximal curl. The initial step involved in placement of the stent requires insertion of the long 6-F ureteral catheter to the renal pelvis. Retrograde pyelography may be used to determine the ureteral length. A flexible guide wire is then passed inside the ureteral catheter to the renal pelvis. The ureteral cathe-
374
Ureretal Opening
FIGURE
Obsewe
3. Cook ureter-al stent in correct location. monofilament nylon suture in distal end.
UROLOGY
/ APRIL 1979 / VOLUME
XIII,
NUMBER 4
to the uppermost portion of the renal collection system. Underestimation of the length may result in proximal migration of the catheter. Therefore, one should err on the long side. We believe proximal stent migration may occasionally occur even after careful estimation of the appropriate length. The stent tip may “catch” on or in an infundibulum and, as the curl forms, the stent may retract up the ureter more than had been predicted. We believe this occurred in Case 2. Bending and twisting of the torso and renal excursion with respiration may cause the flange tip to retract up the orifice. Once retracted, the stiff catheter would likely abut the ureterovesical junction at such an angle that the tip would not likely spontaneously drop back into the bladder. Thus proper stent placement initially may not prevent subsequent stent migration, as in Case 1. Finally, the indication for the Cook stent may be so urgent that placement of the stent will be undertaken when a full selection of stent lengths is not available. This was a faction in 2 of our cases. To permit easy stent retrieval, should proximal migration occur, we advocate placement of
UROLOGY
I
APRIL 1979
/
VOLUME XIII,
NUMBER 4
a 4 to 6-cm., 4-O monofilament suture through the flange of the stent (Fig. 3). One suggestion already received by the manufacturers of the Cook stent is to incorporate a small “eye” in the flange of the catheter through which a suture could be placed. So far this has not been routinely incorporated into the production of the pigtail catheter. In spite of the technical problems which can be associated with the indwelling pigtail stent, it remains a valuable instrument in the treatment of ureteral obstruction and/or ureteral fistula. P.O. Box 63635 806 Madison Avenue Memphis, Tennessee 38163 (DR. SOLOWAY) References 1. Pais VM, Spelhnan RM, Stiles RE, and Mahoney SA: Internal ureteral splints, Urology 5: 22 (1975). 2. Gibbons RP, Correa RJ, Cummings KB, and Mason JT: Experience with indwelling ureteral stent catheters, J. Urol. 115: 22 (1976). 3. Schneider RD, Depauw AP, Montie JE, and Thompson IM: Problems associated with Gibbons ureteral catheters, Urology 8: 243 (1976).
375
