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1007

Technical

Retrograde Stents Joseph

Replacement

W. Yedlicka,

Jr.,1 Richard

of Internal

Aizpuru,

David

W. Hunter,

The ability of internal double-J ureteral stents to maintain ureteral patency has been well documented [1 -3]. However, these stents often need to be changed or removed. The techniques of retrograde cystoscopic manipulation and percutaneous antegrade placement or removal of these stents have been described [1 -8]. We present a simple technique for retrograde removal or exchange of internal ureteral stents by using

a right-angle

snare/catheter

system,

scopic control, reported.

that to our knowledge

Materials

Methods

and

under

fluoro-

Double-J

Wilfrido

Bloomington,

Ureteral

R. Casta#{241}eda-Z#{252}#{241}iga, and Kurt Amplatz

IN; Medi-tech,

Watertown,

MA;

Fig.

1 E) is advanced

in

a retrograde fashion over the guidewire and positioned so that the proximal pigtail is formed in the renal pelvis. The stent stiffener is removed, leaving the guidewire and pusher in place. The wire is then partially withdrawn so that the floppy end of the wire is across the junction between the pusher and the stent. The pusher is then slowly advanced with a gentle rotating motion; the floppy end of the wire allows the distal pigtail portion of the stent to spontaneously re-form

within the bladder

has not been previously

Note

(Fig. 1 F). The pusher

is removed,

and a Foley

catheter is placed into the urinary bladder for a follow-up cystogram to confirm proper stent positioning and patency. If necessary, the stent position can be adjusted, repeating the steps described here.

Results Through

a Foley

advanced

used

exchanged with

Heights, (Fig.

a MN;

bladder

assembly urethra proximal or in the

an

Under

catheter,

guiding

guiding

stent

catheter

carefully

catheter

(Microvena

multiangled

double-J

on the stent. is then

angled snare

1A).

of the

1 B). The

loop

for

right-angle Fig.

end

snare

angiographic

a guidewire

into the bladder. Female patients are in the dorsal male patients are supine. The Foley or angiographic

position; is then

or standard

is then

With

withdrawn

(6-French)

fluoroscopic

the

in order

firmly

a short

to

be

Vadnais guidance,

with

advanced

the stent

lithotomy catheter

Corporation,

is encircled

is

the

snare

loop

to close

grasped, distance

the

the entire through

the

(Fig. 1 C), and the end of the stent grasped with a clamp. The end of the ureteral stent is still either within the renal pelvis proximal

ureter.

A stiff

guidewire

is then

inserted

into

the

exteriorized end of the stent and advanced until the guidewire is coiled within the renal pelvis. The stent is then completely removed, leaving

standard,

the

guidewire

in place

appropriate-length,

(Fig.

Received November 6, 1990; accepted 1 All authors: Department of Radiology, reprint requests to K. Amplatz. AJR 156:1007-1009,

1 D). Next,

10-French

the

double-J

tapered

end

stent

of a

(Cook,

after revision December 1 1 . 1990. Box 292 UMHC, University of Minnesota

May 1991 0361-803X/91/1565-1007

© American

Roentgen

Ureteral stent removals or exchanges were successfully performed in 21 of 22 female patients and two of two male patients during the past 2 years. The majority of these patients had malignant ureteral obstruction. In the single unsuccessful case, manipulation of the snare within the urinary bladder was limited by massive tumor ingrowth that necessitated cystoscopic removal of the occluded stent. We have had no complications except for minor transient hematuria in five cases. In two patients, the new stent was inadvertently pushed too far up the ureter. Both were quickly and easily repositioned (see Discussion). The procedure was very easy to perform, even for inexperienced operators. The average time for retrieval or exchange of the internal ureteral stents was less than 25 mm per case; fluoroscopic time averaged 2-5 mm.

Hospital

and Clinic,

Ray Society

420 Delaware

St. SE.,

Minneapolis,

MN 55455.

Address

YEDLICKA

1008

ET AL.

AJR:156,

May 1991

Fig. 1.-A 62-year-old woman had a right double-J ureteral stent placed for ureteral obstruction due to metastatic ovarian carcinoma. Three months

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after stent placement, phrosis

(seen

A, Right-angle

hydrone-

nitinol snares. Snare loops are 5, 10, 15, and 25 mm

(straight arrows). Guiding catheters (arrowheads), “cheater” (curved arrow). B, A right-angle snare (arrow) through a 6-French guiding catheter has been inserted in a retrograde fashion into urinary bladder. Note distal pigtail of occluded internal ureteral stent (arrowheads). C, 6-French guiding catheter advanced to close snare loop (arrow), enabling removal of occluded ureteral stent (arrowheads) through urethra. D, After guidewire (arrows) was coiled in renal pelvis (contrast material is from a previous CT examination), old stent (arrowheads) was removed, leaving wire in place. E, 10-French double-J ureteral stent set (Cook Co.) pusher (straight solid arrow), stiflener (open arrow), and double-J stent (curved arrow). F, After inner stiffener had been removed, pusher (solid arrows) was used to advance distal end of stent (arrowheads) into bladder over floppy end of guidewire (open arrow). Note that guidewire is only slightly beyond stiffener-stent junction.

A

E

F and complications of that procedure. Retrograde cystoscopic removal or exchange is widely used but usually requires general or epidural anesthesia and the use of a surgery or cystoscopy suite [1 -3, 7, 8]. The retrograde approach with a right-angle snare/catheter system is easy to perform (even for inexperienced operators) and can be done risks

Discussion Internal double-J ureteral stents maintain ureteral patency [1-3].

she had right flank pain and right-sided

on a CT examination).

have been widely

used

to

Antegrade approaches for removal and exchange of these stents have been described [4-6]. However, this is technically more difficult, is much more painful and psychologically demanding for the patient, and requires placement of a large catheter through a percutaneous tract with all the attendant

in any

fluoroscopy

(small 20-25

catheters) mm. This

room.

The

patient’s

discomfort

is minimal

and the procedure is usually completed in technique is best suited for retrograde ma-

AJR:156,

nipulation

in females

enlargement

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RETROGRADE

May 1991

in males

because may

a longer

make

this

REPLACEMENT

urethra

and

procedure

more

prostate difficult

and uncomfortable. At our institution, we perform this procedure on those male patients in whom cystoscopy is difficult or fails and in those male patients at high risk when anesthesia is used. The most difficult part of the procedure is getting the snare loop around the lower end of the stent. Fluoroscopy in two planes is critical, and the new, more maneuverable snare system, although it has not improved our ability to complete the procedure successfully, has markedly reduced the time required. The only other slightly tricky part of the procedure is pushing

the lower

pigtail

out of the urethra

into the bladder.

In two patients, the new stent was inadvertently too far into the ureter. In one patient, a small balloon

was

advanced

over

the

wire

into

the

advanced angioplasty

stent

and

the

stent pulled into the bladder. In the other patient, the lower end of the stent was still in the bladder; it was grasped with the snare and easily repositioned. In conclusion, we believe that the retrograde transurethral approach with a right-angle snare/catheter system under

OF

DOUBLE-J

STENTS

1009

fluoroscopic guidance is the procedure of choice for exchange or removal of internal double-J ureteral stents in female patients and also may be useful in selected male patients.

REFERENCES 1 . Hepperlen stents:

TW, Mardis a new approach.

HK, Kammandel H. Self-retained J Urol 1978;1 19:731

intemal

ureteral

2. VanArsdalen KN, Pollack HM, Wein AJ. Ureteral stenting. Semin Urol 1984:2:180-186 3. Smith AD. Percutaneous ureteral surgery and stenting. Urology 1984;23:37-42 4. LeRoy AJ, Williams HJ, Segura JW, Patterson DE, Benson RR. In-dwelling ureteral stents: percutaneous management of complications. Radiology 1986;1 58:219-222 5. Boren SR, Dotter CT, McKinney M, Rosch J. Percutaneous removal of ureteral stents. Radiology 1984; 152:230-231 6. Mitty HA, Train JS, Dan SJ. Placement of ureteral stents by antegrade and retrograde techniques. Radio! Clin North Am 1986;24:587-600

7. Hezmall HP, Flechner SM, SandIer CM. Controlled of

ectopic

ureteral

catheters

using

fluoroscopic

endoscopic

retrieval

guidance.

Urology

North

1982:9:

1985;25:613-615 8. Smith AD. 109-112

Retrieval

of

ureteral

stents.

Urol

Clin

Am