Retrograde Ureteral Stenting (Double-J Stent Placement)
When ureters are compressed before hysterectomy, the procedure of choice is cystoscopic retrograde ureteral stenting with double-J stents, which should be performed prophylactically in cases with documented hydronephrosis or significant ureteric displacement. 1
Clinical Approach
The decision to perform preoperative ureteric intervention depends on imaging findings and the degree of compression:
When Prophylactic Stenting is Indicated
- Documented bilateral ureteric dilatation/hydronephrosis on preoperative imaging (MRI or CT urography)
- Significant ureteric displacement by pelvic masses (large fibroids, cervical masses)
- Severe compression where the ureter's anatomical course is substantially altered 1
In these high-risk scenarios, bilateral prophylactic double-J ureteric stenting provides a palpable guide during surgery and maintains ureteric patency despite external compression.
Alternative: Percutaneous Nephrostomy (PCN)
If retrograde stenting fails due to complete obstruction (the catheter cannot traverse the compressed segment), this is actually diagnostically valuable—it signals severe ureteric compromise and should heighten intraoperative vigilance 1. In such cases, percutaneous nephrostomy can be placed for decompression prior to definitive surgical therapy 2.
Key Technical Points
Retrograde stenting advantages:
- Less invasive than PCN
- No external drainage tubes
- Allows immediate surgical planning
- Provides intraoperative anatomical landmark 1
Important caveat: The stenting procedure itself carries minimal risk but requires cystoscopic expertise. When attempted preoperatively and unsuccessful, do not view this as failure—it provides critical information about the severity of obstruction and should prompt consideration of PCN or modified surgical approach 1.
Intraoperative Strategy
Even with preoperative stenting, systematic retroperitoneal dissection with early identification and tracing of the ureter at the pelvic brim remains the essential intraoperative safeguard 1. The stent serves as both a protective measure and an anatomical guide but does not replace meticulous surgical technique.
If injury occurs despite precautions: Immediate intraoperative recognition with urological consultation for repair (ureteroureterostomy with DJ stent) yields the best outcomes 1, 3.