Management of Cystoscopic Stent Placement
For cystoscopic ureteral stent placement, ureteral stents should be used but can be safely removed on postoperative day 1 after pelvic surgery in patients with low risk of urinary retention, while prophylactic antibiotics should be administered prior to the procedure and continued post-procedurally. 1
Indications and Placement Technique
Indications for Ureteral Stenting
- Ureteral injury during surgery
- Stricture management
- Solitary kidney
- Renal insufficiency
- Large residual stone burden
- Impacted stones in the upper ureter
- Combination with renal stone removal
Stent Placement Technique
- Use a safety guidewire during the procedure 1
- Fluoroscopy is essential for monitoring guidewire position and stent placement 1
- For internal stents, one or two plastic double pigtail stents should be inserted to maintain patency 1
- The use of metallic stents outside clinical trials is not recommended 1
Antibiotic Management
Prophylactic Antibiotics
- Prophylactic antibiotics are recommended before stent placement 1
- Antibiotics should be continued post-procedurally 1
- Administer within 60 minutes of the procedure and re-dose during the procedure if case length necessitates 1
- Single oral or IV dose of an antibiotic covering gram-positive and gram-negative uropathogens is recommended 1
Special Considerations
- If purulent urine is encountered during the procedure, abort the procedure, establish drainage, continue antibiotic therapy, and obtain a urine culture 1
- Patients with asymptomatic bacteriuria, high BMI, and elderly patients are at higher risk for post-procedure UTIs and should receive antimicrobial prophylaxis 2
Duration of Stenting
Stent Removal Timing
- Transurethral catheter can be removed on postoperative day 1 after pelvic surgery in patients with low risk of urinary retention 1
- Ureteral stents should be used for at least until postoperative day 5, though optimal duration is unknown 1
- Stenting following uncomplicated ureteroscopy (URS) is optional 1
Stent Removal Considerations
- Routine stenting is not recommended as part of SWL (shock wave lithotripsy) 1
- After uncomplicated URS, routine stent placement is not recommended 1
- After uncomplicated PCNL (percutaneous nephrolithotomy), nephrostomy tube placement is optional 1
Complications and Management
Common Complications
- Stent-related symptoms (lower urinary tract symptoms and pain)
- Stent migration
- Urinary tract infection
- Stent breakage
- Encrustation
- Obstruction
Management of Complications
- For stent-related symptoms, α-blockers may be prescribed to reduce stent discomfort 1
- Anti-muscarinics can also be considered for stent-related symptoms 1
- For infection, obtain urine culture and provide appropriate antibiotic therapy 1
Special Populations
Pediatric Patients
- Both SWL and URS are effective treatment options 1
- Stenting principles similar to adults but with size-appropriate stents
High-Risk Patients
- Patients on anticoagulation/antiplatelet therapy: URS is preferred as first-line therapy 1
- Immunocompromised patients: Consider extended antibiotic prophylaxis
Follow-up
- Monitor for signs of UTI (fever, irritative voiding symptoms, abdominal pain)
- Consider urine culture if symptoms develop
- Ensure timely removal of temporary stents to prevent encrustation and associated complications
Pitfalls to Avoid
- Failing to use a safety guidewire during the procedure
- Omitting prophylactic antibiotics in high-risk patients
- Leaving stents in place for too long, leading to encrustation
- Routine stenting when not indicated (e.g., uncomplicated URS, SWL)
- Not recognizing or addressing stent-related symptoms
By following these guidelines, clinicians can optimize outcomes for patients requiring cystoscopic stent placement while minimizing complications and improving patient comfort.