What is the next step in management of a patient with intussuscepted mucosa after semi-rigid ureteroscopy with basket stone extraction of a mid-ureteral stone, where retrograde stent placement is not possible due to failed cannulation of the ureteral orifice?

Management of Intussuscepted Ureteral Mucosa After Failed Retrograde Stent Placement

When retrograde stent placement fails due to intussuscepted ureteral mucosa following basket stone extraction, percutaneous nephrostomy with antegrade ureteral stenting is the recommended next step in management.

Immediate Management Algorithm

1. Percutaneous nephrostomy (PCN) placement

   • Provides immediate urinary drainage
   • Technical success rates approach 100% for dilated collecting systems 1
   • Allows for decompression of the obstructed collecting system
   • Prevents further complications such as hydronephrosis and infection

2. Antegrade ureteral stenting

   • Can be performed in the same session or as a staged procedure
   • Success rates of 95-97% have been reported for antegrade stenting when retrograde approaches fail 2, 3
   • Allows for internal drainage and ureteral healing

Rationale for PCN with Antegrade Stenting

The 2019 WSES-AAST guidelines clearly state that "in any ureteral repair, stent placement is strongly recommended" 1. When retrograde stenting fails, guidelines recommend "percutaneous nephrostomy with delayed surgical repair" 1.

The American College of Radiology guidelines specifically note that "if placement of retrograde double-J ureteral stent is unsuccessful, antegrade ureteral stenting may be considered" 1. This approach is particularly relevant in cases of ureteral injury where stenting is essential for proper healing.

Technical Considerations

• Timing: Allow 1-2 weeks for the nephrostomy tract to mature before attempting antegrade stenting unless urgent internal drainage is required 4

• Technique options:

  • Over-the-wire technique
  • Modified technique with guidewire advancement
  • Combined antegrade/retrograde approach in difficult cases 5

• Potential complications (overall rate 8-10%):

  • Minor: Lumbar pain, infection (most common)
  • Major: Bleeding (rare, 2-4%) 6, 2

Special Considerations for Intussuscepted Mucosa

Intussuscepted mucosa represents a form of ureteral injury that requires stenting for proper healing. The AUA Urotrauma guidelines recommend that "surgeons should perform percutaneous nephrostomy with delayed repair as needed in patients when stent placement is unsuccessful or not possible" 1.

Prolonged manipulation during antegrade stenting attempts should be minimized to reduce the risk of further injury or urosepsis 1. A safety wire should be maintained throughout the procedure.

Follow-up Management

1. Perform a nephrostogram 1-2 weeks after PCN placement to assess ureteral patency
2. If antegrade stenting is successful, the nephrostomy tube can be removed after confirming proper stent function
3. Plan for stent removal in 4-6 weeks after confirming ureteral healing
4. Monitor for signs of infection, obstruction, or stent migration

Pitfalls to Avoid

• Premature conversion: Attempting antegrade stenting too soon after PCN placement before tract maturation
• Excessive manipulation: Can worsen ureteral injury or lead to sepsis
• Inadequate drainage: Failing to place a nephrostomy tube of adequate size
• Neglecting follow-up: Regular stent surveillance with timely exchange is mandatory 6

By following this approach, you can effectively manage intussuscepted ureteral mucosa after failed retrograde stent placement, minimizing the risk of complications and promoting proper ureteral healing.