What is cystoscopy with right ureteral stent placement?

Cystoscopy with Right Ureteral Stent Placement: Procedure and Management

Cystoscopy with right ureteral stent placement is a minimally invasive urological procedure that involves inserting a thin, hollow tube (stent) into the right ureter to relieve obstruction and maintain urine flow from the kidney to the bladder. 1, 2

Procedure Overview

What is Cystoscopy?

• A diagnostic procedure using a cystoscope (thin tube with camera and light) inserted through the urethra into the bladder
• Allows direct visualization of the lower urinary tract including the urethra, bladder, and ureteral orifices
• Can be performed with rigid or flexible cystoscopes depending on the clinical scenario

What is Ureteral Stenting?

• Insertion of a hollow tube into the ureter to maintain patency and urine flow
• Most commonly uses a double-J stent (curled at both ends to prevent migration)
• Stent placement is performed retrograde through the bladder via cystoscopy 1, 3

Indications for Right Ureteral Stent Placement

Obstructive Conditions

• Ureteral stones causing obstruction and hydronephrosis
• Relief of obstruction in patients with sepsis or infection 1
• Extrinsic compression from tumors or retroperitoneal fibrosis

Trauma and Surgical Scenarios

• Ureteral injuries (partial or complete transection)
• Post-surgical management after ureteral repair or reimplantation 1
• Prophylactic use during complex pelvic surgery 3

Other Indications

• Pregnancy with symptomatic hydronephrosis
• Management of ureteral strictures
• Temporary diversion for urinary leaks or fistulas 2

Procedural Technique

Preparation

1. Patient positioning in lithotomy position
2. Sterile preparation and draping
3. Administration of appropriate anesthesia (local, moderate sedation, or general anesthesia) 4

Stent Placement Steps

1. Cystoscope insertion through urethra into bladder
2. Identification of right ureteral orifice
3. Guidewire insertion through the ureteral orifice and advanced to the kidney
4. Retrograde pyelogram may be performed to visualize anatomy (using contrast under fluoroscopy)
5. Ureteral stent advanced over guidewire
6. Confirmation of proper positioning with both curls in place (proximal curl in renal pelvis, distal curl in bladder)
7. Guidewire removal and final positioning check 3

Types of Ureteral Stents

Based on Duration

• Temporary stents: Removed after 2-6 weeks depending on indication
• Long-term stents: Require exchange every 3 months to prevent encrustation 2

Based on Design

• Double-J/pigtail stents: Most common, with curls at both ends
• External stents: One end exits through urethra or skin
• Magnetic stents: Allow removal without cystoscopy using magnetic retrieval device 5

Stent Duration Guidelines

• Partial ureteral lesions: 2-3 weeks 2
• Complete ureteral transection with repair: 4-6 weeks 2
• Ureteral reimplantation: 2-4 weeks 2
• Temporary obstructions (stones/pregnancy): 2-4 weeks 2
• Malignant obstruction: Regular exchanges every 3 months 2

Complications and Management

Common Complications

• Discomfort/pain: "Stent syndrome" - flank pain, bladder spasms, urgency, frequency
• Hematuria: Common initially, should resolve within days
• Infection: Risk increases with prolonged stent duration 6
• Encrustation: Risk increases dramatically after 3 months 2, 7
• Migration: Stent may move from intended position

Management of Complications

• Pain control: Anticholinergics, alpha-blockers, analgesics
• Infection: Appropriate antibiotics based on culture
• Encrustation: May require multiple procedures for removal
• Migration: Repositioning or replacement of stent

Stent Removal

Techniques

• Standard cystoscopic removal: Most common approach
• Magnetic retrieval: For specially designed magnetic stents 5
• String-attached stents: Allow removal without cystoscopy

Considerations for Removal

• Timing: Based on indication and clinical scenario (typically 2-6 weeks) 2
• Anesthesia: Local anesthesia, moderate sedation, or general anesthesia depending on patient factors 4
• Antimicrobial prophylaxis: Consider for high-risk patients (elderly, high BMI, or those with asymptomatic bacteriuria) 6

Special Considerations

Pediatric Patients

• Smaller instruments required
• Often requires general anesthesia
• May use stents with strings to facilitate removal 1

Pregnant Patients

• Nephrostomy catheters often preferred until after delivery 2
• Fluoroscopy avoided when possible

Malignant Obstruction

• Higher technical success with percutaneous nephrostomy in cases of extrinsic compression 1, 2
• Regular stent exchanges required every 3 months 2

By understanding the indications, technique, and management of ureteral stents, clinicians can optimize outcomes and minimize complications for patients requiring this common urological intervention.