What is the protocol for ureteral stent placement and management?

Ureteral Stent Protocol: Placement and Management

Ureteral stent placement is strongly recommended in any ureteral repair to reduce failures (leaks) and strictures. 1

Indications for Ureteral Stenting

• Ureteral contusions require stenting when urine flow is impaired 1
• Partial ureteral lesions should be initially treated conservatively with stent placement, with or without a diverting nephrostomy in the absence of other indications for laparotomy 1
• Complete ureteral transections not suitable for non-operative management require primary repair plus a double J stent 1
• Ureteral injuries discovered during laparotomy should be repaired operatively with stent placement 1
• Delayed diagnosis of partial ureteral injuries should be initially managed with stent placement; if unsuccessful, percutaneous nephrostomy with delayed surgical repair is indicated 1

Stent Placement Techniques

Retrograde Approach (Most Common)

• Performed under fluoroscopic guidance with the patient under sedation/analgesia 2
• A guidewire is placed through the ureteral orifice, followed by stent advancement over the wire 3
• Can be performed using local anesthesia in select cases, though this approach may be painful and should be reserved for urgent situations 4

Antegrade Approach

• Indicated when retrograde access is not possible 1
• Used for:
  • Large impacted stones in the upper ureter
  • Combined renal stone removal
  • Cases after urinary diversion
  • Failed retrograde ureteral access 1

Special Considerations

Ureteral Trauma Management

• For partial lesions: conservative management with stent placement is first-line 1
• For complete transections: surgical repair with stent placement is indicated 1
• For distal injuries (caudal to iliac vessels): reimplantation of ureter into bladder (uretero-neocystostomy) is preferred 1
• In damage control situations: temporary ligation of damaged ureter with nephrostomy tube placement, followed by delayed repair 1

Stenting After Ureteroscopy (URS)

• Routine stenting following uncomplicated URS is optional 1
• Clear indications for post-URS stenting include:
  • Ureteral injury
  • Stricture
  • Solitary kidney
  • Renal insufficiency
  • Large residual stone burden 1

Stenting with Shock Wave Lithotripsy (SWL)

• Routine stenting is not recommended as part of SWL 1
• Studies show no improved fragmentation with stenting and frequent stent-related symptoms 1

Complications and Management

• Common stent-related complications include:
  • Bothersome lower urinary tract symptoms and pain 1
  • Stent migration 1
  • Urinary tract infection 1
  • Breakage 1
  • Encrustation 1
  • Obstruction 1

Stent Removal and Exchange

• Unless a pull string is attached to the distal end, secondary cystoscopy is required for stent removal 1
• Fluoroscopically guided retrograde exchange can be performed with high technical success and low complication rates 5
• For occluded stents, techniques include:
  • Using a 0.018-inch guidewire
  • Advancing an angiographic sheath over the occluded stent
  • Recannulation of the ureteral orifice with a guidewire 5

Pitfalls to Avoid

• Failing to place stents after ureteral repair, which increases risk of leaks and strictures 1
• Attempting retrograde stenting in cases of complete transection, which is often unsuccessful 1
• Overlooking the need for nephrostomy tube placement when stenting is unsuccessful 1
• Neglecting to confirm proper stent placement with imaging 6
• Underestimating patient discomfort with stents, which can temporarily alter quality of life 1