What are the indications for DJ (Double J) stenting in patients with ureteric calculi?

Indications of DJ Stenting for Ureteric Calculi Patients

Double J (DJ) stenting is indicated in ureteric calculi patients with ureteral injury, stricture, solitary kidney, renal insufficiency, or a large residual stone burden following ureteroscopy. 1

Primary Indications for DJ Stenting

• Ureteral injury during ureteroscopy - DJ stenting is necessary when there is trauma to the ureter during stone removal procedures 1
• Pre-existing ureteral stricture - Stenting helps maintain patency in patients with narrowed ureters 1
• Solitary kidney - To prevent complete obstruction in patients with only one functioning kidney 1
• Renal insufficiency - Patients with compromised kidney function require stenting to maintain drainage 1
• Large residual stone burden - When significant stone fragments remain after the initial procedure 1
• Ureteric obstruction with infection/sepsis - Cystoscopic retrograde ureteral decompression with double-J stents is indicated prior to definitive ureteroscopic stone extraction in cases of sepsis 1

Clinical Scenarios Requiring DJ Stenting

Obstructing Stones with Infection

• Fever, leukocytosis with obstructing stone - Retrograde ureteral stenting is usually appropriate for patients with flank pain, fever, and positive urinalysis showing infection 1
• Sepsis with obstructing calculi - DJ stenting has been shown to be safe and effective with an overall decreased duration of hospital stay and ICU admission rate compared to percutaneous nephrostomy (PCN) 1

Special Patient Populations

• Pregnant patients with obstructing calculi - DJ stenting is a preferred option for pregnant patients with hydronephrosis and signs of infection 1
• Pediatric patients - DJ stenting is appropriate for children with bilateral ureteric calculi causing obstructive anuria, especially when stones will be subsequently treated with chemolytic dissolution or extracorporeal shockwave lithotripsy (ESWL) 2

When DJ Stenting is NOT Indicated

• Routine stenting as part of SWL - The evidence shows no improved fragmentation with stenting during SWL, and stents are associated with bothersome symptoms 1
• Uncomplicated ureteroscopy - Several randomized prospective studies have demonstrated that routine stenting after uncomplicated URS may not be necessary 1, 3

Considerations for DJ Stent vs. PCN

• Stone size >2 cm - PCN may be preferred for larger stones due to greater risk of iatrogenic ureteric injury during stenting 2
• Mild hydronephrosis - May increase difficulty and failure rates of PCN insertion 2
• Subsequent treatment planning - The presence of a DJ stent facilitates subsequent ureteroscopy, while PCN facilitates percutaneous nephrolithotomy 4, 2
• High anesthesia risk patients - PCN may be preferred in patients at high risk for anesthesia 1
• Pyonephrosis - PCN may be preferred when larger tube decompression is warranted 1

Potential Complications of DJ Stenting

• Lower urinary tract symptoms and pain - DJ stents are associated with bothersome symptoms that can temporarily alter quality of life 1
• Stent migration - Can occur in approximately 5% of cases 1
• Urinary tract infection - Risk of UTI is approximately 2-6% 1
• Stent encrustation - Can occur when stents are left in place for extended periods 5
• Rare complications - Extremely rare but serious complications include intravascular migration 6

Follow-up Considerations

• Stent removal timing - Secondary cystoscopy is required for stent removal unless a pull string is attached to the distal end 1
• Monitoring for forgotten stents - Patients should be educated about the importance of timely stent removal to prevent complications like encrustation and stone formation 5