Urethral Stent Removal: Procedural Steps
Primary Removal Method: Cystoscopic Extraction
The standard approach for removing a urethral (ureteral) stent is cystoscopic removal, which requires secondary cystoscopy unless a pull string is attached to the distal end. 1
Standard Cystoscopic Removal Steps:
Position the patient in lithotomy position and prepare the external genitalia with antiseptic solution 2
Perform flexible cystoscopy using local anesthesia (typically intraurethral lidocaine gel), which has a mean pain score of 1.27 on visual analog scale 3
Visualize the bladder and identify the distal curl of the double-J stent within the bladder 2
Grasp the distal end of the stent using grasping forceps passed through the cystoscope working channel 3
Remove the stent by gentle traction while withdrawing the cystoscope, ensuring the proximal curl passes through the ureter without resistance 3
Monitor for complications including hematuria (typically minimal and self-limiting) 3
The procedure typically takes less than 5 minutes in experienced hands and can be performed in an office setting. 3 Flexible cystoscopy is significantly more painful in men than women (p = 0.018), though overall pain scores remain low. 3
Alternative Method: String-Assisted Removal
For stents placed with an attached extraction string, removal can be performed without cystoscopy by simply pulling the string, which significantly reduces cost (8.97 vs 455 CNY) and allows earlier removal (5.3 vs 11.2 days). 4
String Removal Technique:
Verify string presence externally at the urethral meatus 4
Apply steady, gentle traction on the string to extract the stent 4
Monitor for resistance - if significant resistance is encountered, stop and proceed to cystoscopic removal 4
Important caveat: String-assisted removal carries a 10.3% risk (6/58 patients) of accidental premature dislodgement, though this still results in net cost savings compared to cystoscopic removal. 4
Novel Cystoscope-Free Method (Emerging Technique)
A gastric tube-based extraction method has shown 96.9% success rate with mean extraction time of 4.3 minutes and pain score of 2.1. 5 This involves:
Insert an F6 or F8 gastric tube with a 3-0 Prolene line through the front end into the urethra 5
Drain urine from the bladder, then inject saline 5
Rotate the gastric tube with the line for 4-5 weeks, then gently pull outward to remove the stent 5
This method is particularly useful during resource-limited situations and reduces cross-infection risk, though it requires multiple attempts in 21.9% of cases. 5
Management of Migrated Stents
For mildly upward migrated stents (below the pelvic brim), ureteroscopic removal under local anesthesia is effective with 91.9% success rate. 3
Ureteroscopic Removal Steps:
Confirm migration location with plain KUB radiograph and flexible cystoscopy 3
Perform semirigid ureteroscopy in the office setting using local anesthesia only 3
Advance the ureteroscope to visualize the migrated stent 3
Grasp and extract the stent under direct vision 3
The mean pain score for ureteroscopic removal is 1.73, which is higher than flexible cystoscopy (p <0.01) but remains tolerable without general anesthesia. 3 All patients can be discharged within 1 hour. 3
Critical Timing Considerations
Stents must be removed within the prescribed timeframe to prevent complications including encrustation, infection, and chronic pain. 6 Even long-forgotten stents (up to 15 years) can be successfully removed cystoscopically, though earlier removal prevents these complications. 7
Common Pitfalls to Avoid
Never force stent removal if significant resistance is encountered - this may indicate encrustation or migration requiring ureteroscopic assistance 3
Do not attempt string removal if the string is not clearly visible or if there is concern about infection 4
Avoid general anesthesia for routine stent removal as it adds unnecessary cost and risk; local anesthesia is sufficient for most cases 3
Do not delay removal beyond the recommended timeframe, as encrustation risk increases significantly with prolonged dwell time 6, 7