What are the recommendations for patients with a ureteral stent?

Ureteral Stent Management Recommendations

Primary Indications for Stent Placement

Ureteral stents should be placed for ureteral injuries (contusions with impaired flow, partial lesions, complete transections), as adjuncts to complicated upper tract surgery, for upper urinary fistulas, and to bypass obstruction from stones or malignancy. 1, 2

Trauma-Related Indications

• Ureteral contusions require stenting when urine flow is impaired 1, 2
• Partial ureteral lesions should be initially treated conservatively with stent placement, with or without diverting nephrostomy, in the absence of other indications for laparotomy 1, 2
• Complete ureteral transections or avulsions not suitable for non-operative management require primary repair plus a double-J stent 1, 2
• For distal ureteral injuries, ureteral reimplantation into the bladder is preferred with stent placement 1, 2
• In any ureteral repair, stent placement is strongly recommended to reduce risk of leaks and strictures 1, 2

Stone Disease Management

• For obstructing stones with fever and leukocytosis (infected obstructed kidney), retrograde ureteral stenting is usually appropriate 1
• Routine stenting following uncomplicated ureteroscopy is optional and does not improve stone-free rates 2, 3
• Clear indications for post-ureteroscopy stenting include ureteral injury, stricture, solitary kidney, renal insufficiency, and large residual stone burden 2
• Routine stenting is not recommended as part of shock wave lithotripsy, as studies show no improved fragmentation and frequent stent-related symptoms 2, 3

Malignant Obstruction

• For advanced cervical carcinoma with bilateral hydronephrosis, retrograde ureteral stenting, percutaneous nephrostomy, or percutaneous antegrade ureteral stenting are equivalent appropriate options 1
• Stent placement for malignant obstruction frequently allows hospitalization of 4 days or less 4

Delayed Diagnosis of Ureteral Injury

• Partial ureteral injuries diagnosed in delayed fashion should undergo attempted ureteral stenting first 1, 2
• If stenting fails or in cases of complete transection, percutaneous nephrostomy with delayed surgical repair is indicated 1, 2

Stent Placement Techniques

Retrograde Approach (First-Line)

• Retrograde stenting is the standard initial approach for most indications 1, 2
• This can be performed under local anesthesia in women, though it is painful (mean VAS 5.89) and 50% would not accept the procedure under local anesthesia again 5

Antegrade Approach (When Retrograde Fails)

• The antegrade approach is indicated when retrograde access is not possible, including large impacted upper ureteral stones, combined renal stone removal, cases after urinary diversion, and failed retrograde access 2
• If initial retrograde stenting fails and the lesion cannot be crossed, interval percutaneous nephrostomy should be considered, followed by secondary attempt at stent placement 1

Critical Timing and Removal

Stents must be removed within the prescribed timeframe to prevent complications including encrustation, infection, and chronic pain. 6

• The standard removal approach is cystoscopic removal, which requires secondary cystoscopy unless a pull string is attached to the distal end 6, 2
• Stents should typically be changed every 8 weeks, as obstruction usually occurs after this timeframe 4
• Forgotten stents lead to significant morbidity from severe encrustation and often require multiple endoscopic procedures for management 3

Infection Prevention

Prophylactic antibiotics are recommended during stent placement to reduce infection risk (approximately 2-6%). 7

• For high-risk patients, ciprofloxacin or trimethoprim-sulfamethoxazole prophylaxis may be considered 7
• Regular assessment of stent necessity is important, as infection risk increases with duration of placement 7
• When infection is present, targeted antibiotic therapy based on urine culture is recommended 7
• Patients at greatest risk for complications include those undergoing bilateral stentless ureteroscopy, those with recent or recurrent urinary tract infections, and pregnant patients—stent placement should be strongly considered in these groups 3

Common Complications and Management

Common stent-related complications include bothersome lower urinary tract symptoms and pain, stent migration (approximately 5%), urinary tract infection, breakage, encrustation, and obstruction. 7, 2, 3

• Patients with stents have significantly more bladder and lower urinary tract symptoms than those without stents 3
• Irritative symptoms occur in a minority of patients and respond well to pharmacologic therapy 4
• Stent migration occurs in approximately 5% of cases 7

Critical Pitfalls to Avoid

• Never fail to place stents after ureteral repair, as this increases risk of leaks and strictures 2
• Do not attempt retrograde stenting alone in cases of complete transection, as it is often unsuccessful—be prepared for percutaneous nephrostomy 2
• Do not overlook the need for nephrostomy tube placement when stenting is unsuccessful 2
• Do not underestimate patient discomfort with stents, which can temporarily alter quality of life—counsel patients appropriately 2
• Never leave stents beyond recommended exchange intervals, as encrustation becomes a major problem after 8 weeks 4

Alternative Approaches When Stenting Fails

When stent placement is not possible or fails, percutaneous nephrostomy should be considered as an alternative for urinary diversion. 7

• For ureteral leaks and strictures, percutaneous nephrostomy decompression as primary management results in decreased need for reoperation and decreased morbidity rates 1
• If the injury is associated with significant obstruction or infection, both ureteral stenting and percutaneous drainage may be necessary 7