Why is bilateral Double J (DJ) stenting performed even when there's a calculus on only one side?

Bilateral DJ Stenting for Unilateral Calculus

Bilateral DJ stenting is NOT routinely indicated when calculus disease is present on only one side—stenting should be limited to the affected kidney unless there is bilateral obstruction, bilateral infection/sepsis, or bilateral pathology requiring intervention. 1

Understanding the Clinical Scenario

The question implies a practice pattern that may reflect confusion about indications for ureteral stenting. Let me clarify when bilateral versus unilateral stenting is appropriate:

Indications for DJ Stenting (Unilateral)

For a single-sided ureteral calculus, DJ stenting is indicated only on the affected side in specific circumstances:

• Obstructing stone with infection/sepsis requiring urgent decompression before definitive stone extraction 1
• Solitary kidney on the affected side to prevent complete renal failure 1
• Pre-existing renal insufficiency where the affected kidney's function must be preserved 1
• Ureteral injury during ureteroscopy on the affected side 1
• Large residual stone burden after incomplete ureteroscopic treatment 1
• Pre-existing ureteral stricture requiring maintained patency 1

When Bilateral Stenting Would Be Appropriate

Bilateral DJ stenting is only justified when BOTH kidneys require intervention:

• Bilateral obstructing calculi with hydronephrosis 2
• Bilateral urosepsis from obstructing pathology on both sides 3, 1
• Bilateral ureteral strictures or injuries 1
• Anuria from bilateral obstruction (regardless of cause) 4

Common Pitfall to Avoid

The most critical error is placing unnecessary bilateral stents when only unilateral pathology exists. This practice:

• Doubles the risk of stent-related complications including lower urinary tract symptoms, pain, migration (5% per stent), and urinary tract infection (2-6% per stent) 1
• Increases patient morbidity through mechanical irritation of both bladder trigones and bilateral vesicoureteral reflux 3
• Requires bilateral cystoscopic removal procedures, doubling procedural risk and cost 1
• Exposes the patient to bilateral encrustation and fragmentation risk if stents are forgotten or left too long 5, 6, 7, 4

Alternative Approaches for Unilateral Disease

For unilateral obstructing calculus with sepsis, choose ONE decompression method on the affected side:

• Retrograde ureteral stenting (DJ stent) has shown decreased hospital stay and ICU admission rates compared to percutaneous nephrostomy in septic patients 1
• Percutaneous nephrostomy (PCN) may be preferred in high anesthesia risk patients or when pyonephrosis requires larger tube decompression 1
• Technical success for DJ stenting approaches 90-95% in most clinical scenarios 2

Quality of Life Considerations

Even unilateral DJ stents significantly impact quality of life through:

• Lower urinary tract symptoms (urgency, frequency, dysuria) from mechanical trigonal irritation 3, 1
• Flank pain from vesicoureteral reflux induced by the stent 3
• These symptoms do not respond to bladder training and resolve only after stent removal 3

Bilateral stenting unnecessarily doubles this symptom burden without clinical benefit when only one kidney is affected.

Definitive Management Timeline

After initial decompression of the affected side:

• Delay definitive stone treatment until sepsis resolves (if present) 3
• Monitor for normalization of temperature, white blood cell count, and inflammatory markers 3
• Plan stent removal once underlying pathology is definitively treated 3, 1
• Change or remove stents within 3 months in patients with calculus disease and persistent infection to prevent fragmentation 4