What is the procedure and management for Double J (DJ) stenting in patients with ureteral obstruction?

Double J (DJ) Ureteral Stenting: Procedure and Management

Primary Indication and Approach

Cystoscopic retrograde DJ stent placement is the preferred first-line method for ureteral decompression in most cases of obstruction, offering shorter fluoroscopy time, reduced hospital stay, and better patient self-care compared to percutaneous nephrostomy. 1, 2

Procedure Technique

Placement Methods

• Endoscopic insertion is the standard approach (used in 58-68% of cases), typically performed under local anesthesia (54% of cases) 3, 4
• The stent is placed cystoscopically through the bladder, advanced retrograde up the ureter into the renal pelvis 1
• Fluoroscopic guidance is used to confirm proper positioning with both coiled ends (proximal in renal pelvis, distal in bladder) 1

Technical Success

• Technical success rates approach 98-100% when performed with appropriate imaging guidance 1, 3
• Average drainage time is approximately 5.8 weeks for temporary indications 3

Clinical Indications

Primary Uses

• Ureteral obstruction from stones, strictures, or malignancy (39-43% of cases) 3, 4
• Adjunct to upper urinary tract surgery including pyeloplasty, ureteroneocystostomy, and fistula repair (29-33% of cases) 3, 4
• Support for endourologic procedures such as ureteroscopy and stone extraction (16-18% of cases) 3, 4
• Preparation for extracorporeal shock wave lithotripsy (7-8% of cases) 3

Specific Clinical Scenarios

• In obstructing stones with sepsis, DJ stenting prior to definitive stone extraction is safe and effective, with decreased hospital stay and ICU admission rates compared to PCN 1
• For malignant obstruction, stenting allows hospital discharge within 4 days in most patients 4
• Upper urinary tract fistulas heal without surgery in 50% of cases when treated with DJ stents 4

When to Choose Alternatives

Percutaneous Nephrostomy Preferred Over DJ Stenting

• High-risk anesthesia patients who cannot tolerate cystoscopy 1
• Pyonephrosis requiring larger tube decompression 1
• Extrinsic ureteral obstruction where retrograde stenting carries higher urosepsis risk 1
• Complete stent occlusion where replacement fails—PCN should be placed immediately 5

Special Anatomic Considerations

• In patients with urinary diversion (ileal conduit), retrograde access is difficult; image-guided percutaneous antegrade access with conversion to retrograde nephroureterostomy is preferred 1, 5
• Internal DJ stents occlude quickly in ileal conduits due to mucous plugging and should be avoided 1, 5

Complications and Management

Common Complications (Overall Rate 6.6-32.7%)

• Irritative bladder symptoms occur in 32.7% of patients, respond well to anticholinergic therapy 4, 6
• Urinary tract infection develops in 14.8% of cases 6
• Hematuria occurs in 10.4% of cases, rarely requiring transfusion (0.01%) 6

Serious Complications Requiring Intervention

• Stent migration: Proximal migration (0.9%) or distal migration (0.7%) 6
• Malposition occurs in 0.3% of cases, including rare retroperitoneal placement or parenchymal perforation 6
• Stent obstruction develops in 1.9% of cases, usually after >8 weeks indwelling 4, 6
• Encrustation and calcification occur in 1.7% of cases, particularly with prolonged indwelling time 6

Management of Complications

• If stent occlusion occurs with failed replacement, place PCN immediately for decompression 5
• For enlarging urinoma, fever, increasing pain, or infection, augment drainage with additional ureteral stent, percutaneous urinoma drain, or PCN 5
• Encrusted or calcified stents require combined endourological techniques for removal 6

Stent Maintenance

Duration and Exchange

• Short-term stenting (<6 weeks) is appropriate for most surgical adjuncts and temporary obstruction 6
• Long-term stenting (>6 weeks) requires regular exchange to prevent obstruction and encrustation 4, 6
• Stents can be changed easily on outpatient basis under local anesthesia with excellent patient tolerance 4
• Obstruction typically occurs after >8 weeks if not exchanged 4

Quality of Life Considerations

Patients with DJ stents report significantly better self-care ability compared to PCN patients, making DJ stenting preferable when both options are technically feasible 2. The stent allows for normal ambulation and activities without external drainage bags 4.