What is the procedure for reinserting a double J (double pigtail) stent after it has fallen out?

Reinsertion of a Displaced Double J Stent

When a double J stent has fallen out, the standard approach is cystoscopic retrograde placement under fluoroscopic guidance, which is the preferred first-line method for ureteral stenting with technical success rates approaching 98-100%. 1

Primary Reinsertion Technique

Perform cystoscopic retrograde stent placement as the initial approach:

• Insert the stent through the bladder cystoscopically 1
• Advance it retrograde up the ureter into the renal pelvis 1
• Use fluoroscopic guidance to confirm proper positioning with both coiled ends visible 1
• This method offers shorter fluoroscopy time, reduced hospital stay, and better patient self-care compared to percutaneous alternatives 1

When Retrograde Placement Fails

If cystoscopic placement is unsuccessful, proceed to percutaneous nephrostomy (PCN) with antegrade stenting:

• PCN demonstrates 100% technical success when retrograde stenting fails 2
• After establishing PCN access, attempt antegrade ureteral stent placement through the nephrostomy tract 2
• This approach allows guidewire and catheter manipulation from above to traverse any obstruction 2
• Consider conversion to a percutaneous nephroureterostomy if needed 3

Clinical Scenarios Requiring Alternative Approaches

Choose PCN over retrograde stenting in these specific situations:

• 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
• Patients with urinary diversion where retrograde access is technically difficult 1, 3

Important caveat: Internal double-J stents occlude quickly in ileal conduits due to mucous plugging and should be avoided in these patients 1, 3

Management of Complications During Reinsertion

If complete stent occlusion prevents replacement:

• Place immediate percutaneous nephrostomy for decompression 1, 3
• Do not persist with failed retrograde attempts, as this increases urosepsis risk 2

If signs of infection or urinoma develop:

• Augment drainage with additional ureteral stent, percutaneous urinoma drain, or percutaneous nephrostomy 1, 3
• Monitor for fever, increasing pain, or enlarging fluid collections 1, 3

Critical Pitfalls to Avoid

Minimize manipulation during infected cases:

• Prolonged guidewire and catheter manipulation while attempting to traverse obstruction increases urosepsis incidence 2
• Limit the degree of manipulation during initial access for decompression of infected collecting systems 2
• Monitor the patient closely intraprocedure and immediately postprocedure for signs of worsening sepsis 2

Ensure proper follow-up:

• Educate patients about the importance of timely stent removal to prevent encrustation, fragmentation, and stone formation 4
• Schedule routine replacement every 4-6 months if long-term stenting is required 5