Management of Blood Clots Obstructing a Ureteral Stent
If a ureteral stent becomes obstructed with blood clots, immediate intervention with stent removal and replacement or conversion to percutaneous nephrostomy (PCN) is required, particularly if the patient develops fever, flank pain, or signs of sepsis. 1
Immediate Assessment and Diagnostic Work-Up
When a patient with a ureteral stent presents with symptoms suggesting clot obstruction (gross hematuria, flank pain, fever), urgent evaluation is mandatory:
- Obtain blood cultures (minimum two sets) and urine cultures before any antibiotic changes to identify causative pathogens and guide definitive treatment 1
- Perform contrast-enhanced CT urogram as first-line imaging to assess stent position/patency, degree of hydronephrosis despite stenting, presence of perinephric stranding or abscess, and any stent-related complications 1
- Do not delay imaging if clinical status worsens—prompt CT is required to identify correctable anatomic causes such as malpositioned stents, new obstruction, or perinephric collections 1
Urgent Drainage Indications
PCN should be instituted without delay in any patient who is septic, hypotensive, or shows worsening renal function, as PCN provides superior drainage compared to internal stents in infected obstructed systems and improves early and long-term cure rates 1
Specific indications for urgent PCN placement include:
- Sepsis and/or anuria due to obstructed kidney requires mandatory urgent decompression of the collecting system 1
- Stent malposition or migration identified on CT 1
- Severe, persistent hydronephrosis despite stent presence 1
- Perinephric abscess or pyonephrosis 1
- Hemodynamically unstable or septic patients may require emergent PCN before imaging if necessary to achieve rapid source control 1
The American College of Radiology specifically recommends PCN for patients with prolonged flank pain, fever, leukocytosis, and dilated collecting system who appear septic 1
Management of Clot Obstruction Without Sepsis
For patients with recurrent gross hematuria and flank pain due to obstructing blood clots but without signs of infection:
- Ureteral stent placement or replacement can facilitate urinary drainage and resolve clot obstruction 2
- In a series of patients with major renal trauma who developed recurrent gross hematuria with flank pain, all had obstructing blood clots present at time of stent placement, and urinary extravasation resolved in all patients at a mean of 8 days after stent placement 2
- Stents should remain indwelling for approximately 4 weeks to ensure resolution of the underlying pathology 2
Antibiotic Management
- Administer antibiotics immediately if infection is suspected, with regimen adjusted following antibiogram results 1
- Preprocedural antibiotics are recommended when urosepsis is suspected or known to be present 3
- Third-generation cephalosporin ceftazidime has shown superiority over fluoroquinolone ciprofloxacin in both clinical and microbiological cure rates 3
- Continue monitoring until temperature, white-blood-cell count, and inflammatory markers normalize before considering stent removal or further intervention 1
Common Pitfalls to Avoid
- Do not postpone imaging when clinical status worsens—delaying CT can miss correctable anatomic causes 1
- Avoid delaying treatment if signs of infection are present, as urosepsis can develop rapidly 1
- Do not rely on internal stent drainage alone in septic patients—PCN has been shown to improve early and long-term cure rates compared to ureteral stent in cases of infection 1
- Persistent gross hematuria lasting more than 48-72 hours after stent placement warrants diagnostic evaluation, as it may indicate complications such as obstruction or infection 1