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Use of Reversed Nephroureteral Stent as Suprapubic Cystoureteral Catheter
0022..:5347 /87 /1372-0235$02.00/0 Vol. i::n, Fe~;ruaty
THE ,)OURN/,L OF UROLOGY
Printed in
Copyright@ 1987 by The Williams & Wilkins Co.
Urologis At lVo USE OF REVERSED NEPHROURETERAL STENT AS SUPRAPUBIC CYSTOURETERAL CATHETER PETER T. NIEH* From the Division of Urology, University of Connecticut Health Center, Farmington, Connecticut
ABSTRACT
By the reversal of the existing nephroureteral stent system a vesicoureteral stent exiting through the suprapubic site is created. The major advantages of this system include avoidance of side holes along the stent, avoidance of a urethral catheter, ease of access for contrast medium studies to monitor healing, comfort and ease of removal. The major application of the system would be for lower ureteral surgery. Development of a 5F catheter with a shorter kidney-to-bladder length would permit use of this system in children. Advances in endourology have produced a dizzying array of stents and nephrnstomy catheters. 1- 3 The Double-Jt stent has side holes along its length, sometimes resulting in protracted ureteral leakage, and requires cystoscopic removal, which involves use of general anesthesia in children or an uncomfortable procedure with local anesthesia in men. The combination of a nephrostomy stent catheter and Smith universal ureteral stent provides external access to the urinary tract after percutaneous nephrostomy as well as elimination of the side holes. However, in situations involving lower ureteral surgery ureteral stenting is accompanied by urethral Foley or suprapubic catheter drainage. A recent experience following a ureteroscopic injury led to improvisation with a nephroureteral stent, which provided complete decompression of the urinary tract via a single suprapubic catheter, ease of management of the patient, easy access for radiographic study and minimal discomfort during use and at removal.
patient became increasingly intolerant of the nephrnstomy entry site, the urethral catheter and the 2 drainage bags. A nephrostogram 17 days postoperatively showed continuing leakage from 1 of the side holes of the well positioned ureteral stent (fig. 2). A floppy-tipped 0.038-inch guide wire was intro-
CASE REPORT
R. G., a 32-year-old man, presented to the emergency room in early September 1985 with colic from partial obstruction of the left ureter a 0.5 X 1 cm. calculus at the L2 to L3 interspace. Recurrent episodes of colic without significant progression led to ureteroscopic extraction of the stone 3 weeks later. After balloon dilation of the distal ureter over a guide wire ureteroscopy with an 11.5F Storz instrument was performed with some difficulty. The stone was extracted with the stone basket but a Double-J stent could not be advanced over a kink in the guide wire. Overnight, the lower abdomen became progressively distended and tender. An excretory urogram (IVP) showed hydroureter and extravasation in the pelvic ureter (fig. 1). Exploration revealed an extensive retroperitoneal urinoma from a 1.5 cm. longitudinal tear in the ureter, which was stented with a silicone Double-J stent from the renal pelvis to the bladder. Episodic leakage through the Penrose site persisted despite urethral catheter drainage and percutaneous nephrostomy. The Accepted for publication August 29, 1986. * Current address: Lahey Clinic Medical Center, 41 Mall Rd., Burlington, Massachusetts, 01805. t Medical Engineering Corp., New York, New York.
FIG. 1. IVP morning after ureteroscopic removal of calculus demonstrates extravasation from distal ureter below pelvic brim. 235
236
NIEH
phrostomy and urethral catheter drainage, which became increasingly uncomfortable. The use of a reversed combination nephrostomy stent catheter as a suprapubic cystoureteral stent (fig. 4) has several advantages, including absence of side holes at the site of leakage, no nephrostomy exit site, no urethral catheter required, a single drainage catheter for the bladder and involved ureter, easy access for contrast medium studies to monitor healing,
FIG. 2. Antegrade filling of ureter 17 days postoperatively shows continued extravasation at site adjacent to side hole in stent.
duced via the nephrostomy tube down the ureter into the bladder 19 days postoperatively. An 8F angiographic catheter was advanced over this guide wire and a stiffer guide wire was introduced. Under endoscopic guidance the trocar of the 8F suprapubic cystocatheter entered the anterior bladder. With rigid biopsy forceps the guide wire was delivered into the sheath of the trocar. By advancing through the nephrostomy site the guide wire emerged from the trocar sheath. With sufficient wire exposed through the suprapubic opening, a 27 cm. long 8.5F nephroureteral stent was advanced over the wire and positioned
FIG. 3. IVP demonstrates good function of left ureteral stent with complete drainage.
in thP- l'P.nal pelvi" 1mrlP-r fl11oro,sf'opi" g,1irhnr<>. 'T'h<> g,1irlP wir<>
then was withdrawn gradually, establishing a J within the renal pelvis and a loop within the bladder. The skin disk supplied with the kit then was used to secure the catheter at the suprapubic site. The cut end of a 16F Foley catheter fit easily over the Luer loc of the stopcock and the flared end was attached to a leg drainage bag. An IVP showed excellent decompression of the collecting system and no leakage with the catheter clamped 28 days postoperatively (fig. 3). The tube was withdrawn easily. DISCUSSION
The application of the pre-formed pigtail configuration to ureteral stents has allowed for long-term internal drainage with little risk for migration. The advantages of pliability of the silicone material for ureteral stents may be outweighed by the lower maximal flow rate possible through the smaller inner diameter compared to the polyethylene versions. 3 The additional side holes permit an increased flow through the system, particularly with distal obstructions, and permit intravesical pressure to be dissipated, minimizing renal pelvic pressures. 3 This latter feature resulted in protracted leakage from 1 of the side holes through the ureterotomy despite percutaneous ne-
FIG. 4. A, percutaneous nephrostomy stent catheter as used currently. B, proposed application as suprapubic cystoureteral stent.
?JSE OF f\fEPflROURETERAL STEDTT AS SUPRAPUBIC CY2,T01JRETERAL CATHETER
easy -~,,-,,•--• during to be CAl,a,u,,;cu. over a guide wire, comfort without cystoscopy. The potential applications for this system of urinary stenting include any ureteral operation, such as ureteroneocystostomy and transureteroureterostomy, as well as ureteral injuries and difficult ureteroscopic procedures, when prolonged ureteral stenting is expecte& In adults, particularly men, the elimination of the urethral catheter and the need for cystoscopic removal of the stent would be welcomed. For use after a ureteroscopic operation, the stiff end of the guide wire could be introduced through the suprapubic cystocatheter trocar from within the bladder with rigid biopsy forceps after carefully feeding the guide wire into the bladder with fluoroscopic mon itoring to detect dislodgement of the tip in the renal pelvis.
237
the smallest stent available is 6F and 25 cm. long. Development of a 5F catheter with shorter kidney-to-bladder lengths would permit use in children. In summary, modification of an existing stenting system that lacks side holes for combined ureteral drainage with suprapubic vesical decompression is described. Advantages over existing methods of internal diversion are presented. REFERENCES
1. Finney, RP.: Double-J and diversion stents. Ural. Clin. N. Amer,,
9: 89, 1982, 2. Smith, A. D.: The universal ureteral stent. Ural. Clin. N. Amer., 9: 103, 1982. 3. Mardis, H.K., Kroeger, R. M., Hepperlen, T. W., Mazer, M. J. and Kammandel, H.: Polyethylene double-pigtail ureteral stents. Ural. Clin. N. Amer., 9: 95, 1982.
THE ,)OURN/,L OF UROLOGY
Printed in
Copyright@ 1987 by The Williams & Wilkins Co.
Urologis At lVo USE OF REVERSED NEPHROURETERAL STENT AS SUPRAPUBIC CYSTOURETERAL CATHETER PETER T. NIEH* From the Division of Urology, University of Connecticut Health Center, Farmington, Connecticut
ABSTRACT
By the reversal of the existing nephroureteral stent system a vesicoureteral stent exiting through the suprapubic site is created. The major advantages of this system include avoidance of side holes along the stent, avoidance of a urethral catheter, ease of access for contrast medium studies to monitor healing, comfort and ease of removal. The major application of the system would be for lower ureteral surgery. Development of a 5F catheter with a shorter kidney-to-bladder length would permit use of this system in children. Advances in endourology have produced a dizzying array of stents and nephrnstomy catheters. 1- 3 The Double-Jt stent has side holes along its length, sometimes resulting in protracted ureteral leakage, and requires cystoscopic removal, which involves use of general anesthesia in children or an uncomfortable procedure with local anesthesia in men. The combination of a nephrostomy stent catheter and Smith universal ureteral stent provides external access to the urinary tract after percutaneous nephrostomy as well as elimination of the side holes. However, in situations involving lower ureteral surgery ureteral stenting is accompanied by urethral Foley or suprapubic catheter drainage. A recent experience following a ureteroscopic injury led to improvisation with a nephroureteral stent, which provided complete decompression of the urinary tract via a single suprapubic catheter, ease of management of the patient, easy access for radiographic study and minimal discomfort during use and at removal.
patient became increasingly intolerant of the nephrnstomy entry site, the urethral catheter and the 2 drainage bags. A nephrostogram 17 days postoperatively showed continuing leakage from 1 of the side holes of the well positioned ureteral stent (fig. 2). A floppy-tipped 0.038-inch guide wire was intro-
CASE REPORT
R. G., a 32-year-old man, presented to the emergency room in early September 1985 with colic from partial obstruction of the left ureter a 0.5 X 1 cm. calculus at the L2 to L3 interspace. Recurrent episodes of colic without significant progression led to ureteroscopic extraction of the stone 3 weeks later. After balloon dilation of the distal ureter over a guide wire ureteroscopy with an 11.5F Storz instrument was performed with some difficulty. The stone was extracted with the stone basket but a Double-J stent could not be advanced over a kink in the guide wire. Overnight, the lower abdomen became progressively distended and tender. An excretory urogram (IVP) showed hydroureter and extravasation in the pelvic ureter (fig. 1). Exploration revealed an extensive retroperitoneal urinoma from a 1.5 cm. longitudinal tear in the ureter, which was stented with a silicone Double-J stent from the renal pelvis to the bladder. Episodic leakage through the Penrose site persisted despite urethral catheter drainage and percutaneous nephrostomy. The Accepted for publication August 29, 1986. * Current address: Lahey Clinic Medical Center, 41 Mall Rd., Burlington, Massachusetts, 01805. t Medical Engineering Corp., New York, New York.
FIG. 1. IVP morning after ureteroscopic removal of calculus demonstrates extravasation from distal ureter below pelvic brim. 235
236
NIEH
phrostomy and urethral catheter drainage, which became increasingly uncomfortable. The use of a reversed combination nephrostomy stent catheter as a suprapubic cystoureteral stent (fig. 4) has several advantages, including absence of side holes at the site of leakage, no nephrostomy exit site, no urethral catheter required, a single drainage catheter for the bladder and involved ureter, easy access for contrast medium studies to monitor healing,
FIG. 2. Antegrade filling of ureter 17 days postoperatively shows continued extravasation at site adjacent to side hole in stent.
duced via the nephrostomy tube down the ureter into the bladder 19 days postoperatively. An 8F angiographic catheter was advanced over this guide wire and a stiffer guide wire was introduced. Under endoscopic guidance the trocar of the 8F suprapubic cystocatheter entered the anterior bladder. With rigid biopsy forceps the guide wire was delivered into the sheath of the trocar. By advancing through the nephrostomy site the guide wire emerged from the trocar sheath. With sufficient wire exposed through the suprapubic opening, a 27 cm. long 8.5F nephroureteral stent was advanced over the wire and positioned
FIG. 3. IVP demonstrates good function of left ureteral stent with complete drainage.
in thP- l'P.nal pelvi" 1mrlP-r fl11oro,sf'opi" g,1irhnr<>. 'T'h<> g,1irlP wir<>
then was withdrawn gradually, establishing a J within the renal pelvis and a loop within the bladder. The skin disk supplied with the kit then was used to secure the catheter at the suprapubic site. The cut end of a 16F Foley catheter fit easily over the Luer loc of the stopcock and the flared end was attached to a leg drainage bag. An IVP showed excellent decompression of the collecting system and no leakage with the catheter clamped 28 days postoperatively (fig. 3). The tube was withdrawn easily. DISCUSSION
The application of the pre-formed pigtail configuration to ureteral stents has allowed for long-term internal drainage with little risk for migration. The advantages of pliability of the silicone material for ureteral stents may be outweighed by the lower maximal flow rate possible through the smaller inner diameter compared to the polyethylene versions. 3 The additional side holes permit an increased flow through the system, particularly with distal obstructions, and permit intravesical pressure to be dissipated, minimizing renal pelvic pressures. 3 This latter feature resulted in protracted leakage from 1 of the side holes through the ureterotomy despite percutaneous ne-
FIG. 4. A, percutaneous nephrostomy stent catheter as used currently. B, proposed application as suprapubic cystoureteral stent.
?JSE OF f\fEPflROURETERAL STEDTT AS SUPRAPUBIC CY2,T01JRETERAL CATHETER
easy -~,,-,,•--• during to be CAl,a,u,,;cu. over a guide wire, comfort without cystoscopy. The potential applications for this system of urinary stenting include any ureteral operation, such as ureteroneocystostomy and transureteroureterostomy, as well as ureteral injuries and difficult ureteroscopic procedures, when prolonged ureteral stenting is expecte& In adults, particularly men, the elimination of the urethral catheter and the need for cystoscopic removal of the stent would be welcomed. For use after a ureteroscopic operation, the stiff end of the guide wire could be introduced through the suprapubic cystocatheter trocar from within the bladder with rigid biopsy forceps after carefully feeding the guide wire into the bladder with fluoroscopic mon itoring to detect dislodgement of the tip in the renal pelvis.
237
the smallest stent available is 6F and 25 cm. long. Development of a 5F catheter with shorter kidney-to-bladder lengths would permit use in children. In summary, modification of an existing stenting system that lacks side holes for combined ureteral drainage with suprapubic vesical decompression is described. Advantages over existing methods of internal diversion are presented. REFERENCES
1. Finney, RP.: Double-J and diversion stents. Ural. Clin. N. Amer,,
9: 89, 1982, 2. Smith, A. D.: The universal ureteral stent. Ural. Clin. N. Amer., 9: 103, 1982. 3. Mardis, H.K., Kroeger, R. M., Hepperlen, T. W., Mazer, M. J. and Kammandel, H.: Polyethylene double-pigtail ureteral stents. Ural. Clin. N. Amer., 9: 95, 1982.