A new technique for transurethral insertion of a silicone rubber tube into an obstructed ureter

Ureteral stent related symptoms: A comparative study

BACKGROUND

In urology, ureteral stents are used to treat obstructive diseases. Hematuria (54%), fever, discomfort, and lower urinary system symptoms are the predominant symptoms related to ureteral stent.

AIM

This article links stent symptoms to double-j width and length, as well as patient's height, weight, and body mass index (BMI). Ureteric Stent Symptoms Questionnaire (USSQ) was used to measure ureteral stent symptoms at 1st and 4th week of stent in situ as well as the 4th week after pigtail removal.

METHODS

A 200-patient prospective study, where patients were allocated into four groups following ureteral stent insertion depending on the stent characteristics. Those groups were: 4.8 Fr./26 cm (Group A), 4.8 Fr./28 cm (Group B), 6 Fr/26 cm (Group C), and 6 Fr/28 cm (Group D).

RESULTS

Men comprised 53.5% of 200 patients. Participants had an average age of 49 ± 15.5 years, height of 175 ± 8.94 cm, and BMI of 23.8 ± 7.6 cm. The laboratory results were identical between groups. At the first and fourth week, groups had similar urine symptoms, pain severity, health status and occupational activities. The difference in pain location was statistically significant. Group A had 82.4% renal back pain in the first week, whereas Group B had 68.8%, Group C 31.3% and Group D 62.5 (p=0.04). At the fourth week, 64.7% of Group A patients reported kidney front pain, compared to 100% of Group B, 93.3% of Group C, and 100% of Group D (p=0.04). There was statistical significance in the sexual activity of the patients. 24.4% of Group C patients stopped sexual activity before stent installation, compared to 10.6%, 8.3%, and 6.4% of the other groups (p=0.03). A moderate percentage of patients had active sexual activity at week 4 (Group A: 7.8%, Group B: 5.8%, Group C: 8.2%, Group D: 4.1%), p=0.83. In multivariate analysis, urinary catheter group, age, weight, height, and BMI did not significantly affect urine index score (UIS), pain index score (PIS), general health (GH), quality of work (QW), and quality of sex (QS).

CONCLUSIONS

Despite various attempts to establish the best ureteral stent, the effect of double-j stent physical features on stent-related symptoms remained unknown. No verdict is conceivable without adequate empirical data.

Evolution of the Ureteral Stent: The Pivotal Role of the Gibbons Ureteral Catheter

OBJECTIVE

To review the pioneering contributions of Dr. Robert Gibbons of Virginia Mason Medical Center to the evolution and development of the modern ureteral stent.

METHODS

We reviewed Dr. Gibbons' extensive work through primary sources, including interviews, projector slides, radiology images, stent prototypes, his personal writings, and archived documents. In addition, we performed a review of historical texts and manuscripts describing important innovations in the development of the ureteral stent.

RESULTS

In 1972, motivated by a desire to provide his patients with a long-term alternative to open nephrostomy and inspired by Drs. David Davis and Paul Zimskind, who in 1967 had described the use of indwelling ureteral silicone tubing, Dr. Gibbons began to experiment with modifications to improve upon existing stents. To address distal migration, Dr. Gibbons added "wings" that collapsed as the stent was advanced and expanded once in proper position to secure the stent in place. Barium was embedded into the proximal tip to facilitate radiographic visualization. A flange was added to the distal end, preventing proximal migration and minimizing trigonal irritation, and a tail was attached to aid in stent removal. The result was the original Gibbons stent, the first commercially available ureteral stent, and the establishment of Current Procedural Terminology code 52332, still used today.

CONCLUSION

The ureteral stent is a fundamental component of urologic practice. In developing the Gibbons stent, Dr. Gibbons played a pivotal role in addressing the challenge of internal urinary diversion particularly for those who needed long-term management. Urologists and the patients they serve owe Dr. Gibbons and other surgeon-inventors a debt of gratitude for their innovative work.

The Upper Urinary Tract

Pyelography is superior to all other imaging techniques for the demonstration of fine detail in the pelveocalyceal system and the ureter. For almost 90 years it has been performed through a retrogradely inserted catheter, but during the recent 30 years antegrade injection via a transparenchymally inserted needle or catheter has become an accepted alternative, especially in case of a dilated upper urinary tract. Both methods have their advantages and their disadvantages. This article presents a review of indications, techniques, and complications. Furthermore, interventional procedures on the upper urinary tract—such as stent placement and balloon dilatation—are now handled by the radiologist, mainly through an antegrade approach. These therapeutic procedures are also reviewed.

Long-term indwelling bilateral ureteral stents for bilateral hydronephrosis of unknown etiology

We describe a rare case of long-term indwelling bilateral ureteral stents that were replaced yearly for 7 years because of azotemia associated with bilateral hydronephrosis of undetermined etiology on radiological examinations. During year 5 the patient had an uneventful gestation with delivery of a normal neonate by cesarean section. Hydronephrosis remained improved for 2 years after withdrawal of the stents.

Antegrade ureteroscopy: a new tool in management of severe ureteral strictures

A new method is described with which ureteral strictures are visualized by antegrade ureteroscopy. Under direct vision a catheter is manipulated through the stricture, which is then dilated. This method is especially useful in patients with a ureteroenterocutaneostomy. A patient is described in whom this technique was successful after other endoscopic techniques had failed.

Encrustation and stone formation: complication of indwelling ureteral stents

Severe encrustation and stone formation on indwelling ureteral stents in 2 patients with a lithogenic history are reported. In both cases this complication occurred in the presence of sterile urine and treatment required pyelolithotomy in one and renal pelvic irrigation with urologic G solution in the other. Analyses of these stones revealed struvite and apatite, respectively. Dissolution of encrustations and stones via renal pelvic irrigation is suggested as a viable alternative to surgical intervention for this problem. A review of the literature shows a correlation between chronic stone formers and stent encrustation, rather than from bacteriuria alone. Long-term antibiotic suppression, more frequent followup with abdominal roentgenograms, and shorter periods of internal stenting are suggested for patients with a lithogenic history.

Failure of the double-curved ureteral stent

Ureteral obstruction no longer requires routine open surgical diversion. With the advent of percutaneous nephrostomy techniques indwelling ureteral stents, the armamentarium exists to provide drainage by nonoperative means. This has been beneficial to many patients but especially to those who are poor risks or who have terminal illnesses and need treatment for relatively brief periods. Herein we report 2 cases of failure of the double-curved polyethylene ureteral catheter to drain effectively, leading to nephrostomy, and a case in which removal of a stent disrupted a repaired ureteropelvic junction, leading to additional surgery. Three patients also are discussed who had severe dysuria and irritation from the stents.

The management of urinary fistulas and strictures with percutaneous ureteral stent catheters

A method is described for percutaneous anterograde introduction of a ureteral stent catheter. The experience and treatment of 5 patients are reported: 2 ureterovaginal fistulas, 2 ureterocutaneous fistulas and 1 ureteral stricture. The capability of the technique to place a stent catheter in the presence of an almost complete separation of the ureter or through ureteral segments deformed by extensive cicatricial changes is emphasized. The method is advocated as a most effective alternative to supravesical drainage in patients with ureteral fistulas and impaired healing potential of ureters devitalized by surgical stripping and/or radiation therapy.

Useful technique for long-term urinary drainage by inlying ureteral stent. Six-year experience

Endoscopically placed inlying ureteral stents have proved useful in the conservative management of patients with ureteral obstruction, urinary fistula, and malignancy and have obviated the need for operative intervention. In high-risk symptomatic patients with widespread malignancy, internal urinary diversion offers the opportunity for an improved quality of life without the surgical risk or potential morbidity of supravesical diversion. Potential candidates for this simple, safe, and effective technique include: those with postsurgical obstruction and/or fistula, retroperitoneal fibrosis, metastatic carcinoma, congenital ureteropelvic junction obstruction, as well as those with reversible obstruction from lymphoma and carcinoma of the prostate who are undergoing radiotherapy and/or chemotherapy. The focus of this report is on the technique we have found successful in providing us with stents that fit our individual patients. Readily available fabricated graduated ureteral catheter can be cut and shaped to particular measurements unlike prefabricated catheters. Minimal preparation time is demanded, and there is no need for extensive stocking of various catheter sizes.

Double-ended pigtail ureteral stent: useful modification to single end ureteral stent

A newly created ureteral stenting catheter of double-ended pigtail design is introduced. The pigtail design at both ends maintains the catheter in place by serving as a solid anchoring device, both intravesically and within the renal pelvis; upward or downward migration of the stent is thus prevented. It is designed also to minimize trigonal irritation. The catheter can be introduced easily either cystoendoscopically or through a percutaneous antegrade route, or by a combination of both methods. It offers the additional advantage of being readily available from an inexpensive stock source; it may be quickly and easily custom made and shaped for any ureter by the physician immediately prior to its insertion. It thus avoids having to have premanufactured, more expensive ureteral stents of different lengths. Open surgery for upper urinary tract decompression can thus be avoided.

Self-retained internal ureteral stents: a new approach

Definitive surgical treatment of ureteral obstruction may not be appropriate in patients with advanced malignancy, complex benign ureteral disease or even simple obstructive disease accompanied by unacceptable operative risk. Endoscopic placement of self-retained internal ureteral catheters (stents) offers satisfactory relief for many of these patients. A new 6F pigtail ureteral stent and placement technique are described. These stents are placed easily, effective and well tolerated for short-term drainage in selected patients with ureteral obstruction.

Problems associated with Gibbons ureteral catheter

Two recent cases of bilateral ureteral obstruction secondary to benign retroperitoneal fibrosis were treated initially with Gibbons indwelling ureteral catheters. Inadequate catheter length, calyceal stone formation, catheter encrustation, and distal migration form the basis for this report.

Indwelling and transrenal splint techniques for pyeloplasty

A report is presented on experience with 118 pyeloplasties using indwelling and transrenal splints. Detailed analysis of infections with both splint modifications has confirmed that better long-term results are achieved with internal drainage, due to the absence of potential contamination between splint and renal parenchyma which exists with external drainage.

Experience with indwelling ureteral stent catheters

A new indwelling ureteral stent to provide long-term ureteral drainage is described. This radiopaque stent is manufactured of non-reactive, non-collapsible tubing and is designed to resist downward expulsion and upward migration. Internal stent diversion offers advantages in managing patients whose ureters are obstructed by malignancy. 1) Endoscopic placement of the ureteral stent is associated with less morbidity and mortality than supravesical diversion. 2) Unilateral obstruction can be corrected at the time of diagnosis, thus ensuring that later supravesical diversion will not be necessary. 3) If time proves that the urinary diversion is no longer desirable in terms of quality of life, the stent can be removed.

Retrieval of indwelling ureteral stent utilizing Fogarty catheter

The efficacy of silicone rubber ureteral stents for long-term urinary diversion has been demonstrated to be of value in certain cases. However, complications, including migration of the stent, do occur. A method for retrieval of the ureteral stent utilizing a Fogarty arterial embolectomy catheter is described.

The management of urinary fistulae following cadaveric renal transplantation

Vesicoureteric, ureteric and calyceal fistulae in cadaver transplants may be successfully treated by early exploration and nephrostomy splintage with silastic tubing for a period of not less than 6 weeks.