DOI:10.2214/AJR.07.3216
AJR 2008; 190:1665-1670
© American Roentgen Ray Society
Fluoroscopic Guidance of Retrograde Exchange of Ureteral Stents in Women
Ruey-Sheng Chang1,
Huei-Lung Liang1,2,
Jer-Shyung Huang1,2,
Po-Chin Wang1,
Matt Chiung-Yu Chen1,
Ping-Hong Lai1,2 and
Huay-Ben Pan1
1 Department of Radiology, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st
Rd., Kaohsiung, Taiwan, Republic of China.
2 Department of Radiology, National Yang-Ming Medical School, Kaohsiung, Taiwan,
Republic of China.
Received September 26, 2007;
accepted after revision December 28, 2007.
Address correspondence to H. L. Liang
(hlliang{at}vghks.gov.tw).
Abstract
OBJECTIVE. The purpose of this study was to review our experience
with fluoroscopically guided retrograde exchange of ureteral stents in
women.
MATERIALS AND METHODS. During a 48-month period, 28 women (age
range, 38-76 years) were referred to our department for retrograde exchange of
a ureteral stent. The causes of urinary obstruction were tumor compression in
26 patients and benign fibrotic stricture in two patients. A large-diameter
snare catheter (25-mm single loop or 18- to 35-mm triple loop) or a foreign
body retrieval forceps (opening width, 11.3 mm) was used to grasp the bladder
end of the stent under fluoroscopic guidance. The technique entailed
replacement of a patent or occluded ureteral stent with a 0.035- or 0.018-inch
guidewire with or without the aid of advancement of an angiographic
sheath.
RESULTS. A total of 54 ureteral stents were exchanged with a snare
catheter in 42 cases or a forceps in 12 cases. One stent misplaced too far up
the ureter was replaced successfully through antegrade percutaneous
nephrostomy. Ten occluded stents, including one single-J stent, were managed
with a 0.018-inch guidewire in three cases, advancement of an angiographic
sheath over the occluded stent into the ureter in five cases, and
recannulation of the ureteral orifice with a guidewire in two cases. No
complications of massive hemorrhage, ureter perforation, or infection were
encountered.
CONCLUSION. With proper selection of a snare or forceps catheter,
retrograde exchange of ureteral stents in women can be easily performed under
fluoroscopic guidance with high technical success and a low complication
rate.
Keywords: fluoroscopy • interventional radiology • stent • stent exchange • stent retrieval • ureter • ureteral obstruction • ureteral stenosis
Introduction
Internal ureteral stents are used to maintain ureteral patency in
the management of various benign and malignant forms of ureteral obstruction.
Because of migration, encrustation, obstruction, and infection, these stents
have to be removed or exchanged within 4-6 months of placement
[1-3].
Cystoscopic retrograde removal or exchange of these stents has been widely
described [4,
5]. However, because of the
rigidity and larger diameter (usually 18-22 French) of a cystoscope, some
patients need deep sedation or general or epidural anesthesia for pain
management during the procedure
[6,
7].
McFarlane et al. [5]
reported favorable results of combined flexible cystoscopy and fluoroscopy in
the radiology suite in the performance of retrograde ureteropyelography and
ureteral stent placement. Yedlicka et al.
[6] introduced the technique of
fluoroscopic transurethral exchange of a ureteral stent with a snare catheter.
Park et al. [7] described four
modified methods of facilitating removal or exchange of ureteral stents in 17
women. The limited references and varying techniques reported in the
literature
[1-3,
7] may reflect the fact that
most interventional radiologists doubt the feasibility of the procedure. We
present our experience with simplified techniques of retrograde exchange of
ureteral stents in 28 women.
Materials and Methods
This retrospective study included 28 women (mean age, 60 years; range,
38-76 years) referred to our department for exchange of ureteral stents during
a 48-month period. All but two of the patients were referred by gynecologists.
The other two were referred by urologists. Twenty-one patients had unilateral
stents and seven had bilateral stents, for a total of 54 ureteral stents
exchanged. Twenty-six of the cases of ureteral obstruction were caused by
compression by gynecologic malignant tumors. One patient had iatrogenic
transection of both ureters, and one had fibrotic stricture of an ileal
conduit. Conventional ureteral stents (Percuflex Plus, Boston Scientific) were
used in 42 procedures, and inlay stents (Optima, Bard) in 12. The average time
between stent insertion and replacement was 3.2 months for the conventional
stents and 7 months for the inlay stents.
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Fig. 1B —66-year-old woman with right obstructive uropathy due to
recurrent cervical carcinoma. Fluoroscopic image shows snare catheter
(arrows) curved downward to reach stent (arrowhead) abutting
on mucosa.
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All procedures were performed in an interventional radiology suite, and
written informed consent was obtained from all patients. Institutional review
board exemption was obtained for this retrospective chart and image review.
Prophylactic antibiotics (cefazolin, 1,000 mg) and analgesia (fentanyl
citrate, 100 µg) were routinely administered IV immediately before the
procedure. Results of microscopic examination of the urine were checked before
the procedure for each patient.
Retrieval Technique
Patients were placed in a supine position, and local asepsis was performed
with povidone-iodine. Topical urethral anesthesia was achieved through coating
a 14-French Foley catheter with lidocaine gel and inserting it into the
urinary bladder to allow passage of a stiff 0.035-inch guidewire (Radifocus,
Terumo). A 9- to 10-French angiographic sheath was then inserted over the
guidewire after removal of the Foley catheter. To improve technical
manipulation during the procedure, the bladder was slightly distended by
injection of 150-200 mL of normal saline solution or diluted contrast medium
to prevent mucosal folds from covering the stent. Under fluoroscopic guidance,
a snare catheter (Amplatz goose-neck snare with a loop diameter of 25 mm,
Bard, or triple-loop snare with a loop diameter of 18-35 mm, Mini EnSnare,
Inter-V) was introduced through the sheath into the bladder lumen. The choice
of single- or triple-loop catheter was the operator's preference.
The snare was manipulated so that the stent tip would be inside the loop of
the snare. For stents with the end located at the lateral bottom of the
urinary bladder, the snare catheter was pushed straight up to the upper wall
of the bladder and allowed to curve gently downward to reach the stent
abutting on the mucosa (Figs.
1A and
1B). The guiding catheter was
advanced to close the snare loop on the stent. With a firm grasp, the stent
was removed with the sheath outside the urethra. Care was taken to maintain
the pelvic end of the ureteral stent in place in the middle of the ureter. If
the snare catheter failed to entrap the ureteral stent or the guidewire
directly contacted the stent during its insertion through the sheath, an
8-French foreign body retrieval forceps (FG-53SX-1, Olympus) (opening width,
11.3 mm) with rat teeth and alligator jaws was used for stent retrieval (Figs.
2A,
2B and
2C). The device was inserted
through the sheath. Under fluoroscopic guidance, with rotation of the forceps
catheter or deflection of the sheath if necessary, the distal shaft (as close
as possible to the distal end) of the stent was grasped with the forceps and
removed by the method described earlier.
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Fig. 2B —68-year-old woman with bladder end of double-J catheter in
bladder diverticulum. Fluoroscopic image shows bladder end of stent in bladder
diverticulum (arrow), which excludes possibility of exchange with
snare catheter.
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Replacement Technique
The stent was withdrawn just beyond the urethral meatus, and a 0.035-inch
stiff guidewire was inserted through the exteriorized end of the stent up to
the renal pelvis. A new stent the same size as the original (diameter, 7-8
French; length, 24-26 cm) was advanced in a retrograde direction with a
pusher. When the pelvic end of the stent reached the renal pelvis and
recoiled, the guidewire was withdrawn. The pusher was further advanced with
the bladder end of the stent recoiled in the bladder. Care was taken so that
the distal end of the stent remained in the bladder and was not placed in the
distal ureter.
For patients with ureteral stent obstruction through which a 0.035-inch
guidewire would not pass, the following alterations were made. If the
obstruction was at the renal end of the stent, including the blind end
single-J stent, an 0.018-inch guidewire was inserted to pass through a lateral
hole in the stent into the ureter toward the renal pelvis. If the stent
obstruction was at the bladder end, a 15-cm 9- to 10-French sheath with the
valve end cut off was advanced over the occluded stent into the distal ureter.
The occluded stent was removed, and a guidewire was inserted into the renal
pelvis. In the rare instances the sheath did not advance across the
ureterovesical junction owing to acute angulation, a hydrophilic guidewire was
used to cannulate the ureteral orifice through the sheath alongside the
occluded stent into the ureter (Figs.
3A,
3B and
3C). The new stent was
exchanged by the method described earlier.
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Fig. 3B —55-year-old woman with solid blockade of bladder end of
stent. Fluoroscopic image shows guidewire (arrow) inserted through
sheath alongside occluded stent (arrowhead) for successful
cannulation of ureteral orifice.
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For a tight ureteral stricture through which the ureteral stent would not
pass, balloon dilation of the stenotic segment with a 5- to 6-mm diameter
balloon catheter was performed. If necessary, a cutting balloon catheter can
be used. The procedure time was measured from the time of guidewire insertion
into the bladder to completion of implantation of the new stent.
Results
A total of 54 ureteral stents were exchanged in the 28 women in this study.
The number of procedures performed on each patient varied from one to six with
a mean of two. All stents were successfully grasped with either a snare
catheter in 42 patients (single-loop snare, 30 stents; triple-loop snare, 12
stents) or a foreign body retrieval forceps in 12 patients, including the
patient with an ileal conduit (Figs.
4A,
4B,
4C and
4D). Fifty-three (98%) of the
54 stents were exchanged successfully. Because of blind-end or renal-end
obstruction of the stent in three procedures, an 0.018-inch guidewire was used
to accomplish the stent exchange. Obstruction of the bladder end was
encountered in seven procedures. In five of these procedures, a 9- or
10-French sheath was advanced over the stent into the ureter. In the other two
procedures, the ureter was successfully catheterized with a guidewire after a
failed attempt to advance the sheath into the ureter.
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Fig. 4C —79-year-old woman with bladder carcinoma after cystectomy.
Fluoroscopic image shows that owing to occlusion of renal end of stent,
0.035-inch guidewire did not pass through; 0.018-inch (0.5 mm) guidewire was
inserted through sidehole (arrow) of stent into renal pelvis
(arrowhead).
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The basic patient characteristics and the methods used to exchange the
ureteral stents are summarized in Table
1. One stent was misplaced too far up in the ureter. The surgeon
was initially consulted to adjust the stent position, but the ureteral orifice
was not visualized with the flexible cystoscope owing to diffuse inflammation
of the bladder mucosa. Percutaneous nephrostomy and antegrade exchange of the
stent with the aid of a forceps catheter were performed successfully.
The average procedure time for stent exchange was 30 minutes (range, 20-55
minutes), and the fluoroscopic time was usually 3-7 minutes. Balloon dilations
were performed in three procedures on two patients. After balloon dilation,
all the stents were advanced through the narrow segment into the renal pelvis.
A cutting balloon 5.5 mm in diameter was used in one patient with benign
ureteral stricture after the initial ureteral stents were indwelling for 6
months (Figs. 5A and
5B).
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Fig. 5A —38-year-old woman who incurred iatrogenic ureteral injuries
during surgical intervention for ovarian endometriosis. Bilateral ureteral
stents were placed during operation. Stents were occluded and replaced in
retrograde manner twice within 6 months. Fluoroscopic image shows segmental
fibrotic narrowing (arrow) in lower part of ureter.
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Fig. 5B —38-year-old woman who incurred iatrogenic ureteral injuries
during surgical intervention for ovarian endometriosis. Bilateral ureteral
stents were placed during operation. Stents were occluded and replaced in
retrograde manner twice within 6 months. Fluoroscopic image shows cutting
balloon (arrow) used to dilate stenotic segment. Inlay stent was
inserted and remained patent for 8 months.
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Most patients experienced mild transient pain as the stent was withdrawn
through the urethra. No patients had signs of infection, such as fever or
leukocytosis, or gross hematuria within 2 weeks after the procedure as
recorded in the chart or documented through telephone communication. No other
major complications, such as ureteral perforation, were encountered.
Discussion
Ureteral stents are widely used to maintain luminal patency in various
forms of benign or malignant urinary obstruction. Studies
[8,
9] have shown that the
prevalence of complications increases with longer indwelling times of ureteral
stents. These stents must be removed and replaced within 4-6 months to prevent
recurrent obstruction or infection due to encrustation
[3]. The time to replacement of
the ureteral stents recommended by Edwards and Robertson
[1] was even shorter (average,
5.6 weeks) than 4-6 months. At our hospital, performing the exchange procedure
in the radiology department is cost minimizing (
$335) compared with
cystoscopic exchange of the ureteral stent in the operating room (
$433).
The standard technique used to exchange a ureteral stent is cystoscopy.
Yedlicka et al. [6] introduced
the technique of retrograde exchange of double-J ureteral stents with a snare
catheter. De Baere et al. [2]
later reported their experience with ureteral stent exchange with an 0.018- to
0.035-inch guidewire lasso technique. Park et al.
[7] described four techniques
for retrograde grasping of a ureteral stent in the bladder lumen. In our
series, most (77.8%) of the ureteral stents were grasped by means of the
simple snare technique with a larger snare loop (
25 mm of either single-
or triple-loop catheter). The mechanism for retrieval of the larger snare
catheter was somewhat similar to that of the modified snare technique
described by Park et al.
[7].
A grasping forceps or myocardial biopsy forceps has been used occasionally
for removal or exchange of ureteral stents
[2,
7]. These forceps are
considered unsuitable for this type of procedure because of the small size of
the jaw and unwanted grasping of the bladder mucosa. We chose a foreign body
retrieval forceps with a wide jaw opening (11.3 mm) for this purpose. Because
of the large jaw, with or without a deflecting sheath, the ureteral stent is
more easily grasped firmly with the forceps without damage to the bladder
mucosa. In this study, we used the forceps to exchange 12 ureteral stents
without difficulty, including a stent end in a bladder diverticulum (Figs.
2A,
2B and
2C) and one in an ileal conduit
(Figs. 4A,
4B,
4C and
4D). Our experience suggests
that the forceps catheter is good for retrieving various foreign bodies not
only in the urinary bladder but also in the renal pelvis and ileal
conduit.
Ureteral stent occlusion can occur anywhere along the lumen, precluding
stent exchange with a conventional 0.035-inch guidewire. If the occlusion is
in the upper part (including the blind-end stent), an 0.018-inch guidewire can
be inserted from the exteriorized end through a lateral hole of the stent. In
this way, the stent can remain in the ureter and the guidewire can be extended
into the renal pelvis. For a stent with solid blockage in the bladder end,
Edwards and Robertson [1]
described their exchange technique in one patient as "further withdrew
the stent, and cut above the obstruction, thus the ureteral access was still
maintained allowing retrograde stent placement." Because the length of
the obstruction within the stent usually is unknown, cutting the stent can
eventually cause loss of the tract, rendering stent exchange impossible. Thus
we prefer to advance an open-end sheath over the occluded stent into the
distal ureter for exchange of the stent. If success is not achieved, guidewire
catheterization through the sheath can usually maintain the track into the
ureter.
For a patients with ileal urinary diversion, to place an internalized stent
may be questioned because the mucus produced by the ileal conduit can cause
early stent occlusion. Such patients are ideally treated with drainage through
an externalized stent into a urostomy bag rather than with an internalized
stent. We, however, placed an internalized stent in one patient because of
concern about catheter maintenance by the patient. Retrograde ureteral stent
removal or exchange in an ileal conduit with a snare catheter has been
described [3,
10]. Wetton and Gedroyc
[3] stated that the presence of
the ileal conduit increased the technical difficulty of stent replacement. In
our series, we successfully used a forceps catheter to replace a ureteral
stent in an ileal conduit. The moderate amount of space within an ileal
conduit generally allows manipulation of a forceps catheter. Therefore, we
consider a forceps catheter a good alternative tool for removal or exchange of
a ureteral stent in an ileal conduit.
A potential complication during stent replacement is pushing the new stent
too far up the ureter. It happened in one of our patients and is described in
reports by Yedlicka et al. [6]
and de Baere et al. [2]. When
it is advanced too far, the bladder end of the stent can be managed and
repositioned directly by use of the retention-string method. If the guidewire
is not yet totally withdrawn, an alternative is to insert a small angioplasty
balloon into the stent to pull the stent down into the bladder. This maneuver
can be performed with cystoscopic assistance for removal or exchange of the
stent. In our patient, inflammation of the bladder hampered visualization of
the ureteral orifice, rendering cystoscopic grasping impossible. We therefore
used the antegrade approach through the percutaneous nephrostomy track to
remove and exchange a new stent. The technique of antegrade removal or
exchange of a ureteral stent had been described
[11]. It requires a large
percutaneous track for grasping the ureteral stent in a small space, causing
the antegrade approach to be more painful and difficult. This approach should
be reserved for use in patients for whom retrograde insertion is impossible or
fails.
The retrograde stent exchange technique may be somewhat difficult in male
patients because of the longer male urethra and prostate enlargement. In
addition, a longer double-J catheter would have to have been placed initially
to keep the stent in the ureter during retrieval of the stent from the
urethral meatus. We have performed retrograde exchange of double-J catheters
in only two men. One procedure was successful, but the other failed because of
the patient's intolerance of the procedure. To use the retrograde technique in
men may require further evaluation, especially for adequate anesthesia.
Retrograde exchange of ureteral stents under fluoroscopic guidance is easy
and safe. It can be performed under topical anesthesia by radiologists after a
short training period. The success rate is high with a low incidence of
complications among women. Patients with urothelial cancer who need ureteral
stent placement and periodic cystoscopic evaluation of the bladder are not
candidates for retrograde fluoroscopic exchange.
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Abstract
Introduction
