DOI:10.2214/AJR.07.3999
AJR 2008; 191:1530-1535
© American Roentgen Ray Society
Antegrade Retrieval of Ureteral Stents Through an 8-French Percutaneous Nephrostomy Route
Huei-Lung Liang1,2,
Tsung-Lung Yang1,2,
Jer-Shyung Huang1,2,
Yih-Huie Lin1,2,
Chen-Pin Chou1,2,
Matt Chiung-Yu Chen1 and
Huay-Ben Pan1,2,3
1 Department of Radiology, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st
Rd., Kaohsiung, 81346 Taiwan.
2 Department of Radiology, National Yang-Ming Medical School, Taipei,
Taiwan.
3 Department of Radiation Technology, I-Shou University, Kaohsiung,
Taiwan.
Received March 18, 2008;
accepted after revision May 29, 2008.
Address correspondence to H. B. Pan
(panhb{at}vghks.gov.tw).
Abstract
OBJECTIVE. The purpose of this study was to describe the technique
of antegrade retrieval of ureteral stents under fluoroscopic guidance through
an 8-French nephrostomy.
MATERIALS AND METHODS. During an 8-year period, we retrieved 26
ureteral stents from 24 patients who were not candidates for retrograde
removal or had other conditions precluding use of a retrograde approach. A
loop snare or grasping forceps was used to retrieve a ureteral stent in the
renal pelvis or calyx or upper ureter through an 8-French vascular sheath with
a safety wire in place. A snare catheter advanced into the bladder for
retrieval of the bladder end was used in patients in whom retrieval with both
a loop snare and a grasping forceps failed.
RESULTS. All 26 ureteral stents were successfully retrieved by the
antegrade approach. Ten stents were retrieved with a snare alone and nine with
a forceps alone. Five stents were retrieved successfully with a forceps after
initial failures with snare catheters. Two stents were retrieved with snare
catheters advanced into the bladder. The major complication of nephrostomy
wound infection occurred in a patient with a urinary tract infection who
underwent a one-stage procedure. All minor complications, including pelvic
perforation in one patient and blood clot in the renal pelvis in four
patients, resolved spontaneously without adverse sequelae.
CONCLUSION. Antegrade percutaneous retrieval of a ureteral stent
through an 8-French nephrostomy is safe and effective and has a high degree of
technical success. It can be used as a routine interventional practice in
radiology.
Keywords: percutaneous • retrieval • ureteral stent
Introduction
Ureteral stents are widely used and readily placed by both the retrograde
and antegrade approaches [1].
Classically, cystoscopic guidance with a forceps in the retrograde direction
is the standard approach to removal or exchange of an indwelling ureteral
stent [2,
3]. Retrograde retrieval,
however, can be difficult or impossible because of proximal migration of the
stent, previous surgery on the bladder, the anatomic features of the ureter,
or enlargement of the prostate
[4]. An antegrade approach
through a percutaneous nephrostomy is an alternative for retrieval of a
ureteral stent, but only a small number of references to this approach appear
in the radiology literature. The studies either were limited to a small number
of patients
[5–10]
or were performed with fluoroscopic or nephroscopic guidance with the
nephrostomy track dilated to 12–32 French
[4,
11].
Shin et al. [12] reported
on the largest series (27 patients) of antegrade removal or exchange of
ureteral stents with a snare or basket catheter through an established
9-French nephrostomy track. To achieve greater technical success, they used a
sheath or angioplasty balloon catheter and pushed or pulled the stent to move
the stent tip into a more favorable position in some patients. The technique
described by Shin et al. is not without risk of damage and laceration of
urothelial mucosa. We describe our method of antegrade retrieval of a ureteral
stent through an 8-French nephrostomy route in 24 patients. Our method, which
entails use of a snare or forceps catheter, can be performed successfully on
all patients who need antegrade retrieval of a ureteral stent. The emphasis is
on development of a favorable nephrostomy track for forceps retrieval.
Materials and Methods
This retrospective study included 24 patients (13 men, 11 women; mean age,
58.2 years; range, 23–85 years) referred to our department for antegrade
removal or exchange of a ureteral stent during an 8-year period. Conventional
ureteral stents (7- or 8-French, Percuflex Plus, Boston Scientific) were used
in all patients. All procedures were performed in an interventional radiology
suite with written informed consent from all patients. Institutional review
board exemption was obtained for this retrospective chart and image review. IV
prophylactic antibiotics (1,000 mg cefazolin) and analgesia (100 µg
fentanyl citrate) were given routinely immediately before the procedure.
Indwelling ureteral stents had been inserted for percutaneous
nephrostolithotomy in six patients; ureterolithotomy in one patient; and
management of malignant urinary obstruction in 12 patients, anastomotic
stricture of the ileal conduit in two patients, intraoperative ureteral injury
in one patient, tuberculous ureteritis in one patient, and ketamine abuse in
one patient. Nineteen ureteral stents were placed in an antegrade percutaneous
manner, six stents were placed in a retrograde percutaneous manner, and one
stent was placed intraoperatively in one patient who sustained ureteral injury
during pelvic surgery for cervical carcinoma. Sixteen patients (18 stents) had
undergone percutaneous nephrostomy drainage before antegrade retrieval.
Thirteen of the 24 patients had been referred by urologists because of
ureteral perforation during stent insertion in two patients, proximal and
distal stent migration in two patients each, failure of cystoscopic removal in
three patients (ileal conduit in two and postoperative prostate carcinoma with
urethral stricture in one), refusal of cystoscopic procedure in two men, and
request by urologists with unspecified reasons in the other two patients. In
the 11 patients (12 stents) referred by physicians who were not urologists,
eight procedures had been performed at the physician's request because a
percutaneous nephrostomy had already been established, two stents had migrated
upward, and two cases of urinary tract infection (UTI) necessitated
simultaneous percutaneous nephrostomy drainage. The basic characteristics of
the 24 patients are listed in Table
1.
View larger version (81K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —41-year-old woman with recurrent cervical cancer after
antegrade ureteral stent insertion. Fluoroscopic image shows snare catheter
introduced into upper ureter to retrieve free end of ureteral stent.
|
|
Patients with a preexisting nephrostomy were placed in a prone position,
and local asepsis was obtained with povidone–iodine. The procedure was
performed under local anesthesia with lidocaine injection at the nephrostomy
site. Under fluoroscopic guidance, a 0.035-inch small-J
polytetrafluoroethylene (PTFE) guidewire (1100-1800, Cliny) was introduced
into the renal pelvis or calyx, and an 8-French nephrostomy catheter
(Angiomed, Bard) was exchanged with an 8-French 13-cm-long vascular sheath
(RCF-8.0-38-J, Cook). The guidewire was left within the sheath to function as
a safety guidewire. A snare 10–20 mm in diameter with a 6-French guiding
catheter (Amplatz Goose-Neck Snare, ev3) usually was used as the initial
instrument for retrieving the stent in these pa tients. The snare catheter was
inserted through the 8-French sheath and manipulated to place the stent tip
inside the snare loop (Fig. 1A,
1B,
1C,
1D). The guid ing catheter was
advanced to close the snare loop on the stent. With a firm grasp, the stent,
which was not pulled into the sheath, was removed entirely with the snare
catheter and the sheath.
If the snare catheter failed to entrap the stent, a 6-French flexible
foreign body retrieval forceps with an opening width of 8 mm, alligator jaws,
and a 70-cm working length (FG-53SX-1, Olympus) was used to directly grasp the
stent in the collecting system. In early cases in which both snare and forceps
catheters failed to retrieve the stent, we developed a new favorable
percutaneous nephrostomy route by repuncturing a renal calyx to retrieve the
stent (discussed later). With increased experience with fluoro scopically
guided transurethral retrograde exchange of ureteral stents in the bladder
[13], we inserted a snare
catheter through the ureter into the bladder to grasp the bladder end of a
ureteral stent (Fig. 2A,
2B,
2C,
2D).
View larger version (123K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B —54-year-old man after percutaneous nephrostomy lithotomy.
Fluoroscopic image shows further downward migration of stent into distal
ureter (arrowhead) during manipulation. Snare catheter was advanced
into bladder to retrieve bladder end of stent (arrow).
|
|
In patients without a preexisting percutaneous nephrostomy, percutaneous
nephrostomy was performed under sonographic and fluoroscopic guidance with
either direct puncture of the calyx where the stent end was positioned (Fig.
3A,
3B,
3C,
3D) or through a calyx. The
latter technique enabled tandem alignment of the calyx and ureteral stent
(Fig. 4A,
4B,
4C) on guiding sonographic
images. An 8-French sheath was inserted along a 0.035-inch small-J PTFE
guidewire into the renal pelvis. The guide wire was left as a safety
guidewire, and a 6-French forceps catheter was advanced through the sheath.
The stent was nudged by the forceps to confirm its location. By manipulating
the forceps under fluoroscopic control, we flipped the stent into the jaws of
the forceps. When the jaws were closed, the stent was seen to crumple with no
distortion of the pelvicaliceal system. Afterward, the stent, together with
the forceps catheter and sheath, was withdrawn, and the safety guidewire was
retained in the collecting system for reinser tion of a percutaneous
nephrostomy catheter. The fluoro copic time was recorded from the time of
guide wire insertion into the renal pelvis to completion of reinsertion of the
percutaneous nephrostomy catheter.
View larger version (88K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A —23-year-old woman with dysfunction of ureteral stent and
history of ketamine abuse. Sonogram shows fine needle (arrowhead)
inserted into calyx where end of ureteral stent (straight arrow) was
positioned. Debris (curved arrow) fills renal calyx and pelvis.
|
|
View larger version (104K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B —23-year-old woman with dysfunction of ureteral stent and
history of ketamine abuse. Excretory urogram shows filling defects within
calyx (arrowhead). Needle tip (arrow) abuts stent end.
|
|
View larger version (111K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C —23-year-old woman with dysfunction of ureteral stent and
history of ketamine abuse. Fluoroscopic image shows forceps catheter
(arrow) used to grasp stent directly in calyx. Guidewire
(arrowhead) is retained in distal ureter.
|
|
View larger version (88K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A —70-year-old man after operation for prostate cancer.
Cystoscopy failed to pass urethral stricture. Fluoroscopic image shows both
snare and forceps catheters failed to retrieve ureteral stent through
preexisting percutaneous nephrostomy route in upper renal calyx
(arrow).
|
|
View larger version (89K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B —70-year-old man after operation for prostate cancer.
Cystoscopy failed to pass urethral stricture. Fluoroscopic images show new
puncture from lower calyx (arrowhead, B), which made direct
contact with pigtail end of stent within renal pelvis. Stent was retrieved
with forceps catheter (arrow).
|
|
View larger version (90K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4C —70-year-old man after operation for prostate cancer.
Cystoscopy failed to pass urethral stricture. Fluoroscopic images show new
puncture from lower calyx (arrowhead, B), which made direct
contact with pigtail end of stent within renal pelvis. Stent was retrieved
with forceps catheter (arrow).
|
|
If stent placement had to be repeated immediately, an angiocatheter (RC1,
Cook) was advanced over the safety guidewire into the renal pelvis. A
0.035-inch hydrophilic wire (Radifocus, Terumo) was inserted into the urinary
bladder and exchanged with a stiff guidewire (Amplatz Super Stiff, Boston
Scientific) for antegrade ureteral stent insertion. For patients who did not
need an indwelling stent, an 8-French nephrostomy tube was inserted for renal
drainage. Antegrade excretory urography was performed to confirm the presence
of contrast extravasation or a filling defect within the collect ing system.
The percutaneous nephrostomy cath eter was removed 2–3 days after the
procedure unless otherwise indicated.
Technical success, indication for antegrade retrieval, interval between
stent placement and retrieval, the instruments used to retrieve the stent, and
procedure-related complications are shown in
Table 1. According to the
quality improvement guidelines of the Society of Interventional Radiology,
major complications were defined as those neces sitating further treatment or
prolonged hospitalization and minor complications as those that resolved
spontan eously [14]. Blood
clot formation was defined as a filling defect within the pelvicaliceal system
during stent removal with hematuria identified in the drained urine. Tract
leakage was defined as identification of contrast medium leakage outside the
pelvicaliceal system. Clinical follow-up was done by review of medical records
and follow-up imaging with renal sonography.
Results
A total of 26 ureteral stents were retrieved (15 removed, seven exchanged,
four repositioned) in 24 patients. The average interval between stent
insertion and retrieval was 82.7 days (range, 2–225 days). All the
ureteral stents were successfully retrieved with antegrade technique. Thus,
the technical success rate was 100%.
The average interval between percutaneous nephrostomy and stent retrieval
was 18.2 days (range, 2–110 days) in the 16 patients (18 stents) with
preexisting percutaneous nephrostomy tracks. In these patients, retrieval of
10 stents in the renal pelvis or calyx or upper ureter (55.5%) was successful
with a snare catheter alone. Seven stents were not retrieved in initial trials
with a snare catheter, and forceps catheters were used successfully to
retrieve four stents. In the cases of three stents, both snare and forceps
catheters failed, and one stent in a patient treated early in the series was
retrieved by means of repuncture of the renal calyx to develop a favorable
percutaneous nephrostomy track for forceps retrieval (Fig.
4A,
4B,
4C). The other two stents were
retrieved successfully by readvancement of the snare catheter through the
established percutaneous nephrostomy into the bladder to retrieve the bladder
end of the stent (Fig. 2A,
2B,
2C,
2D). A stent in a UTI patient
was retrieved with a forceps catheter alone. She underwent a two-stage
procedure by an in-plan nephrostomy route established 3 days earlier.
As for the eight patients without a preexisting percutaneous nephrostomy,
all ureteral stents were retrieved successfully with forceps catheters in a
one-stage procedure (caliceal puncture and removal of the stent at the same
session). The fluoroscopic time for this patient group was estimated to be
less than 2–3 minutes. Four patients (five stents) had had symptoms and
signs of UTI at admission. Stent retrieval was performed with a two-stage
procedure for three of these stents and a one-stage procedure for the other
two.
A major complication occurred in one UTI patient (urine culture,
Klebsiella pneumoniae; extended-spectrum β-lactamases). She
underwent a one-stage procedure for retrieval of the stent, but a wound
infection developed at the nephrostomy site necessitating a 12-day hospital
stay for IV antibiotic treatment. Four patients had various degrees of
hematuria and thrombus in the collecting system, but all cases cleared rapidly
within 2–3 days. None of the patients needed a transfusion. Two of the
cases of complications occurred after urolithotomy, and antegrade pyelogram
showed that a blood clot had been retained in the collecting system before the
retrieval procedure. Pelvic perforation with contrast leak was found in one
patient with spontaneous seal-off on the follow-up antegrade pyelogram 2 weeks
later. One of the seven stents exchanged failed immediately, and the failure
was attributed to underlying malignant obstruction. There were no cases of
stent fragmentation, substantial hemorrhage, or other complications
attributable to the procedure.
Discussion
It is generally accepted that dysfunctioning ureteral stents should be
removed cystoscopically. In some instances, however, removal of ureteral
stents from below is neither possible nor preferred. Examples are proximally
migrated ureteral stents, cases of previous surgery on the bladder, and
certain anatomic features of the ureter
[4]. Patients with recurrent
hydronephrosis, especially with symptoms or signs of UTI, after previous
ureteral stent insertion usually are first referred to a radiologist for
percutaneous nephrostomy drainage. Afterward, urologists are consulted to
remove or exchange the dysfunctioning ureteral stents by a retrograde
approach. From the technical perspective, once a percutaneous nephrostomy
drainage route has been established, later retrieval of a ureteral stent can
be performed by an antegrade approach without retrograde cystoscopy if an easy
and safe antegrade method is available for this purpose.
Reports of percutaneous antegrade retrieval of ureteral stents are limited
[4–12],
however. Retrieval has been performed with the nephrostomy track dilated up to
24–32 French to accommodate the nephroscope or to 12–14 French for
use of snare or forceps catheters, the latter range being considered the
minimally requested size for retrieval of a folded 8-French stent
[11]. The larger nephrostomy
track for stent retrieval was considered traumatic for patients. Shin et al.
[12] reported the feasibility
of antegrade retrieval of a double-J stent through a 9-French nephrostomy. Our
experience also confirmed that with a safety guidewire in place, a 7- to
8-French stent catheter and an 8-French sheath can be removed as a unit
without difficulty. Because the size of the nephrostomy track for stent
retrieval can be the same as that of a track for simple urinary drainage, and
a well-formed track decreases the risk of bleeding, the presence of a
preexisting percutaneous nephrostomy can be considered an indication for
antegrade stent retrieval under fluoroscopic guidance.
The use of snares to retrieve foreign bodies was initially described for
the vascular system [15].
Yeung et al. [11] stated that
snares and baskets are of limited utility in the renal calyx and ureter
because they can be used only if the stent has a free edge. The causes of
technical failure were attributed to embedding of the stent end against the
wall and to the small amount of space in the renal pelvis and calyx. Shin et
al. [12] used a snare or
basket catheter alone to retrieve ureteral stents, and technical failure
occurred in some of their cases. To facilitate technical success, they used a
9-French sheath or an inflated 6-mm angioplasty balloon, pushing or pulling
the stent in the renal pelvis or ureter to manipulate the stent tip into a
more favorable position. They achieved a technical success rate of 95%. Shin
et al. reported that a sheath or balloon catheter should be used with caution
because it can damage and lacerate the uro thelial mucosa.
In our series, we retrieved only 11 of 17 stents (65%) successfully with
initial trials of snare catheters in the 16 patients with a preexisting
percutaneous nephrostomy. Compared with procedures on the vascular system
[15] and urinary bladder
[13], in operations on the
renal pelvis or calyx or the ureter, it is more technically difficult to
manipulate a snare loop to entrap the pigtail stent end. Yeung et al.
[11] reported on a patient
with a fractured stent. The distal fragment in the ureter was pushed into the
bladder and then removed with cystoscopy.
In two of our patients the ureteral stents were not grasped with either
snare or forceps catheters. Instead of pushing the stent downward, we advanced
a snare catheter into the bladder. Because the bladder has room for
manipulation of a snare catheter, the retrieval procedure is likely to be
successful without retrograde cystoscopy. Again, it must be emphasized that
retrograde access should be the primary method of retrieval, especially in
women, if a large portion of the stent is within the bladder. But for patients
referred to the radiology department for antegrade ureteral stent retrieval
for any reason, the novel technique we describe can be used with a high rate
of success in difficult cases.
As for types of forceps, Meranze et al.
[6] used a flexible forceps to
remove foreign bodies from the renal pelvis (two patients) and to obtain a
tissue biopsy specimen from the ureter (one patient). Breen and Cowan
[10] and Yeung et al.
[11] chose a rigid forceps
because of simplicity of directional control and ease of deduction of the
position of the instrument in the collecting system. We used a flexible
forceps because of its advantage in negotiating around bends (e.g., in the
upper ureter or calyx). We also had no difficulty directing the flexible
forceps or in judging the relation between the forceps tip and the stent, as
stated by Yeung et al. Thus, we successfully retrieved ureteral stents from
all eight patients undergoing one-stage procedures and from four patients
undergoing two-stage procedures. We consider a flexible forceps an ideal
choice for antegrade retrieval of ureteral stents.
Although bleeding from the newly made track can increase the difficulty of
a one-stage procedure (caliceal puncture and removal of the stent at the same
session), the technique has been recommended because the collecting system
often is dilated, allowing room for manipulation of instruments
[11]. The advantage is
theoretical, however; caution must be exercised when the one-stage procedure
is performed on patients with UTI. A one-stage procedure on one of our two UTI
patients was complicated by nephrostomy wound infection. It is possible that
bacteria in the collecting system are brought out along the nephrostomy track
during the retrieval procedure, causing wound infection. Although our
experience is limited, only two UTI patients in our series underwent a
one-stage procedure, it may be safer to use a two-stage procedure for an
infected ureteral stent.
Percutaneous antegrade retrieval of ureteral stents with a snare or forceps
catheter under fluoroscopic guidance is safe and effective. An in-plan
nephrostomy route is essential for easy and quick retrieval of ureteral
stents. Caution should be exercised if a one-stage procedure is to be
performed on a patient with UTI.
References
- Uthappa MC, Cowan NC. Retrograde or antegrade double-pigtail stent
placement for malignant ureteric obstruction? Clin
Radiol 2005; 60:608
–612[CrossRef][Medline]
- Smith AD. Retrieval of ureteral stents. Urol Clin North
Am 1982; 9:109
–112[Medline]
- Ganatra AM, Loughlin KR. The management of malignant ureteral
obstruction treated with ureteral stents. J Urol2005; 174:2125
–2128[CrossRef][Medline]
- LeRoy AJ, Williams HJ Jr, Segura JW, Patterson DE, Benson RC Jr.
Indwelling ureteral stents: percutaneous management of complications.
Radiology 1986;158
: 219–222[Abstract/Free Full Text]
- Zegel HG, Teplick SK, Khanna OP. Removal of a dislodged ureteral
stent through a percutaneous nephrostomy. AJR1981; 137:629
–630[Free Full Text]
- Meranze SG, Pollack HM, Banner MP. The use of grasping forceps in
the upper urinary tract: technique and radiologic implications.
Radiology 1982;144
: 171–173[Free Full Text]
- Boren SR, Dotter CT, McKinney M. Rosch J. Percutaneous removal of
ureteral stents. Radiology 1984;152
: 230–231[Abstract/Free Full Text]
- Ellis JH, Bordeur FJ Jr, Marx MV, et al. Superelastic guide-wire
snare for removal of foreign bodies from the urinary tract.
Radiology 1992;183
: 871–873[Abstract/Free Full Text]
- Patel U, Kellett MJ. The misplaced double J ureteric stent:
technique for repositioning using the nitinol "goose-neck" snare.
Clin Radiol 1994;49
: 333–336[CrossRef][Medline]
- Breen DJ, Cowan NC, Fluoroscopically-guided retrieval of ureteric
stents. Clin Radiol 1995;50
: 860–863[CrossRef][Medline]
- Yeung EY, Carmody E, Thurston W, Ho CS. Percutaneous
fluoroscopically guided removal of dysfunctioning ureteral stents.
Radiology 1994;190
: 145–148[Abstract/Free Full Text]
- Shin JH, Yoon HK, Ko GY, et al. Percutaneous antegrade removal of
double J ureteral stents via a 9-F nephrostomy route. J Vasc Interv
Radiol 2007 18:1156
–1161[CrossRef][Medline]
- Chang RS, Liang HL, Huang JS, et al. Fluoroscopic guidance of
retrograde exchange of ureteral stents in women. AJR2008; 190:1665
–1670[Abstract/Free Full Text]
- Ramchandani P, Cardella JF, Grassi CJ, et al. Quality improvement
guide-lines for percutaneous nephrostomy. J Vasc Interv
Radiol 2003; 14[9 Pt
2]: S277–S281[Medline]
- Dotter CT, Rosch J Bilbao MK. Transluminal extraction of catheter
and guide fragments from the heart and great vessels: 29 collected cases.
AJR 1971; 111:467
–472
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
