How is stent placement performed for iatrogenic ureteral injury repair?

Updated: Nov 12, 2020
  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

After the perineum is prepared and draped in the standard sterile manner and the patient is sedated adequately or anesthetized, a cystoscope is inserted into the bladder.

After the bladder is examined and the ureteral orifices are identified, the ureteral orifice on the side of the injury is cannulated with a ureteral catheter. A dilute diatrizoate-gentamicin mixture is injected slowly through the ureteral catheter under fluoroscopy, revealing the course of the ureter and identifying potential sites of injury.

A Teflon-coated guidewire is placed under fluoroscopic guidance through the ureteral catheter and up the ureter into the renal pelvis. A double-J stent is placed over the wire and is pushed so that its proximal J-hook is placed within the renal pelvis and its distal J-hook is within the bladder. Then, the wire is pulled, and the stent position is reaffirmed fluoroscopically.

Proper length of the stent can be estimated from the measured length of the ureter on retrograde pyelography from the ureteral orifice to the ureteropelvic junction. Allowing for roughly 10% magnification from the radiograph, subtract 2-3 cm and select that length ureteral stent. If, after placement, the stent is not well positioned because of inadequate or surplus length, it is best to replace it with a stent of proper dimensions.

Barrett et al describe an intraoperative radiographic technique for measuring ureteral length that led to selection of stents of appropriate length in 23 of 25 cases (92%). In this technique, a radiographic nipple marker is affixed to the skin over the ureteral orifice (UO) and an angiographic catheter with radiopaque markings at 1 cm intervals is used to measure the distance from the ureteropelvic junction to the marker at the UO. [14]


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