Fluoroscopic Guidance of Retrograde Exchange of Ureteral Stents in Women

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1 Interventional Radiology Original Research Chang et al. Fluoroscopy for Ureteral Stent Exchange Interventional Radiology Original Research Ruey-Sheng Chang 1 Huei-Lung Liang 1,2 Jer-Shyung Huang 1,2 Po-Chin Wang 1 Matt Chiung-Yu Chen 1 Ping-Hong Lai 1,2 Huay-en Pan 1 Chang RS, Liang HL, Huang JS, et al. Keywords: fluoroscopy, interventional radiology, stent, stent exchange, stent retrieval, ureter, ureteral obstruction, ureteral stenosis DOI: /JR Received September 26, 2007; accepted after revision December 28, Department of Radiology, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd., Kaohsiung, Taiwan, Republic of China. ddress correspondence to H. L. Liang (hlliang@vghks.gov.tw). 2 Department of Radiology, National Yang-Ming Medical School, Kaohsiung, Taiwan, Republic of China. JR 2008; 190: X/08/ merican Roentgen Ray Society Fluoroscopic Guidance of Retrograde Exchange of Ureteral Stents in Women OJECTIVE. The purpose of this study was to review our experience with fluoroscopically guided retrograde exchange of ureteral stents in women. MTERILS ND METHODS. During a 48-month period, 28 women (age range, 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. 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 or inch guidewire with or without the aid of advancement of an angiographic sheath. RESULTS. 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 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. I nternal ureteral stents are used to maintain ureteral patency in the management of various benign and malignant forms of ureteral obstruction. ecause 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 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, years) referred to our department for exchange of ureteral stents during a 48-month period. ll 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 JR:190, June

Chang et al. fibrotic stricture of an ileal conduit. Conventional ureteral stents (Percuflex Plus, oston Scientific) were used in 42 procedures, and inlay stents (Optima, ard) in 12.

ll procedures were performed in an interventional radiology suite, and written informed consent was obtained from all patients.

2 Chang et al. fibrotic stricture of an ileal conduit. Conventional ureteral stents (Percuflex Plus, oston Scientific) were used in 42 procedures, and inlay stents (Optima, ard) 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. ll procedures were performed in an interventional radiology suite, and written informed consent was obtained from all patients. Institu tional review board exemption was obtained for this retrospective chart and image review. Pro phylactic antibiotics (cefazolin, 1,000 mg) and analgesia (fentanyl citrate, 100 µg) were routinely administered IV immediately before the proc edure. 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 inch guidewire (Radifocus, Terumo). 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 ml of normal saline solution or diluted contrast medium to prevent mucosal folds from covering the stent. Under fluoroscopic guidance, a snare catheter (mplatz goose-neck snare with a loop diameter of 25 mm, ard, or triple-loop snare with a loop diameter of 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 (Fig. 1). 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 (Fig. 2). 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. Replacement Technique The stent was withdrawn just beyond the urethral meatus, and a inch stiff guidewire was inserted through the exteriorized end of the stent up to the renal pelvis. new stent the same size as the original (diameter, 7 8 French; length, 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 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 inch guidewire was inserted to pass through a lateral hole in the stent into the ureter toward the renal Fig year-old woman with right obstructive uropathy due to recurrent cervical carcinoma., Photograph shows triple-loop snare catheter., Fluoroscopic image shows snare catheter (arrows) curved downward to reach stent (arrowhead) abutting on mucosa. 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 (Fig. 3). The new stent was exchanged by the method described earlier. 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 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. ll stents were successfully grasped with either a snare catheter in 42 patients 1666 JR:190, June 2008

Fluoroscopy for Ureteral Stent Exchange Fig. 2 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

(single-loop snare, 30 stents; triple-loop snare, 12 stents) or a foreign body retrieval forceps in 12 patients, including the

ecause of blind-end or renal-end obstruction of the stent in three procedures, an 0.

In five of these procedures, a 9- or 10-French sheath was advanced over the C Fig.

, Fluoroscopic image shows sheath (arrows) does not advance into ureter.

3 Fluoroscopy for Ureteral Stent Exchange Fig year-old woman with bladder end of double-j catheter in bladder diverticulum., Photograph shows foreign body retrieval forceps with opening width of 11.3 mm., Fluoroscopic image shows bladder end of stent in bladder diverticulum (arrow), which excludes possibility of exchange with snare catheter. C, Fluoroscopic image shows stent successfully grasped with forceps catheter. (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 (Fig. 4). Fifty-three (98%) of the 54 stents were exchanged successfully. ecause of blind-end or renal-end obstruction of the stent in three procedures, an 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 C Fig year-old woman with solid blockade of bladder end of stent., Fluoroscopic image shows sheath (arrows) does not advance into ureter., Fluoroscopic image shows guidewire (arrow) inserted through sheath alongside occluded stent (arrowhead) for successful cannulation of ureteral orifice. C, Fluoroscopic image shows ureteral stent successfully exchanged. 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. The basic patient characteristics and the methods used to exchange the ureteral stents C JR:190, June

Chang et al. C D Fig. 4 79-year-old woman with bladder carcinoma after cystectomy. and, Fluoroscopic images show lower end of stent in ileal conduit grasped with forceps catheter.

5 mm) guidewire was inserted through sidehole (arrow) of stent into renal pelvis (arrowhead). D, Fluoroscopic image shows stent replaced by retrograde technique. are summarized in Table 1.

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.

The average procedure time for stent exchange was 30 minutes (range, 20 55 minutes), and the fluoroscopic time was usually 3 7 minutes.

4 Chang et al. C D Fig year-old woman with bladder carcinoma after cystectomy. and, Fluoroscopic images show lower end of stent in ileal conduit grasped with forceps catheter. C, Fluoroscopic image shows that owing to occlusion of renal end of stent, inch guidewire did not pass through; inch (0.5 mm) guidewire was inserted through sidehole (arrow) of stent into renal pelvis (arrowhead). D, Fluoroscopic image shows stent replaced by retrograde technique. 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, minutes), and the fluoroscopic time was usually 3 7 minutes. alloon dilations were performed in three procedures on two patients. fter balloon dilation, all the stents were advanced through the narrow segment into the renal pelvis. 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 (Fig. 5). 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. t 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 aere et al. [2] later reported their experience with ureteral stent exchange with an to inch guidewire lasso technique. Park et al. [7] described four techniques for retrograde grasping of a ureteral stent in the bladder lumen. In our 1668 JR:190, June 2008

5 Fluoroscopy for Ureteral Stent Exchange TLE 1: Patient Characteristics (n = 28) ge (y) Initial Stent Placement Cause of Urinary Obstruction Ureter 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]. 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. ecause 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 (Fig. 2) and one in an ileal conduit (Fig. 4). 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. No. of Sessions Snare Forceps Technique for Stent Obstruction 38 Retrograde Iatrogenic transection oth to 10-French sheath used to advance stent into ureter (5 procedures) 56 ntegrade Cervical cancer Left ntegrade Cervical cancer Right inch wire for renal-end obstruction 49 ntegrade Endometrial cancer Right ntegrade Cervical cancer oth ntegrade Cervical cancer Left ntegrade Endometrial cancer Left ntegrade Cervical cancer Right ntegrade Cervical cancer Right ntegrade Cervical cancer Left ntegrade Ovarian cancer Left inch wire for renal-end obstruction 56 ntegrade Cervical cancer Right ntegrade Cervical cancer oth ntegrade Cervical cancer oth ntegrade Cervical cancer Right ntegrade Ovarian cancer oth ntegrade Cervical cancer Right oth sheath and wire used to cannulate ureteral orifice 40 ntegrade Cervical cancer oth ntegrade Cervical cancer oth ntegrade Endometrial cancer Left ntegrade Cervical cancer Left oth sheath and wire used to cannulate ureteral orifice 68 a Retrograde Cervical cancer Left ntegrade Cervical cancer Left ntegrade Cervical cancer Left ntegrade Cervical cancer Left ntegrade Cervical cancer Right ntegrade Cervical cancer Right a ntegrade Fibrotic stricture of ileal conduit after surgery for bladder cancer Note ll but two patients were referred by gynecologists. a Referred by urologist. Right inch wire for renal-end obstruction Ureteral stent occlusion can occur anywhere along the lumen, precluding stent exchange with a conventional inch guidewire. If the occlusion is in the upper part (including the blind-end stent), an 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 JR:190, June

Thus we prefer to advance an open-end sheath over the occluded stent into the distal ureter for exchange of the stent.

6 Chang et al. was still maintained allowing retrograde stent placement. ecause 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. Fig year-old woman who incurred iatrogenic ureteral injuries during surgical intervention for ovarian endometriosis. ilateral 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., Fluoroscopic image shows cutting balloon (arrow) used to dilate stenotic segment. Inlay stent was inserted and remained patent for 8 months. 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 aere 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. References 1. Edwards RD, Robertson IR. Transureteral ureteric stent retrieval using the mplatz gooseneck snare. J Intervent Radiol 1992; 7: de aere T, Denys, Pappas P, Challier E, Roche. Ureteral stents: exchange under fluoroscopic control as an effective alternative to cystoscopy. Radiology 1994; 190: Wetton CW, Gedroyc WM. Retrograde radiologic retrieval and replacement of double-j ureteric stents. Clin Radiol 1995; 50: Uthappa MC, Cowan NC. Retrograde or antegrade double-pigtail stent placement for malignant ureteric obstruction? Clin Radiol 2005; 60: McFarlane JP, Cowan C, Holt SJ, Cowan MJ. Outpatient ureteric procedures: a new method for retrograde ureteropyelography and ureteric stent placement. JU Int 2001; 87: Yedlicka JW Jr, izpuru R, Hunter DW, Castaneda-Zuniga WR, mplatz K. Retrograde replacement of internal double-j ureteral stents. JR 1991; 156: Park SW, Cha IH, Hong SJ, et al. Fluoroscopyguided transurethral removal and exchange of ureteral stents in female patients: technical notes. J Vasc Interv Radiol 2007; 18: eiko DT, Knudsen E, Denstedt JD. dvances in ureteral stent design. J Endourol 2003; 17: Dyer R, Chen MY, Zagoria RJ, Regan JD, Hood CG, Kavanagh PV. Complications of ureteral stent placement. RadioGraphics 2002; 22: Drake MJ, Cowan NC. Fluoroscopy guided retrograded ureteral stent insertion in patients with a ureteroileal urinary conduit: method and results. J Urol 2002; 167: Katske F, Celis P. Technique for removal of migrated double-j ureteral stent. Urology 1991; 37: JR:190, June 2008

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