Ureteral stent placement in hydronephrosis during pregnancy

In this study we describe 22 cases of retrograde ureteral stent placement in pregnant women with therapy-resistant flank pain due to hydronephrosis. Eleven were primiparous and one patient expected twins. Eight of 22 patients presented symptoms of pyelonephritis. In 21 cases the hydronephrosis was located on the right and in 4 cases it was bilateral. Maximal lower calix diameter was 12 mm (range 9–22 mm). With the exception of two cases, sonographically controlled stent placement was performed under local anesthesia without sedation. All patients were painfree within 6 days and were given prophylactic low dosis of antibiotic until the day of delivery. Renal function remained within the normal limits. Double-J stent displacement occured in 3 patients – of which one underwent nephrostomy. Postnatal examination demonstrated urolithiasis in 4 of 19 patients. This study provides evidence for effectiveness of retrograde ureteral Double-J stent placement as a therapeutic option in cases of severe symptomatic hydronephrosis during pregnancy with a low morbidity rate.     

双J管内引流治疗妊娠期肾积水合并急性肾盂肾炎的体会

目的：评估妊娠期肾积水合并急性肾盂肾炎内引流的治疗效果及安全性。方法：采用经膀胱镜下置入输尿管双J管治疗院外抗生素治疗失败的妊娠期肾积水合并急性肾盂肾炎患者34例。结果：34例全部顺利置人输尿管双J管并保留2～4天,术中和术后无明显并发症,经抗炎治疗后所有患者48h内体温恢复正常,腰痛症状消失。胎儿出生后无畸形、智力障碍及先天性疾病报告。结论：经膀胱镜下逆行置人输尿管双J管具有操作简单、效果满意等优点,可作为临床上妊娠期肾积水合并急性肾盂肾炎单用抗生素治疗无效时的重要辅助治疗手段。     

Ureteral stent placement in hydronephrosis during pregnancy

Summary In this study we describe 22 cases of retrograde ureteral stent placement in pregnant women with therapy-resistant flank pain due to hydronephrosis. Eleven were primiparous and one patient expected twins. Eight of 22 patients presented symptoms of pyelonephritis. In 21 cases the hydronephrosis was located on the right and in 4 cases it was bilateral. Maximal lower calix diameter was 12 mm (range 9–22 mm). With the exception of two cases, sonographically controlled stent placement was performed under local anesthesia without sedation. All patients were painfree within 6 days and were given prophylactic low dosis of antibiotic until the day of delivery. Renal function remained within the normal limits. Double-J stent displacement occured in 3 patients – of which one underwent nephrostomy. Postnatal examination demonstrated urolithiasis in 4 of 19 patients. This study provides evidence for effectiveness of retrograde ureteral Double-J stent placement as a therapeutic option in cases of severe symptomatic hydronephrosis during pregnancy with a low morbidity rate.      

同侧两根双J管引流在结石伴息肉导致输尿管狭窄患者中的应用

目的观察同侧两根双J管引流在结石伴息肉导致输尿管狭窄患者中的应用效果。 方法选取2012年1月至2017年6月期间我院收治的输尿管结石伴息肉导致输尿管狭窄患者80例，采用随机数字法将患者分为研究组及对照组，每组各40例。研究组患者腔内碎石术后同侧输尿管内留置两根双J管，对照组患者腔内碎石术后留置单根双J管。根据术中情况，双J管留置4～12周，平均8周。拔管后4周复查血肌酐和泌尿系超声，了解输尿管结石残留情况和肾积水程度，比较两组患者血肌酐、结石清除率和肾积水的变化。 结果拔管后4周，两组患者血肌酐下降和结石清除率差异均无统计学意义（P>0.05）。研究组和对照组手术后肾积水均有明显的改善，肾积水下降值分别为（23.5±7.0）mm vs （20.1±7.3）mm差异有统计学意义（P<0.05）。 结论输尿管结石伴息肉导致输尿管狭窄的患者，输尿管腔内碎石术后同侧留置两根双J管短期引流效果优于留置单根双J管，但远期效果和机制需要大样本进一步研究验证。     

Early and late complications of double pigtail ureteral stent

OBJECTIVES: To analyze the early and late complications of indwelling ureteral stents in a series of 146 patients with nephroureteral lithiasis. MATERIALS AND METHODS: 146 patients with obstructing nephrolitiasis were treated for urinary diversion with double pigtail ureteral stent before extracorporeal shock-wave lithotripsy (ESWL) and following ureterorenoscopic treatment of lithiasis. All patients were scheduled for stent removal or replacement at specific 3-month intervals until stone-free status was achieved. RESULTS: Early complications during the first 4 weeks after stent insertion were stent discomfort (37.6%), irritative bladder symptoms (18.8%), hematuria (18.1%), bacteriuria (15.2%), fever >104 degrees F (12.3%) and flank pain (25.3%); late complications included hydronephrosis (5.7%), and stent migration (9.5%), encrustation (21.6%), fragmentation (1.9%) and breakage (1.3%). CONCLUSIONS: Ureteral stents have proven to be an invaluable tool for endourologists. Morbidity is minimal for up to three months but longer indwelling times are associated with an increasing frequency of incrustation, infections, secondary stone formation and obstruction of the stented tract.     

Percutaneous nephrostomy versus the placement of double pigtail ureteral stent for the treatment of postrenal failure secondary to malignancies]

From August 1989 through September 1991 we performed percutaneous nephrostomy under ultrasonic guidance in 26 kidneys of 25 patients. We also indwelled double pigtail ureteral stents by endoscopy in 14 kidneys of 13 patients. No patients died because of renal failure. The survival was dependent on progression of primary disease and performance status. Neither significant nor life-threatening complications were encountered. The difference in the improvement of renal function between nephrostomy group and stent group was not statistically significant. Although the indwelling ureteral stent method requires no external drainage bag, this method has certain drawback such as occasional obstruction of stent. Especially in poor risk patients, percutaneous nephrostomy technique seems to be better than placement of double pigtail ureteral stent in the treatment of postrenal failure secondary to malignancies.     

Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review

Gastric leak remains the main complication after sleeve gastrectomy, but there are no standardized guidelines for its treatment. Good results have been reported using endoscopic double-pigtail stent. To estimate its effectiveness, we carried out this systematic review. Eleven eligible articles were identified by searching PubMed, Embase, and Cochrane Library databases. A total of 385 patients met the inclusion criteria. The pooled proportion of successful leak closures by using double pigtail drainage was 83.41%. The proportion of successful leak closures by using double pigtail drainage by experienced operators as first-line treatment was 84.71%. Our review suggested that double-pigtail stent could be a valid approach to manage the postbariatric gastric leak, with low rate of complications and a good tolerance by patients. More high-quality studies with large samples sizes should be undertaken to better evaluate and compare the variety of techniques available.     

输尿管良性狭窄内切开前行球囊扩张的临床研究

目的 探讨输尿管良性狭窄内切开前使用球囊扩张的必要性.方法 16例输尿管良性狭窄患者行钬激光输尿管内切开前,6例采用球囊扩张狭窄段,10例采用输尿管硬镜扩张狭窄段.回顾性分析其临床资料和随访结果,包括病因、狭窄部位、诊断方法和超声等随访情况.结果 输尿管硬镜扩张者3例失败,改用球囊扩张成功;使用球囊扩张的患者均扩张成功.狭窄长度为0.8～1.4 cm.用球囊扩张的手术时间短于用输尿管硬镜扩张,但手术费用高于用输尿管硬镜扩张,差异均有统计学意义(P<0.05).随访3～28个月,无围手术期并发症,2例用输尿管硬镜扩张患者出现再狭窄.结论 输尿管良性狭窄内切开前使用球囊扩张安全、有效,但费用较高.     

Changing to a loop-type ureteral stent decreases patients’ stent-related symptoms

The first indwelling ureteral splint was described in 1967. A ureteral stent can cause unpleasant side effects, such as urinary frequency, urgency, incontinence, hematuria, bladder pain and flank pain, which have a negative impact on a patient’s quality of life. It is necessary to minimize the amount of material in the bladder in order to decrease stent-related symptoms. This study investigated the stent-related symptoms after changing from a double pigtail to a loop-type ureteral stent in the same patient group. This study followed 25 patients who underwent ureteral stent exchange from double pigtail to loop-type ureteral stent between September 2009 and February 2010. Ureteral stents were exchanged using topical, conscious sedation and general anesthesia for the various procedures including stent exchange, before/after shock wave lithotripsy and before/after ureteroscopy. The stent length was selected to be the same as whole ureteral length and the caliber based on the previous stent. A self-administered stent-related symptom questionnaire was used to assess stent-related symptoms in comparison to the previous double-pigtail stents. A total of 25 patients with a median age of 56.5?years underwent ureteral stent exchange. All patients had stone disease except two patients who had ureteral stricture. Almost all of stent-related symptoms without nocturia showed a significantly lower score with the loop-type ureteral stent than in double-pigtail stent. None of the patients experienced urinary tract infection either before or after undergoing ureteral stent exchange. Changing to loop-type ureteral stent significantly decreased ureteral stent-related symptoms.     

钬激光经输尿管镜手术治疗输尿管狭窄（附52例报告）

目的探讨输尿管镜下钬激光（Ho：YAG激光）内切开术治疗输尿管狭窄的方法及疗效。方法2004年7月-2007年4月，采用经输尿管镜钬激光于输尿管后外侧全层内切开治疗52例输尿管狭窄，术中留置F5-F6号双J管2根，术后8～12周拔除双J管，拔管后3—6个月进行超声、静脉肾盂造影检查。结果46例随访3—24个月，平均17个月。40例治愈（治愈率87％），患者肾脏积水、输尿管扩张减轻，狭窄段消失或减轻，腰部胀痛症状缓解，无明显感染症状；4例好转，肾积水、输尿管扩张未加重，腰部胀痛症状缓解，无再感染史；2例无效，肾积水、输尿管扩张加重，反复有腰部胀痛及感染症状。结论输尿管镜下钬激光内切开输尿管全层加留置2根双J管治疗输尿管狭窄，创伤小，疗效好，视野清，并发症少。     

Predicting the success of retrograde stenting for managing ureteral obstruction

PURPOSE: Retrograde ureteral stenting is often considered the first line option for relieving ureteral obstruction when temporary drainage is indicated. Several retrospective studies have implied that in cases of extrinsic obstruction retrograde ureteral stenting may fail and, therefore, percutaneous nephrostomy drainage is required. We examined the efficacy of retrograde ureteral stenting for resolving ureteral obstruction and identified clinical and radiological parameters predicting failure. MATERIALS AND METHODS: Enrolled in our prospective study were 92 consecutive patients with ureteral obstruction, which was bilateral in 8. Retrograde ureteral stenting was attempted in all cases by the urologist on call. When stent insertion failed, drainage was achieved by percutaneous nephrostomy. Patients were followed at 3-week intervals for 3 months. Each followup visit included a medical interview, blood evaluation, urine culture and ultrasound. Stent malfunction was defined as continuous flank pain manifesting as recurrent episodes of acute renal colic, 1 or more episodes of pyelonephritis, persistent hydronephrosis or elevated creatinine. Preoperative data and outcomes were compared in cases of intrinsic and extrinsic obstruction. Univariate and multivariate analysis was done to identify predictors of the failure of ureteral stent insertion and long-term function. RESULTS: The etiology of obstruction was intrinsic in 61% of patients and extrinsic in 39%. Extrinsic obstruction, which was associated with a greater degree of hydronephrosis, was located more distal. Retrograde ureteral stenting was successful in 94% and 73% of patients with intrinsic and extrinsic obstruction, respectively. At the 3-month followup stent function was maintained in all patients with intrinsic obstruction but in only 56.4% with extrinsic obstruction. On multivariate logistic regression the type of obstruction, level of obstruction and degree of hydronephrosis were the only predictors of stent function at 3 months. Stent diameter and preoperative creatinine had no predictive value. CONCLUSIONS: Retrograde ureteral stenting is a good solution for most acutely obstructed ureters. In patients with extrinsic ureteral obstruction a more distal level of obstruction and higher degree of hydronephrosis are associated with a greater likelihood of stent failure. These patients may be better served by percutaneous drainage.     

Usefulness of short-term retrievable ureteral stent in pediatric laparoscopic pyeloplasty

PURPOSE: Methods of stenting after laparoscopic pyeloplasty have included indwelling Double-J stents and percutaneous nephrostomy tubes. The disadvantages of these methods are that they necessitate a second surgery for stent removal or require an external drainage bag. To circumvent these issues, the tolerance, safety and outcomes of using a Double-J ureteral stent with a dangler, permitting early office removal, was investigated in a series of pediatric laparoscopic pyeloplasties. MATERIALS AND METHODS: Medical records from a consecutive series of pediatric patients undergoing transperitoneal laparoscopic pyeloplasties were reviewed. Indications for surgery included ipsilateral flank pain with severe hydronephrosis (12 patients), recurrent pyelonephritis with severe hydronephrosis (2), and hematuria and flank pain (6). All patients were discharged home within 24 to 48 hours of the procedure with prophylactic oral antibiotics. The stent was removed by postoperative day 18 during a followup office visit. Patient tolerance of the indwelling stent, outpatient removal and success of pyeloplasty were assessed. RESULTS: A total of 20 patients underwent transperitoneal laparoscopic pyeloplasty by 1 surgeon (LAB) between 2001 and 2005. All patients underwent cystoscopy and retrograde Double-J ureteral stent placement before pyeloplasty under the same anesthesia. Mean patient age at operation was 11.3 years (median 11.3, range 4.6 to 17.2). Stents were left indwelling for a mean of 10.3 days (median 10, range 7 to 18). All patients tolerated the Double-J stent well, with 2 requiring anticholinergic therapy for mild urgency symptoms and 1 demonstrating urinary tract infection. All patients tolerated outpatient stent removal via the dangler at the office without discomfort. One patient was lost to followup. At a mean followup of 1.04 years (range 0.1 to 2.88) 17 of 19 patients (89%) had resolution of flank pain/urinary tract infections, with sonographic improvement in hydronephrosis with or without endoscopic intervention. Six patients (30%) had flank pain with or without continuous hydronephrosis and required re-stenting, and 3 also required balloon dilation. Of these 6 patients 2 (10%) had recurrent ureteropelvic junction obstruction and required open pyeloplasty. All patients are now clinically and radiologically unobstructed and asymptomatic. CONCLUSIONS: Pediatric transperitoneal laparoscopic pyeloplasty with indwelling Double-J ureteral stent with a dangler is successful and the stent is well tolerated. Whether the duration of ureteral stenting affects the surgical success will require further controlled long-term studies.     

Use of the double pigtail stent in stone retrieval following unsuccessful ureteroscopy

Insertion of a double pigtail stent is known to cause ureteric dilatation. We analysed the effect of an indwelling double pigtail stent on the success rate of calculus extraction by second ureteroscopy when the initial ureteroscopy fails. Over a 12-month period, a first ureteroscopy failed in 42 patients; 30 were then treated by ureteroscopy combined with a ureteric stent and 12 were treated without a ureteric stent. The group with an indwelling stent had a successful second ureteroscopy or spontaneously passed the calculus in 24 cases (84%) compared with 5 unstented cases (45%). Ureterolithotomy was necessary in 2 patients with a stent and 3 with no stent. It was concluded that following failed ureteroscopic manipulation of calculi, insertion of a double pigtail stent was associated with a higher subsequent success rate for removal of stone by ureteroscopy and a consequent lower rate of ureterolithotomy.     

Primary double pigtail stenting as a treatment of upper urinary tract leaks

During a 5-year period 21 consecutive patients with iatrogenic or traumatic upper urinary tract leaks (nonmalignant) underwent treatment 5 to 28 days later with an indwelling double pigtail stent via an antegrade or retrograde approach. Six patients underwent initial nephrostomy drainage for relief of obstruction causing decreased renal function and/or septicemia. Stent placement was successful in 20 patients and complete healing occurred within 2 to 7 weeks in all 20. At followup 2 to 32 months later (median 3 months) no stricture formation or deterioration of kidney function was noted. There were no major complications and 85% of the patients were able to leave the hospital without any form of external drainage within 1 week after stent placement.     

Management of pregnancy and delivery after augmentation cystoplasty

We report 2 cases of women who became pregnant and experienced vaginal delivery after augmentation cystoplasty. CASE 1: A 23-year-old woman with spina bifida became pregnant 3 years after augmentation sigmoidocystoplasty which had been performed to treat intractable urinary tract infection and urinary incontinence. During pregnancy, she developed febrile urinary tract infection twice which required antibiotics together with tight adherence to clean intermittent catheterization. At 36 weeks of gestation, she was safely delivered of a healthy baby. No deterioration of urinary continence level and renal function was observed after the delivery. CASE 2: A 32-year-old woman became pregnant 23 years after augmentation ileocecocystoplasty which had been performed to reconstruct diverted urinary tract due to a congenital hour-glass bladder. At 19 weeks of gestation, she developed acute pyelonephritis and hydronephrosis at right kidney which required antibiotics and indwelling urethral catheter. At 21 weeks of gestation, a drip infusion of ritodrine hydrochloride was started and maintained until 34 weeks of gestation to inhibit premature uterine contraction. At 29 weeks of gestation, she developed acute pyelonephritis and progressive hydronephrosis at left kidney, for which percutaneous nephrostomy drainage was deemed to be mandatory. She was delivered of a healthy baby at 36 weeks of gestation. Ten days after the delivery, both nephrostomy tube and indwelling urethral catheter were removed and clean intermittent catheterization was resumed. Total renal function was maintained during and after the pregnancy, and no deterioration of urinary continence was observed after the delivery. Since urinary tract infection is extremely common during pregnancy after augmentation cystoplasty, prevention and prompt intervention for urinary tract infection should be mandatory. Significant upper tract obstruction, if developed, should be treated by an effective urinary drainage. Thus, urological as well as obstetrical appropriate management is mandatory for the safe accomplishment of pregnancy and delivery after augmentation cystoplasty.     

Prevention and treatment of symptoms associated with indwelling ureteral stents: A systematic review

Temporary drainage of the upper urinary tract by internal ureteral stents is a routine procedure in endourology. However, it is associated with a clear side‐effect profile. Our aim was to evaluate prevention and treatment options of stent‐related symptoms. We carried out a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines using MEDLINE and SCOPUS, and identified 107 appropriate records. A high number of these studies showed clear methodological limitations. Available data clearly support the use of α₁‐blockers in patients suffering from stent‐related symptoms. It seems that antimuscarinic monotherapy or combination with α₁‐blockers might also play an important role, whereas the use of classical analgesics in the treatment of stent‐related symptoms has not been assessed systematically within clinical trials so far. Improvements in stent design and material seem to have the potential to reduce stent‐related symptoms. However, so far there is no type of stent with outstanding characteristics and clear evidence suggesting fundamental advantages compared with a standard double pigtail stent. Although stent diameter does not seem to influence patients’ comfort, it seems to be beneficial to choose a proper stent‐length. Coated and drug‐eluting stents, as well as intravesical drug application, seem to be promising concepts to prevent stent‐related symptoms, but still have to be considered as experimental approaches. Furthermore, thorough patient education has the potential to reduce the morbidity associated with ureteral stenting. Further research in the field seems to be mandatory.     

非结石因素导致肾积水的治疗体会（附103例报告）

目的：分析非结石因素导致肾积水的病因，探讨其外科治疗方法。方法：对2004年5月～2007年5月收治的103例非结石因素导致肾积水的患者临床资料进行回顾性研究，其中行肾切除术者18例，肾盂输尿管成形术22例，输尿管狭窄钬激光切开术16例，输尿管球囊扩张术3例。置双J管内引流5例，肾、膀胱造瘘术17例，其他方法14例，观察等待8例。结果：术后随访4～8周．复查B超、IVU了解术后情况。除8例患者经治疗后症状无缓解，肾功能恢复不佳，需进一步治疗外，其他患者近期效果较好，症状和肾积水情况改善或无进展。结论：在积极进行病因治疗的同时，对于不同程度的肾积水．应采取不同的治疗手段。     

Forgotten DJ stent presenting with emphysematous pyelonephritis: A life threatening complication

IntroductionEmphysematous pyelonephritis (EPN) is an uncommon suppurative infection of renal parenchyma and perirenal tissue characterized by production of gas within renal parenchyma, collecting system or perinephric tissue.Case presentationWe report a case of young non diabetic female with past history of extracorporeal shock wave lithotripsy (ESWL) who presented with intermittent lower abdominal pain, dysuria and left lower limb swelling. Abdomen examination was notable for tenderness at left iliac fossa and fullness at left renal angle. Blood investigation showed leukocytosis and deranged creatinine levels. Urine analysis showed pyuria. Transabdominal ultrasound revealed left nephrolithiasis with moderate hydronephrosis, vesical calculus and double J (DJ) stent in situ. Patient was diagnosed as acute pyelonephritis and started on intravenous antibiotics. Despite on medical management, the condition deteriorated and progressed to septic shock. Computed tomography of kidneys, ureters and bladder (CT KUB) showed air fluid level in calyceal system with perinephric collection and confirmed diagnosis as emphysematous pyelonephritis. Patient underwent surgical drainage to control the sepsis. Few days later after control of sepsis and optimization, left nephrectomy and removal of retained DJ stent was done.Clinical discussionThis case report highlights the need to consider emphysematous pyelonephritis as a possible diagnosis in patients harbouring DJ stents even in young non diabetics. Early aggressive medical management coupled with urological intervention is a valuable alternative to upfront emergent nephrectomy. However, surgery should not be delayed in patient with fulminant infection at presentation or who failed on conservative management.ConclusionEmphysematous pyelonephritis warrants high index of suspicion for timely diagnosis and can be fatal if not recognized early and promptly treated.     

Spontaneous rupture of a hydronephrotic kidney during pregnancy

Acute abdominal pain during pregnancy can be of urologic origin. Hydronephrosis of pregnancy can be complicated by symptomatic renal colic, pyelonephritis, and secondary renal abscess formation. In this report, rupture of a hydronephrotic kidney with retroperitoneal urinoma formation was treated by retroperitoneal drainage and internal ureteral diversion until a term delivery was achieved. However, if severe renal hemorrhage accompanies renal rupture, surgical exploration of the kidney with partial or complete nephrectomy may be necessary.     

Endoscopic biliary stents and obstructive jaundice

Eighty-four patients with obstructive jaundice due to various causes were treated with endoscopically placed plastic stents. Seventy-two patients had malignant obstructive disease, 5 patients had common bile duct stones, 4 patients had bile duct injuries, and 3 patients had inflammatory processes resulting in common bile duct obstruction. Straight as well as double pigtail stents ranging from 9 to 12 F. were used. Restenting was employed only in patients with malignancy, and the longest period of a single stent drainage was 406 days with the average of 132 days. There was one procedure-related mortality in a patient with pancreatic cancer in whom the stent was misplaced. Inadequate drainage resulted in cholangitis and death. There were 14 nonfatal complications which included 1 myocardial infarction, 2 liver abscesses, 2 early closures (at 8 and 18 days), 1 episode of cholecystitis, 3 displacements of the stent which required restenting, and 4 spontaneous passages of the stent through the gastrointestinal tract. There were no perforations and no significant bleeding was encountered.