Technical Note

Technical A Simplified Method for Migrated Ureteral Stents

Repositioning

Note

Distally

Brian 0. CoIey1 and Mark J. Hogan

T

he use ofureteral

et al. in 1967

stenting

is typically

[1]. In pediatrics, performed

teral stunt placement involving the distal

which

are rare,

we

disease

report

have devised these stents

oroscopy

suite,

ing room

and cystoscopy.

Patient

ureteral

for stone

two

boys with ureteral stunts in ends were malpositioned in the

posterior urethra. We method for repositioning

Subjects

practice,

by Zims-

and for difficult ureteropelvic Although complications of ure-

before lithotripsy junction repairs. cases

has become

the first description

since

kind

stunts

part of urologic

a standard

obviating

a return

a simple in the flu-

to the operat-

and Methods I

This 5-year-old boy was born prematurely and had a history of diuretic use for bronchopulmonary dysplasia

complicated

sis. After

conservative

by symptomatic management

nephrolithiafailed,

an open

nephrolithotomy was performed at a hospital that did not have pediatric stents. A 7-French ureteral stent, the smallest adult ureteral stent available, was placed. The patient was transferred to our institution for postoperative

care,

where

he complained

of moderately

severe pelvic and perineal pain. An abdominal film revealed the distal end of the ureteral stent to be within

the posterior

urethra

(Fig.

1A). Because

ofthe

patient’s pulmonary status, the urology service sought to avoid another general anesthetic exposure. Received 1 Both

January

Fig. 1-5-year-old boy (patient 1) with ureteral stents. A, Distal end of internalized stent is within posterior urethra (arrowheads). Also seen is second externalized stent with tip near right ureterovesical junction (arrow). B, Guidewire has been placed into urethral catheter (arrow), balloon inflated with contrast material, and stent pushed back into bladder (arrowheads).

The patient was brought

to the interventional

radiol-

sedation was achieved with IV sodium pentobarbital and morphine. A Foley catheter and the glans penis were sterilized and a loogy suite

and conscious

1% lidocaine gel. was injected into the urethra. With gentle traction on the Foley catheter, a 0.035-inch straight guidewire (SF-35-80: Cook,

cal anesthetic,

Bloomington,

IN)

was advanced

under

fluoroscopic

13, 1997; accepted without revision February 14, 1997.

authors: Children’s

Radiological

Institute,

Columbus Children’s

Hospital,

700

Children’s Dr., Columbus,

OH 43205. Address

correspondence

to B. D. Coley.

AJR1997:169:567-568 0361-803X/97/1692-567 ©American Roentgen Ray Society

AJR:169, August 1997

567

Coley

and

Hogan

stents,

Aubert

distal rected

[21 reported

et al.

the stent

external

to the

patient.

edge, no other reports correct distal migration ureteral

to push

the stent.

through

the

amount

tal to the stent,

of contrast

material

was

used

to opacify

and

distend the Foley balloon. The stiffened Foley catheter was advanced, and the stent engaged and pushed back

into

the

bladder

(Fig.

IB)

where

it reformed

and remained in satisfactory position ftr the remainder of the patient’s care. Symptoms of pelvic and perineal pain resolved after stent repositioning.

Patient

2

from

the 4.5-French

stent

after

placement.

A

radiograph obtained during recovery showed the distal end of the stent to be within the prostatic urethra (Fig. 2A). The patient was brought to the interventional

radiology

suite

and

local

preparations

and anesthesia were performed as in patient 1 . No additional sedation was used because the patient was

platz

recovering

568

from

guidewire

(Medi-Tech,

support.

catheter was brought With

back

As into

and the balloon

advancement

before,

the

Foley

the urethra

just

was gently

inflated.

of the Foley

catheter

and

dis-

with

Watertown.

general

a 6-cm MA)

anesthesia.

soft

An

straight

was placed

Am-

end

through

the

PD,

teral splints I 20:840-844

Discussion

in children, they are still useful in certain cases of hydronephrosis [2] and stone disease. While generally well-tolerated by patients,

ureteral

and stent with

uncommon, reported,

many including

erosion, stone proximal migration manipulation either

approaches

transurethral

focus

complications stent fracture,

formation, [4]. Most on

reports

[6, 7] after proximal

of

retrieval

stent migraureter.

and was technique

cystoscopy

in

well-tolerhas

ad-

because

it of

Fetter

In

ureteral

TR,

Wilkerson

indwelling

inserted

JL. Clinical

silicone

cystoscopically.

rubber

ure-

J Uro! 1967;

ureteral

stents. J Urn! 1988:139:37-38 M, Pattnaik PK. Knotted

Kundargi P. Bansal per

end:

a new

complication

in

dwelling ureteral stent. J Uro! 5. Low RK, Kogan BA, Stoller retrieval

double-J

[5, 6] or percutaneous

tion from the bladder into the distal a review of 16 children with double-J

4.

wire

knotting,

stent

cases.

repositioning

2. Aubert D, Rigaud P. Zoupanos G. Double pigtail ureteral stent in pediatric urology. Eur J Pediatr Surg 1993;3:281-283 3. Pollard 5G. Macfarlane R. Symptoms arising from double-J

some may experience urinary tract symptoms and pain with indwelling ureteral stents [3]. been

support

in both

References use of long-term

Although

and ure-

avoids general anesthesia and the expense an operating room and staff.

I. Zimskind

have

stents

This

repeat

stiff

fluoroscopic

puncture

simple

department

over

not

a guidewire

the stiffening

by the patients.

vantages

catheter

was

wire,

the stent was engaged and pushed into the bladder where it reformed normally (Fig. 2B).

Ureteral stents are common in adult urologic practice. Although less frequently used

This 5-year-old boy had a duplication ofthe left renal collecting system and obstructive hydronephrosis of the lower pole moiety. He underwent pyeloplasty and ureteral stenting via cystoscopy, with the urologist reporting difficulty removing the wire

stiffening

to of

the stent in

(with

catheter

allowed

the radiology to

of

knowl-

Foley

Placing

catheter

to reposition

method

the catheter

provided

injury)

ated provide

Foley

to avoid

required

control

with

enough

thral

under fluoroscopic

portion

To our

to reposition

the soft

guidance

the Foley catheter

of cor-

describe techniques or malpositioning

However,

alone.

control to the tip of the catheter. The balloon was deflated and the catheter withdrawn just distal to the ureteral stent within the posterior urethra. A small

attempt

I was made

patient

Our

girl,

stents.

Our first

Fig. 2-5-year-old boy (patient 2) with ureteral stent A, Postoperative radiograph shows ureteral stent within posterior urethra (arrow). B, After manipulation with urethral catheter, stent has reformed and is normally positioned (arrow).

one case

migration in a 1-month-old by excision of the exposed

of a proximally

ureteral

stent.

the

use

upan

in-

1994;l5l:995-996

ML. migrated

J Uro!

of

Intraluminal pediatric

1995; 154:223-224

6. Slaton JW, Kropp KA. Proximal ureteral stent migration: an unavoidable complication? J Urn! 1996; 155:58-61 7. LeRoy AJ, Williams HJ Jr. Segura JW, Patterson DE. Benson RC Jr. Indwelling ureteral stents: percutaneous management of complications. Radio!ogv

1986;

158:219-222

AJR:169, August 1997