Overview
Definition:
Ureteric stent placement involves inserting a thin, hollow tube into the ureter to bypass an obstruction, facilitate urine flow, and promote healing
Perioperative care encompasses the management of patients before, during, and after the procedure to optimize outcomes and minimize complications.
Epidemiology:
Ureteric stents are commonly placed for various reasons, including ureteral stones, strictures, post-surgical drainage, and management of intrinsic or extrinsic ureteral compression
The incidence of stent placement is high, with millions of procedures performed globally each year.
Clinical Significance:
Effective perioperative management is crucial for preventing immediate and long-term complications, ensuring patient comfort, and facilitating successful recovery
This knowledge is vital for surgical residents preparing for high-stakes examinations like DNB and NEET SS.
Indications And Contraindications
Indications:
Management of ureteral stones causing obstruction or pain
Treatment of ureteral strictures
Post-operative drainage after ureterolithotripsy, ureteroscopy, or pyeloplasty
Management of extrinsic compression of the ureter by tumors or fibrosis
Temporary diversion during other urological procedures.
Contraindications:
Active urinary tract infection (relative contraindication, requiring treatment first)
Ureteral avulsion or severe injury where stenting may not be feasible
Known allergy to stent material (rare)
Absolute contraindication is lack of identifiable ureteral lumen for insertion.
Preoperative Preparation
Patient Assessment:
Detailed medical history including comorbidities, allergies, and previous urological procedures
Complete physical examination
Assessment of renal function with serum creatinine and estimated glomerular filtration rate (eGFR)
Urine culture and sensitivity to rule out infection.
Imaging:
Review of pre-procedure imaging (CT Urogram, IVU, Ultrasound) to delineate the anatomy, location and cause of obstruction
Plain X-ray KUB to identify radiopaque stones if relevant.
Patient Counseling:
Informed consent explaining the procedure, potential benefits, risks, alternatives, and expected recovery
Discussion about potential stent-related symptoms like flank pain, urgency, and frequency.
Prophylactic Antibiotics:
Administration of broad-spectrum intravenous antibiotics 30-60 minutes prior to the procedure to reduce the risk of bacteriuria and urosepsis
Common choices include fluoroquinolones or cephalosporins, guided by local resistance patterns.
Procedure Overview
Anesthesia:
Typically performed under general anesthesia or spinal anesthesia, depending on patient factors and surgeon preference
Local anesthesia with sedation may be used in select cases for simpler procedures.
Access And Guidance:
Access is usually gained via the urethra and bladder
A guidewire is advanced into the ureter under cystoscopic or fluoroscopic guidance
The stent is then threaded over the guidewire and positioned across the obstruction.
Stent Placement Techniques:
The choice of stent material (e.g., silicone, polyurethane), length, and diameter is based on patient anatomy and the nature of the obstruction
Double-J stents are most common, with one curl in the renal pelvis and the other in the bladder.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and pain levels
Assessment for signs of infection, bleeding, or urinary retention
Adequate hydration is encouraged.
Pain Management:
Administration of analgesics (e.g., NSAIDs, paracetamol) to manage post-operative pain and stent discomfort
Opioids may be required for severe pain
Antispasmodics can help with bladder irritation.
Antibiotics:
Continuation of prophylactic antibiotics for 24-48 hours postoperatively, or as per institutional protocol
Subsequent outpatient management of potential urinary tract infections.
Activity And Diet:
Encourage mobilization as tolerated
Generally, no specific dietary restrictions, but adequate fluid intake is important
Advise patients to avoid heavy lifting or strenuous activities for a few days.
Complications
Early Complications:
Hematuria (gross or microscopic)
Dysuria, urinary frequency, and urgency (stent symptoms)
Ureteral colic or flank pain due to stent migration or bladder irritation
Urinary tract infection (UTI) or urosepsis
Inadvertent stent migration or dislodgement.
Late Complications:
Stent encrustation and calculus formation
Ureteral stricture formation at the site of the stent
Bladder irritation and chronic discomfort
Chronic flank pain
Rarely, ureteral perforation or avulsion during insertion or removal.
Prevention Strategies:
Meticulous technique during insertion
Use of appropriate stent material and size
Adequate hydration postoperatively
Prompt treatment of UTIs
Regular follow-up for stent removal or exchange
Patient education on recognizing and reporting symptoms.
Stent Removal And Follow Up
Timing Of Removal:
Stents are typically removed after a period ranging from a few days to several weeks, depending on the indication
Removal is usually done via cystoscopy under local anesthesia.
Follow Up Schedule:
Post-removal follow-up often involves repeat imaging (e.g., ultrasound, KUB X-ray) to confirm resolution of obstruction and assess for any residual issues
Long-term follow-up is dictated by the underlying condition.
Patient Education For Removal:
Patients should be informed about the date and method of stent removal
They should be advised to report any significant increase in pain, fever, or hematuria prior to the scheduled removal.
Key Points
Exam Focus:
Understanding indications, contraindications, prophylactic antibiotic use, common stent symptoms, management of complications like encrustation and infection, and timing of stent removal are high-yield for DNB/NEET SS exams.
Clinical Pearls:
Always ensure adequate hydration post-procedure
Educate patients thoroughly about expected stent symptoms to reduce anxiety
Proactive management of flank pain with analgesics and antispasmodics is essential for patient comfort
Timely stent removal prevents encrustation.
Common Mistakes:
Failure to obtain urine culture before placement in suspected UTI
Inadequate prophylactic antibiotic coverage
Ignoring significant stent-related symptoms
Delaying stent removal leading to encrustation
Improper stent sizing or positioning.