XI. Surgical Procedures: Insertion of a JJ Stent

I.  Introduction

The goal of inserting a JJ stent is to relieve upper urinary tract obstruction (UTO).  The causes of UTO are numerous, but the most common causes are stone disease and extrinsic compression from non-urologic neoplasms.  

II. Technique

We will first detail the procedure for inserting a new JJ stent for UTO.  The method for replacing a JJ stent is very similar and will be mentioned briefly separately.

1. After performing a complete cystoscopic examination and identifying the ureteral orifice for the kidney that is obstructed, an open-ended ureteral catheter is placed into the appropriate distal ureter so that a retrograde pyelogram (RPG) can be performed to delineate the anatomy of the collecting system as well as the point of obstruction.  A wire is then placed through the ureteral catheter, and the wire and catheter are navigated up into the desired kidney past the point of obstruction under fluoroscopic and cystoscopic guidance.  The choice of wire is at the discretion of the operating urologist; we use a 0.038 Guidewire.  (See review of wires under ureteroscopy Atlas.)  Also, we use an open-ended ureteral catheter during this portion of the procedure because it can reduce ureteral mucosal trauma as well as providing backing for the wire, especially when one has to navigate a very tortuous ureter, similar to the one in Figure 1.  If one is having a very difficult time negotiating a tortuous ureter, either a Glidewire or Sensor tip wire can be substituted.

Figure 1.  Retrograde pyelogram demonstartaing severe hydronephrosis with a markedly tortuous ureter. Note how the ureteral catheter cannot navigate the kinking of the ureter.

 2. Once one has gained access to the kidney past the obstruction, one can either insert a dual-lumen access catheter over the existing wire or remove the wire from inside the open-ended ureteral catheter to perform another RPG if needed.  The benefits of a dual-lumen access catheter is that you can perform a RPG without potentially losing access as well as place another wire through the second port or collect cytology.

 3. With access gained, a JJ stent can then be chosen.  The appropriate stent length is a function of the patient’s height.  In general, a 6x24 stent will suffice for the vast majority of patients.  If one is going to err, err in choosing a longer stent because you can coil the extra length in the dilated collecting system or in the bladder.

 4. The JJ stent can be then placed under a combination of cystoscopic and fluoroscopic guidance or solely under fluouroscopic guidance. 

 5. Many people still prefer to use the cystoscope during stent placement.  In that case, if the cystoscopic sheath is no longer in the patient’s bladder, backload the wire through the sheath.  The sheath then can be passed over the wire into the bladder without the cystoscope much as you would pass an urethral sound.  The wire then can be backloaded through a working bridge as one attaches the cystoscope.  Some attendings do not like residents or fellows to blindly pass the sheath, so one may have to attach the sheath and cystoscope and backload the wire through the working bridge.  Cystoscopic access to the bladder can then be attained under direct vision.

Figure 2.  Placement of two JJ stents in renal pelvis. The proximal curls are well-placed. During the placement, the assistant surgeon will begin to slowly remove the wire to assure the curls as we see in the the figure. Once the curls are well-placed, attention will be placed directed to ensure appropriate cystoscopic placement of the distal curls in the bladder.

 6. Once the cystoscope is in place, the JJ stent is passed over the wire up until its distal end becomes flush with one of the nipples of a port of the working bridge.  The pusher is then advanced up to the JJ stent.

 7. At this point, it is very important that the surgeon and the assistant work in unison.  We usually prefer to have the surgeon look in the bladder while the assistant monitors fluoroscopy.  Communication is a must!

 8. The surgeon then uses the pusher to advance the stent up into the kidney.  He/she will do so until the second thick black mark denoting the distal end of the stent is seen.  The surgeon will keep the cystoscope looking at the ureteral orifice with irrigation running slowly so that vision is clear without overdistending the bladder.

 9. Once the second black mark is seen, the assistant will give the surgeon an idea of where the stent is in the kidney.  If the proximal end of the stent is located adequately in the renal pelvis, the assistant will slowly pull the wire under fluoroscopy to assess the location of the proximal curl. (Figure 2)  If adequate, the surgeon will then move the cystoscope back to the bladder neck and wait until the junction between the stent and pusher is seen.  Once seen, the wire can be pulled.  The distal curl can then be visualized in the bladder.

10.  There are a few tips you can use if there is trouble negotiating the point of obstruction.  First, it is imperative that the assistant is holding the wire tightly ensuring that there is no slack.  Second, one can place the nose of the cystoscopic sheath at the ureteral orifice on the stent to give “backing”.  Third, one can use the pusher to tap on the distal end of the stent with short forceful bursts.  This technique can be useful when negotiating an impacted stone.  Finally, if one is having a great deal of difficulty, the bladder can be emptied and the sheath can be placed right at the ureteral orifice and turned so that the stent is pressed up against the bladder wall.  At this point, one should try use short tapping bursts on the stent with the pusher.  All these steps usually result in bypassing the obstruction.

11.  If one prefers to use fluoroscopic guidance only for stent placement, the steps are essentially the same.  The key difference in using fluoroscopy is to know the landmarks at which to pull the wire.  The proximal end of the pusher has a metallic marker that can be seen radiographically.  This marker indicates the junction between the pusher and the distal end of the stent.  In a male, this interface should be seen at the top of the pubic symphysis before pulling one’s wire. (Figure 3)  In the female, one can use either a midpoint between the pubic symphysis and the midline of the inferior pubic arch or simply just use the midline of the inferior pubic arch. (Figure 3)

Figure 3.  Bony pelvic anatomy denoting location of where radioopaque marker on the pusher should be when removing the wire while placing a JJ stent under fluoroscopic guidance only. Note the appropriate placement of the distal curl in the bladder.

12.  The procedure for replacing a JJ stent is essentially the same as described above.  There are only a couple points that require comment.  First, when removing the indwelling JJ stent, grab the distal curl as close to the tip as possible.  Some urologists will pull the whole cystoscope out with the JJ stent to minimize the chance of losing access.  Others will simply pull the stent out through sheath.  Use fluoroscopy as you pull the stent out to ensure continued ureteral access.  Finally, placing a wire through the existing stent can be troublesome due to calcifications/debris.  Here are some helpful tips to try:  (1) cut the distal end of the stent that is outside the meatus—sometimes the calcifications are only distal; (2) use the stiff end of the Guidewire—if there is loose debris, the stiff end may be able to push through it; and (3) if all else fails, place a new open-ended ureteral catheter into the ureter next to the indwelling JJ stent.

III. Complications

The most common technical complication associated with JJ stent placement is either ureteral or renal pelvic perforation.  If this occurs, simply complete the procedure for management.  If one cannot bypass the obstruction or access is lost and cannot be regained, a percutaneous nephrostomy tube will need to be placed to relieve the UTO.

 

This page was written for UrologyMatch.com by Daniel J. Canter, MD

Dr. Canter  is a graduate of the University of Pennsylvania Urology Residency Program.