Knowledge of when and how to place a ureteral stent is an important skill for practicing urogynecologists. This training, however, is highly variable amongst fellowship programs. The objectives of this video are to describe ureteral stent selection, to discuss the necessary tools needed for ureteral stent placement, and to demonstrate a technique for successful stent placement. Between 50 and 90% of urinary tract injuries occur following gynecologic procedures. Recent work has demonstrated that the rate of ureteral injury in women who undergo pelvic surgery may range from 0.2 to 17.3 per 1,000 surgeries. Early recognition is essential. Failure to do so can lead to significant morbidity such as ureterovaginal fistula, hydronephrosis, or loss of kidney function. Morbidities associated with stent placement include pain, urinary urgency, and decreased work capacity. With this in mind, it is important to choose the appropriate ureteral stent. The ideal stent would be one that had the following characteristics. Appropriate stent size selection helps to minimize medical morbidity associated with placement. Several approaches have been developed to assist surgeons with selecting proper stent size. A helpful aid is the table displayed here, linking patient height to stent length. The following formula may be used to calculate appropriate stent size, again, based on patient height. The patient height in inches, minus 42, equals the stent length in centimeters. Another method is direct ureteral measurement using fluoroscopy to determine the distance from the ureterovesical junction to the ureteropelvic junction. Other stent characteristics to remember include width, stiffness, presence of hydrophilic coating, and presence of coiling at proximal or distal ends. While they may be inserted with greater ease, stents with smaller widths and hydrophilic coating may have a higher rate of migration. Coiling can prevent stent migration, however too much coiling at either end can be associated with medical morbidity. A stent commonly used is a 6 French polyurethane double J stent with coiling at both proximal and distal ends. The strings attached to the distal end may aid in intra-office stent removal. Equipment necessary for ureteral stent placement includes a cystoscope, the appropriate ureteral stent, and fluoroscopy or other imaging modality to ensure proper placement. Here, assembly of the working cystoscope is demonstrated connecting the telescope, the bridge, and the sheath. Each component of this unit can be varied depending on the procedure being performed. In the case of ureteral stent placement, a 30 degree scope, a simple bridge, and an open-ended 20 to 22 French sheath prove very helpful. The 30 degree scope provides an excellent view of the bladder base and posterior bladder wall. This often facilitates safe ureteral stent placement. Other instruments needed are a guide wire, an open-ended catheter, and a pusher. Here we demonstrate ureteral stent placement using live video and graphic animation. An open-ended catheter is inserted through the cystoscope. The catheter is advanced approximately two centimeters into the ureteral orifice as indicated by the centimeter spaced markings. With the open-ended catheter still in place, a guide wire is inserted all the way to the renal pelvis with the help of fluoroscopy. The catheter is removed. An appropriately sized ureteral stent is inserted. A pusher is used to advance the stent up to the renal pelvis. The guide wire is slowly pulled out and a curl is noted in the renal pelvis. When the guide wire and the pusher are completely removed, a curl is noted in the distal end of the stent sitting in the bladder. A pylogram demonstrates the stent curl in the renal pelvis indicating proper placement. Cystoscopy is used to capture the 180 degree stent curl in the bladder. In conclusion, this video provides guidance on ureteral stent selection and familiarizes the viewer with equipment necessary for successful ureteral stent placement. The demonstration of stent placement presented here may prove helpful to practicing urogynecologists and urogynecologists in training.

ureteral stents

urogynecologists

training variability

urinary tract injuries

stent selection