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FUNDAMENTALS OF URINARY TRACT
DRAINAGE- CATHETERS, STENTS, PCN
TUBES
Dr. Prashant Kumar Chauhan
Lucknow, India
INDEX
Lower urinary tract drainage
Transurethral catheter
Supra pubic catheter
Upper urinary tract drainage
Ureteric stents
PCN tubes
Transurethral catheter
 History
 Indications
 Catheter selection
 Catheter design
 Types of catheters
 Techniques of catheterization
 Difficult catheterization
 complications
Brief History
 The word “catheter” comes from Greek, meaning “to let or
send down.
 Catheters were used as early as 3,000 B.C. to relieve painful
urinary retention.
 In those times, many materials were used to form a hollow
catheter shape, including straw, rolled up palm leaves,
hollow tops of onions.
 Malleable catheters were developed in the 11th century.
 Coudé tip catheters were developed in the 18th and 19th
centuries to facilitate male catheterization.
 After World War II, Sir Ludwig Guttman introduced the
concept of sterile intermittent catheterization in patients with
with spinal cord injury after World War II.
Benjamin the inventor of modern catheter
 Benjamin Franklin, the
inventor and colonial
statesman, fashioned silver
catheters for use by his older
brother John.
 John suffered from kidney
stones and needed to
undergo a daily ritual of
placing a bulky metal
catheter into his bladder.
 Franklin worked with his
local silversmith on his design
for a flexible catheter.
INDICATIONS
Conveniently be divided into two
categories:
Diagnostic
Therapeutic
THERAPEUTIC
Acute or chronic urinary retention
neurological conditions, Bladder outlet
obstruction
Gross haematuria
bladder irrigation and drainage of bloody
urine and blood clots
Urethral stricture
Dilation with urethral catheters
Intravesical therapy
Dimethyl sulfoxide for interstitial cystitis
Alum for intractable haematuria
Mitomycin C or bacilli calmette-guérin
solution for non-muscle invasive bladder cancer
DIAGNOSTIC
Monitor urinary output
in critically ill or post-operative patients
Postvoid residual urine volume
 the most accurate method of measurement
Intravesical and urethral pressure
as in urodynamic studies
Thermometer-tipped catheters
during prolonged surgeries for
thermometry and adequate drainage
Retrograde cystography
To opacify the urinary tract for diagnostic
purposes
CATHETER
SELECTION
A wide variety of catheters are
available for transurethral
catheterization. These vary in the
following
Differences in materials used in
manufacture
Variations in length
Circumference
Shape of the catheter tip
Number of channels
Varieties of coatings
CATHETER
DESIGN
AND SIZE
The choice depends on
The indication for use
Expected fluid requiring drainage
Anticipated indwelling time
Age
Previous history
Patient anatomy
One should choose the smallest size
available based on these variables.
The golden rule is to use the smallest catheter size.
The use of large-size catheters (18 Fr or larger) is not
recommended
more erosion of urethral mucosa
stricture formation
do not allow adequate drainage of periurethral gland
secretions
causing a build up of secretions that may
lead to irritation and infection
large catheters can cause pain and discomfort
CATHETER
DESIGN
Single lumen :
basic catheter design is constructed
with a single lumen to allow for
drainage or instillation.
Double lumen :
most frequently used retention
mechanism is the retention balloon,
which is inflated through a
dedicated channel.
CATHETER
DESIGN
Triple lumen :
simultaneous instillation and
drainage of fluids
haematuria, clot retention and
pyuria
haemostasis after TURP
compressing vessels at the bladder
neck
Three-way, two-way, and single-lumen catheters
MATERIALS
AND
COATINGS
Rubber
Latex
Silicone
Polyvinylchloride (PVC)
Silicone-coated latex catheters
Hydrophilic-coated catheters
Bacterial-coated catheters
Antibiotic-impregnated catheters
Silver Alloy-Coated Catheters
Rubber
Rubber catheter red in colour
Contains high Sulphur
Heat resistant
Causes more irritation
Latex
Softer
Smooth
High stretch index
Insoluble in urinary medium
It can be kept for long time
Increases in allergies -skin irritation,rashes, blisters
Urethritis and urethral strictures
Silicone
Relatively inert
Silicone catheters are thin-walled
Rigid catheters
Larger diameter drainage lumen
Silicone-coated latex catheters
Silicone-coated latex catheters have a chemically
bonded coating of silicone elastomer.
Hydrophilic-coated catheters
Absorb water to produce a slippery outside surface
Less discomfort
Fewer traumatic catheterizations
Decreased incidence of symptomatic urinary tract
infections (UTIs)
Decreased incidence of urethral strictures
Antibiotic-impregnated catheters
Antibiotic-impregnated catheters may delay
bacteriuria in short term catheterization (<1 week).
Bacterial-coated catheters
Bacterial-coated catheters have the theoretical
benefit of colonizing the urine with a nonvirulent
strain of Escherichia coli.
Silver alloy-coated catheters
Silver alloy-coated catheters have a bacteriostatic
effect because they reduce microbacterial
adherence and migration of bacteria to the bladder.
These catheters also minimize biofilm formation
through their release of silver ions that prevent
bacteria from settling on the surface.
There appear to be few adverse effects and
microbial resistance to the active agent is unlikely.
TYPES OF
URETHRAL
CATHETERS
• Simple rubber catheter (K90 = 14 Fr,
K91 = 10 Fr, Teiman,Nelaton catheter).
• Metallic catheters
Simple
catheters
(Non
indwelling)
• Foley catheter
• Gibbons catheter
• Malecots catheter
• Pig tail catheter
Self-
retaining
catheters
FOLEY
CATHETER
Foley catheter is a self-retaining
catheter because of balloon
mechanism at the end, balloon
connected to a nozzle with a valve
mechanism to the other end through a
small tube running through the wall of
catheter.
Fundamentals of urinary tract drainage
Dr. Frederic Basil Foley
The name came from the designer,Dr
Frederic Basil Foley, a surgeon
working in Boston, Massachusetts in
the 1930s.
His original design was adopted by C.
R. Bard, Inc., who manufactured the
first prototypes and named them in
honor of the surgeon.
Fundamentals of urinary tract drainage
Uses:
Urinary drainage
To irrigate the bladder
To administer chemotherapy
In urological surgery or other surgery on
contiguous structures
To obtain accurate measurements of urinary
output in critically ill or post-operative patients
To undertake urodynamic studies
Other uses
EXTRA-AMNIOTIC
SALINE INFUSION
 A foley catheter can also be used to
ripen the cervix.
 The balloon is inserted behind the
cervical wall and inflated.
 The catheter is pulled slightly taut and
taped to the inside of the woman's
leg.
 As the cervix dilates over time, the
catheter is readjusted to again be
slightly taut and retaped to maintain
pressure. When the cervix has dilated
sufficiently, the catheter drops out.
CONTROL OF
EPISTAXIS
They are also used
in cases of
severe epistaxis to
block blood from
freely flowing
down the nasal
passage into the
mouth.
ROBINSON
CATHETER
It is a straight rubber tube catheter.
The tip of the Robinson catheter is
rounded.
with one or two drainage ports along
the side.
If a Robinson catheter is left indwelling,
it must be secured to the glans penis
by suture or tape.
It is radiopaque due to lead oxide
content.
Available in 8–22 Fr size.
ROBINSON CATHETER
USES :
 short-term catheterization
 as in measurement of residual urine and
instillation of medication, chemotherapeutic
or contrast material into the urinary bladder
 intermittent self-catheterization
 chronic urinary retention
COUDE
CATHETER
Also known as Delinotte tip or Mercier
tip
This is curved at the tip (French word
for “elbow”).
Catheter is slightly stiffer than the
Robinson catheter.
Coude catheters are manufactured with
and without retention balloons.
COUDE CATHETER
 USES :
Same as for Foley catheter (but typically used after failure of
Foley placement) in a man with an enlarged prostate.
Coude catheter navigates the S-shaped curve of the bulbous
urethra, which is exaggerated in BPH.
Hypertrophied or strictured bladder neck. The curved shape
of the coude catheter is designed to guide it over the bladder
neck.
History of urethral strictures is contraindication - higher risk
for false tracts
PEZZER
CATHETER
This is self-retaining with a mushroom-
shaped tip.
PEZZER CATHETER
USES :
It is most commonly used for suprapubic
cystotomy drainage. The catheter should be
secured to the skin by suture or tape
MALECOT
CATHETER
These catheters have a flower at the
end of catheter as self-retaining
mechanism.
“Mandarin” keeps the tip flat during
insertion and removal.
 These catheters are less secure then
Foley as they tend to fall out with firm
pull.
MALECOT CATHETER
USES :
Not used as urethral catheters, mainly used as
nephrostomy catheter.
Malecot's catheter can be kept for period of time (3
months)
It drains fluid adequately
Less infection rate
Removal is easy
 Suprapubic cystostomy (SPC)
 In case of urinary retention when foley’s
catheterization fails
 Prostate or urethral surgeries
 To drain abscess cavity
 Perinephric abscess
 Pyonephrosis
 Subphrenic abscess
 Amoebic liver abscess
 Nephrostomy
 Cholecystostomy
 Gastrostomy and caecostomy
Fundamentals of urinary tract drainage
WHISTLE-
TIP
CATHETER
Also known as Couvelaire tip catheter
This is a straight catheter with a
beveled opening at the tip and another
opening in the side.
WHISTLE-TIP CATHETER
 a
USES :
It provides better irrigation and drainage than the
Robinson catheter.
This catheter is open at the end and allows drainage of
large amounts of debris (e.g. blood, clots)
COUNCILL
CATHETER
These are similar to Foley catheters,
except that they have an opening at
the end to allow use with a screw-tip
stylet that can be attached to a filiform.
 Councill catheters are especially useful
when passage of any other type of
catheter is difficult.
COUNCILL CATHETER
USES :
This type of catheter is most commonly used in
bypassing a urethral stricture or false passage.
After a stricture is dilated with filiforms and followers,
the Councill catheter is attached to the filiform and
guided into the bladder. The stylet and filiform (or
guide wire) are then removed through the lumen of the
Councill catheter.
NELATON
CATHETER
Nelaton catheter is a simple tube with
rounded tip which ensures an easier
insertion
Holes at side and a connecting piece
at the opposite end to connect to a
collecting bag.
Most are made up of pvc
(polyvinylchloride)
Rigidity and radiopacity
NELATON CATHETER
USES :
Used to drain urine from the bladder temporarily in
retention of urine.
To find out residual urine. If it is more than 30-50 mL, it
signifies obstruction.
While doing cystography to infuse dye in to the Urinary
bladder.
To collect urine from the bladder for culture and
sensitivity.
Single gentle passage of the catheter is tried as a
diagnostic method to identify the urethral/ bladder/ renal
injuries. Haematuria signifies urinary tract injury.
For administration of intravesical chemotherapy.
To dislodge and push back the calculus impacted in the
urinary meatus or in the urethra.
Others
For suction of throat/endotracheal tube/
tracheostomy tube.
Can be used as tube drain.
CATHETER STYLETS
 are malleable metal guides that, when placed into a Foley or
other type of catheter, can be used to provide stiffness and
shape.
 There are two type of stylets—one with a blunt tip, used with
a Foley catheter, and one with a screw tip, used with a
Councill catheter.
 This procedure is useful to accomplish passage through a
urethral stricture or tight bladder neck.
 Catheter stylets also may be used following TURP to avoid
undermining the bladder neck. When a catheter stylet is used,
the bladder should always be full to avoid injuring the
posterior bladder wall.
TECHNIQUE OF URETHRAL
CATHETERIZATION
 After establishing the indication for catheterization, a
medical and surgical history, focusing on position at the side
of the patient corresponding to the physician’s dominant
hand (if the physician is right handed, the position is on the
right-hand side of the patient)
All materials expected to be required should be
readily available on the sterile drape.
The patient should be in supine position at a
comfortable height for the individual performing the
catheterization.
A frog-leg position is preferred for female patients.
When an indwelling catheter is being placed, the
balloon should be checked for integrity before
catheterization.
Lubrication of the catheter is advised for smooth
catheterization and minimization of risk of urethral
trauma.
 Four categories of lubricants exist:
Plain lubricant
Lubricant-anesthetic
Lubricant-disinfectant
Lubricant-anesthetic-disinfectant
 The systemic uptake of lidocaine through intact mucosa
reaches a very low peak concentration that never reaches a
toxic level. If toxicity occurs
confusion
lethargy
seizures
disorientation
anaphylactic shock.
The effect of lubricant can be enhanced
by
Cooling the lubricant to 4° C  a cryoanalgesic
effect
Slowly instilling (3 to 10 seconds)
A minimum amount of 20 ml of cooled lubricant
 Minimum of 15 minutes of exposure
CATHETERIZATION IN MALE PATIENTS
The true external
urethral meatus is
exposed by retracting
the foreskin if present.
In the presence of
phimosis
catheterization can be
attempted blindly with a
smaller-gauge flexible catheter
meatal stricture or
stenosis is apparent
passing a catheter of
a smaller size should
be attempted first
Gentle dilation of the
stenosis with sounds
can be attempted
After skin and meatus
preparation and sterile
draping to be done.
The initial maneuver is to
grasp the penis with the
nondominant hand, which is
from then on regarded as no
longer sterile.
 The pendulous curvature of the
penis is eliminated by pulling the
shaft upward. The catheter is
inserted into the meatus after
lubrication and advanced
approximately 7 to 12 cm.
 The penis should be brought into
a horizontal position, parallel to
the patient. Some slight
resistance can be appreciated at
the membranous urethra, the
most fragile segment.
The entire catheter is
introduced into the
penis, up to the
bifurcation of the
catheter and balloon
valve.
After verifying the
correct position of the
catheter in the
bladder, inflate the
balloon with sterile
water, which has been
demonstrated to be
the optimal filling
solution.
In uncircumcised
patients, the
foreskin is reduced
to its normal
position to avoid
paraphimosis.
The penis and catheter
should be taped in an
upright position to prevent
pressure ulceration from
occurring at the curve in the
pendulous urethra and
iatrogenic hypospadias at
the urethral Meatus.
Ideally, a closed circuit should be maintained with the
catheter connected to a sterile closed bag system,
positioned lower than the bladder to allow gravity to
assist in bladder emptying.
CATHETERIZATION IN FEMALE PATIENTS
 nondominant hand is used to spread the inner labia to
reveal the external urethral meatus.
 This hand is now considered contaminated.
 The urethral meatus should be found 1 to 2.5 cm inferior to
the clitoris.
 After the meatus has been cleaned and lubricated, the
catheter is inserted into the meatus and gently advanced
until approximately half the catheter has been inserted.
CATHETERIZATION IN CHILDREN
 Catheter use in children is predominantly for diagnostic
purposes or postoperative drainage.
 In infants, suprapubic puncture for obtaining a urine sample
is often preferred over a bag sample because it is more likely
to be sterile.
 Bladder catheterization, however, is preferred over
suprapubic aspiration because it is less painful and has a
higher success rate in obtaining a satisfactory urine sample.
 As in adults, it is useful to align the preputial opening with the
meatus to facilitate catheterization.
 Compared with women, the urethral orifice in young girls may
be partly obscured behind the hymen. To reveal the meatus, it
is useful to apply some downward pressure on the hymen.
DIFFICULT CATHETERIZATION
 This is commonly the result of an enlarged prostate or a
closed striated sphincter.
 The attempted catheter is retracted, and the catheter tip
evaluated for the presence of blood.
 If the catheter tip is clean, the next option is a 14-Fr or 16-Fr
silicone catheter because it is somewhat stiffer and may pass
the slight resistance more effectively.
 If blood is present at the catheter tip, there is a possibility of a
false passage and a coudé-tipped catheter should be used for
the next attempt.
 Although the female urethra is short, catheterization can be
challenging because of inability to find the urethral meatus.
 In obese patients or in patients unable to assume the frog-leg
position, the use of stirrups and assistance for retraction to
optimize visualization is advised and may be useful.
Fundamentals of urinary tract drainage
COMPLICATIONS
1. Catheter-associated urinary tract infection
2. Inability to deflate the Foley balloon
3. Pericatheter urine leakage
4. Accidental removal
5. Catheter blockage
6. Hematuria
7. Bladder stones
8. Urethral stricture
9. Bladder cancer
Catheter-associated urinary tract infection
(CAUTI)
From 15% to 25% of hospitalized patients undergo a
urethral catheter placement at some point during
their stay.
UTIs account for approximately 35% of hospital-
acquired infections.
CAUTI is defined as significant bacteriuria in a
patient with symptoms or signs indicating a UTI,
whereas asymptomatic bacteriuria refers to
significant bacteriuria in asymptomatic patients.
Asymptomatic bacteriuria does not require
antibiotic treatment
The most important risk factor for developing
CAUTI is prolonged catheterization(longer than 6
days)
Guidelines for preventing CAUTI
Avoidance of catheter use
Maintenance of a closed drainage system
Removal of a catheter as soon as possible.
Catheters should be placed under antiseptic
conditions
Smallest possible catheter with adequate
lubrication.
Routine irrigation should be avoided.
Inability to deflate the Foley balloon
Instilling an extra 1 or 2 ml of fluid in the balloon
and trying to repeat aspiration.
Cutting off the inflation valve may assist if the valve
is not functioning correctly.
If the balloon still does not deflate one can pass a
guidewire through the inflation channel to try and
perforate the balloon.
Ultrasound-guided needle puncture of the balloon is
typically the final approach.
Inability to remove a catheter with a fully deflated
balloon can also be caused by catheter encrustation.
The main causal factor of catheter encrustation is
infection with proteus mirabilis.
SUPRAPUBIC
CATHETER
DRAINAGE
INDICATIONS
Suprapubic catheterization is indicated (when
transurethral catheterization is contraindicated or
technically not possible
Urethral injuries
Urethral obstruction
Bladder neck masses
Benign prostatic enlargement
Prostate cancer
Short-term suprapubic catheter placement is often
useful in postoperative situations after urogenital
surgery to allow for bladder or urethral tissue
healing.
In patients requiring a long-term indwelling catheter
in whom CIC is not feasible, a suprapubic catheter is
often a better option than a transurethral catheter.
CONTRAINDICATIONS
Previous lower abdominal surgery resulting in
unsafe percutaneous passage to the bladder
Bladder cancer
Uncorrected coagulopathies or anticoagulation
Abdominal wall infection at the desired site
Pelvic cancer with or without pelvic radiation
(increased risk of adhesions)
TECHNIQUE OF SUPRAPUBIC
CATHETER PLACEMENT
PERCUTANEOUS
For suprapubic catheter placement, the patient
should be placed in supine position at a
comfortable height for the physician.
In most patients the distended bladder displaces the
intraperitoneal bowel loops out of the pelvis and
away from the pubic symphysis.
A minimum bladder volume of 300 mL on bladder
scan is advised before suprapubic catheter
placement is attempted
 The patient’s infraumbilical abdomen should be prepared and
draped in a sterile fashion. In performing blind puncture, the
symphysis should be palpated and the access site should be
chosen approximately one to two fingerbreadths above the
symphysis.
 In obese patients with an abdominal pannus, placement of
the tract in a skin fold is avoided to prevent dermatitis.
 Local anaesthetic is injected into the skin and along the
preferred trajectory using a 10- to 20-mL syringe and an 18-
gauge needle.
 The tract should be almost perpendicular to the skin.
Aspirating urine will confirm access to the bladder.
 A midline 5- to 10-mm transverse incision is made at the
injection site.
SELDINGER TECHNIQUE
 The safest technique for catheterization is the Seldinger
technique.
 A floppy-tip guidewire is advanced into the bladder through
an 18-Fr access needle.
 The percutaneous tract is dilated with coaxial dilators.
 A Cope loop or Councill catheter can be placed over the
guidewire into the bladder after the tract is dilated.
Fundamentals of urinary tract drainage
TROCAR TECHNIQUE
 The trocar technique employs a peel-away trocar that
envelops the catheter.
 The trocar should be advanced firmly but under steady
control of the trocar.
 Once entry into the bladder has been confirmed by urine
flashback or aspiration, the catheter is advanced completely
into the bladder, and the trocar is retracted and peeled away.
 If the suprapubic catheter does not have a retention
mechanism, the catheter is sutured to the skin.
Fundamentals of urinary tract drainage
Open Suprapubic Cystostomy
Open suprapubic catheter placement should be
undertaken when a percutaneous technique cannot
be performed safely.
After the infraumbilical abdomen is prepared and
draped, a small incision is made about one to two
fingerbreadths above the pubic symphysis,
providing access to the retroperitoneal space of
Retzius.
Two stay sutures are placed to stabilize the bladder,
and a small incision is made through the bladder wall
between the sutures, allowing for easy passage of a
16- to 18-Fr catheter.
 The catheter should be introduced through the skin
in line with the bladder incision to prevent kinking
and should be secured in the bladder with a purse
suture to prevent urine extravasation.
COMPLICATIONS
Haematuria
Leakage of urine
Accidental catheter loss
Frequent blockage of a suprapubic catheter
Excessive granulation tissue at the suprapubic tract
URETERAL STENTS
URETERAL STENTS
The first appearance of the term “stent” in the
literature originated from a new dental impression
material described by an English dentist, Charles T.
Stent.
The use of ureteral stents in surgery was described
as early as the 19th century
The first urologist to access the ureter
endoscopically was Dr. James Brown at Johns
Hopkins Hospital in 1893.
Zimskind, however, in 1967 was the first to describe
the cystoscopic placement of indwelling ureteral
stents for obstructed ureters.
Gibbons was the first to patent a barbed stent as a
self-retaining mechanism.
The first “double-J” (DJ) or double pigtail stent was
developed almost simultaneously by Finney and
Hepperlen.
CHARACTERICTIS OF THE IDEAL STENT
Easy to insert
Ability to relieve intraluminal and extraluminal obstruction
Has excellent flow characteristics
Resistant to encrustation and infection
Chemically stable after implantation in a urinary
environment
Stents should therefore have
High tensile strength
A low friction coefficient
Memory
A self-retainment mechanism
Should be both biocompatible and affordable
Biomaterials
1.Silicone
Silicone is the most biocompatible material
High friction coefficient and flexibility
 More difficult to navigate through a tortuous or
obstructed ureter.
 Poor tensile strength
 Susceptible for extrinsic compression
2. Polyethylene
First plastic polymer
Become brittle in urinary medium
Encrustation
Blockage
Fragmentation
3.Polyurethane
Good tensile strength
Can be passed over guidewire
Does not collapse on extrinsic pressure easily
Rigidity causes more stent related discomfort
Can damage ureter
Prone to encrustation and colonization
Ideally should be removed within 3 months.
COATINGS
 Hydrogel
COATINGS
Hydrogel is a commonly
applied stent coating
composed of hydrophilic
polymers that absorb water.
This added surface water
reduces friction and increases
elasticity, rendering the stent
easier to insert.
 Hydrogel
COATINGS
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC)
copolymer, and
polyvinylpyrrolidone (PVP
COATINGS
Pentosan polysulfate (PPS),
phosphorylcholine (PC)
copolymer,and
polyvinylpyrrolidone (PVP)
are newer coatings that have
been demonstrated to
reduce
 inflammatory response
 encrustation
 biofilm formation
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
COATINGS
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine
(pvpi)
COATINGS
Polyvinylpyrrolidone-iodine
(PVPI) complex modified
polyurethane Tecoflex stents
appear to be
 highly hydrophilic
 Reduce encrustation
 Reduce adherence of P.
aeruginosa and S. aureus
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine (pvpi)
COATINGS
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine (pvpi)
 Diamond-like carbon (dlc) coating
COATINGS
Diamond-like carbon (DLC)
coating
 renders the stent surface
ultra smooth
 decreasing friction
 Improving biocompatibility
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine (pvpi)
 Diamond-like carbon (dlc) coating
COATINGS
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine (pvpi)
 Diamond-like carbon (dlc) coating
 Oxalobacter Formigenes
COATINGS
Oxalate degrading enzymes
 reduction in encrustation
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine (pvpi)
 Diamond-like carbon (dlc) coating
 Oxalobacter Formigenes
COATINGS
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine (pvpi)
 Diamond-like carbon (dlc) coating
 Oxalobacter Formigenes
 Triclosan-eluting Stents (triumph)
COATINGS
The Triumph stent
 significantly reduced stent-
related pain and urinary
symptoms
 reduced symptomatic UTI
rate
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine (pvpi)
 Diamond-like carbon (dlc) coating
 Oxalobacter Formigenes
 Triclosan-eluting Stents (triumph)
COATINGS
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine (pvpi)
 Diamond-like carbon (dlc) coating
 Oxalobacter Formigenes
 Triclosan-elutingStents (triumph)
 Ketorolac-eluting stent
(Lexington)
COATINGS
Ketorolac-eluting stent
(Lexington) was developed
with the goal of reducing
stent-induced pain
symptoms.
 Hydrogel
 Pentosan polysulfate (PPS),
phosphorylcholine (PC) copolymer,
and polyvinylpyrrolidone (PVP
 Polyvinylpyrrolidone-iodine (pvpi)
 Diamond-like carbon (dlc) coating
 Oxalobacter Formigenes
 Triclosan-elutingStents (triumph)
 Ketorolac-eluting stent (Lexington)
COATINGS
NEWER COATINGS
Drug-eluting and antiadhesive
under investigation
improving stent handling
reducing biofilm formation
preventing encrustation
improving patient comfort
silver coatings
reducing biofilm adherence without the risk of
inducing resistance
Stent Design
variations to the initial DJ stent developed by Finney
include
Different biomaterials as discussed
Different diameters and lengths
More or fewer side holes
An open or closed tip
3F Microstent
 The newly developed 3F Microstent
uses a film anchor as a proximal
retaining mechanism.
 Once above the obstruction, the film
anchor is deployed by retracting the
integrated guidewire.
 Flow characteristics of the 3F Microstent
are equivalent to those of a 4.7-Fr DJ
stent.
 Because a smaller-caliber stent occupies
less space in the ureter, stone passage
may improve.
THE DUAL-LUMEN STENT
 It was developed with the goal of optimizing urinary
drainage.
 It significantly improved the flow in an ex vivo obstructed
ureter model compared with a single 7-Fr stent and had
similar flow rates compared with two ipsilateral 7-Fr stents.
 Insertion of a dual-lumen stent has a practical advantage
over insertion of two ipsilateral stents because it can be
inserted in one pass.
SPIRASTENT
It is a DJ stent with helical metal ridges.
It was designed to obtain better flow and easier
stone fragment passage by theoretically increasing
the distance between ureter wall and stent.
Although in vitro study showed promising results,
the stent appeared to allow less flow than the
conventional DJ stent
Open-Pass ureteral stent
 The Open-Pass ureteral stent has 15 to 17 radially expanding
baskets along its length.
 It was developed for dilation of the ureter up to 20 Fr
 stone fragments entrapment after SWL
 Entrapped stone fragments are subsequently removed with
the removal of the stent
Stent with an antireflux valve
Stents equipped with an antireflux valve mechanism
at the intravesical portion of the stent demonstrate
a significant decrease in reflux rate compared with a
conventional DJ stent.
Resulting in less flank and bladder pain and thus
improved patient comfort.
Stent with an antireflux valve
DUAL DUROMETER
The hypothesis that less or softer material in the
bladder would result in fewer symptoms has
influenced stent design toward variable diameter.
Stents developed for use after endopyelotomy have
a conventional 7-Fr proximal and distal coil and a
broader body of 10 Fr.
TAIL STENTS OR BUOY
STENTS
 Tail stents or buoy stents were
developed to prevent stent-related
lower urinary tract symptoms .
 composed of a 7-Fr or 10-Fr upper
body that tapers down to a 3-Fr
distal tail rather than a coil.
 Tail stents and buoy stents (10 Fr to
3 Fr) are reported to have
significantly better drainage,
reduced bladder inflammation, and
reduced irritative.
MAGNETIP STENT
The Magnetip stent has been developed to avoid
cystoscopic removal of the stent.
 It has a metallic bead at the distal tip and can be
removed with a magnetic-tipped urethral catheter.
 Studies have demonstrated up to 100% successful
retrieval in women and 75% to 97% in men.
INDICATIONS
INTRINSIC OBSTRUCTION
Stones
Tumours
Strictures
EXTRINSIC OBSTRUCTION
compression by
tumour
overlying vessels
Retroperitoneal fibrosis
lymphadenopathies
Absolute and usually emergent indication
Bilateral obstruction
Unilateral obstruction in the absence of a
functional contralateral kidney
Ureteral obstruction with hydronephrosis and
urinary infection or sepsis.
Intractable renal colic that cannot be controlled
by analgesia
Relative indications
Stent placement before or after treatment of
urolithiasis has been a subject of controversy.
It is safer to place a ureteral stent in combination
with SWL for a stone larger than 1.5 to 2 cm.
Stenting a ureter post-URSL is, on the other hand,
still advised if there are sizeable residual fragments,
in the presence of an anatomically or functionally
solitary kidney
if the ureter has been balloon dilated
if the patient has a UTI
if a complication such as bleeding or perforation
has occurred
 Routine placement of an internal stent after uncomplicated
percutaneous nephrolithotomy (PCNL) with a low tract is not
necessarily required.
 Stenting is, however, advised in the presence of
Residual stone burden in the kidney
Migration of residual fragments to the ureter
Extensive edema
Perforation of the collecting system
High tract placement with risk of hydrothorax
For performance of tubeless PCNL
In the presence of persistent urinary leakage after
nephrostomy tube removal
 Stents are widely used in urologic reconstructive surgery for
splinting the ureter.
 Stents have a dual role in this setting
the first being scaffolding the tissue to improve organized
healing
second being to allow urine to flow unhindered past the
operated field.
Stents have shown usefulness in
Ureteral trauma treatment
Ureteral realignment
Pyeloplasty
Ureteral reimplantation
Ureteroureterostomy
And other reconstructive procedures as renal
transplantation.
 Stents are often placed prophylactically before
Gynecologic surgery
Urologic surgery
Abdominal surgery
 This facilitates identification of the ureter during surgery and
theoretically may reduce iatrogenic ureteral trauma.
Others :
Several authors have reported on the use of stents in
the treatment of malignant pathology of the upper
urinary tract with, BCG or Mitomycin C.
After intravesical instillation of the agent,
vesicoureteral reflux may permit the substance to
reach the upper urinary tract.
When a single ureteric stent is insufficient in relieving benign
or malignant extrinsic ureteral compression, placing an
additional ipsilateral stent has been reported to be
successful in achieving adequate kidney drainage.
Persistent urinary extravasation after blunt renal trauma can
be treated by ureteral stent placement with high success
rates.
TECHNIQUES
Stents can be placed using various techniques
including
Retrograde placement
Antegrade placement
During open surgery
Laparoscopic surgery of the urinary tract
 Stent placement in males
supine position - flexible cystoscopy
lithotomy position - rigid cystoscope
 Stent placement in females
frog-leg position - flexible cystoscopy
lithotomy position- rigid cystoscopy
 The distal end of the stent is positioned by advancing the
radiopaque marker under fluoroscopic guidance at the middle
of the pubic symphysis in male patients and the lower border
of the pubic symphysis in female patients.
Complications
 Stent-associated symptoms can have a significant impact on
patient quality of life.
Hematuria
urgency
frequency
dysuria
 bladder and flank pain are the most prevalent symptoms
related to indwelling ureteral stents.
 Irritation of the bladder mucosa and especially the trigone by
the distal portion of the stent, reflux of urine, and smooth
muscle spasm are thought to contribute to stent-related
symptoms.
 Positioning the proximal coil in the upper pole of the kidney
in contrast to in the renal pelvis appears to be better tolerated
by stented patients.
 Several authors have reported that stents crossing the
midline of the bladder have a significant and deleterious
influence on associated discomfort.
IDEAL STENT LENGTH
 Pilcher and Patel suggested a predictive model for ideal
stent length based on patient height:
shorter than 5 feet 10 inches  22-cm stent;
5 feet 10 inches to 6 feet 4 inches  24-cm stent;
taller than 6 feet 4 inches  26-cm stent
 straight linear measurement from PUJ to VUJ on
preoperative intravenous pyelography correlated better with
the actual ureteric length than the patient’s height
Distance from xiphisternum to pubic symphysis
Ideal stent length for children has been formulated
as “child’s age + 10” cm
Stent migration
 Despite the self-retaining design of DJ ureteral stents, distal
migration into the bladder or proximal into the ureter is
possible.
 Proximal stent migration into the ureter has been reported
to occur in 1% to 8% of patients.
 This can largely be prevented by choosing a sufficiently long
stent and having an adequate loop both in the renal pelvis
and in the bladder
 Migration of the stent into the bladder can be treated by
stent exchange.
Urinary Tract Infection
 Ureteral stents are inherently subject to bacterial colonization
and therefore represent a source of UTI.
 In chronically stented patients, bacterial colonization reaches
100%
 Indwelling time, female sex, diabetes, and chronic kidney
disease are factors influencing colonization of ureteral stents.
Encrustation
 Minor encrustation on stent surfaces is often present and
usually does not result in stent blockage or resistance at
stent removal.
 More extensive and clinically significant encrustation can be
a very challenging complication and often arises from a
forgotten or retained stent.
 The duration of indwelling time of ureteral stents is the most
important risk factor for development of encrustation.
 Additional risk factors for stent encrustation include
pregnancy, UTI or urosepsis history of stone disease,
metabolic or congenital abnormalities.
 Calcium oxalate appears to be the major component of stent
encrustation in the absence of UTI, pH values below 5.5, and
hyperuricosuria.
The forgotten or neglected stent is a multifactorial
problem that originates from both poor patient
compliance and health system issues related to
patient follow-up.
To prevent forgotten or neglected stents
 Patient education
 Several reminder mechanisms as
Log books
Card
Web-based registries
Computerized logs
Software that arranges stent change or removal and
sends reminder e-mails to patient and physician.
NEPHROSTOMY TUBE
HISTORIC NOTE
Thomas Hillier reported on the first PCN for the
drainage of a hydronephrotic kidney in a 4-year old
boy in 1865.
Fernström’s report on the first percutaneous stone
extraction in 1976 initiated the PCNL era.
INDICATIONS
 Acute or chronic upper urinary tract obstruction in which
access to the kidney is impossible from the lower urinary
tract because of stones, infections, tumours, or anatomic
anomalies.
 patient's creatinine level is rising above the reference range
and the urine cannot be drained through the ureter.
 Renal pelvis disorders (UPJ obstruction, ureter duplex, ureter
fissures, double renal collecting systems)
 Hydronephrosis in renal transplant allografts
Available Materials and Nephrostomy Tube
Design
Similar to ureteral stents
An ideal nephrostomy tube is
Biocompatible
Has excellent flow characteristics
Is easy to insert
Resists Infection, encrustation, and dislodgement
 And does not induce symptoms
Councilman catheter
This is a modified Foleys catheter, with a end on
hole.
 This type of nephrostomy drainage is useful if the
nephrostomy tube requires frequent changes.
Kaye’s Tamponade
balloon
 Originally the catheter was
designed to arrest post-PCNL
bleeding.
 The tamponade is provided by
the balloon and the central
channel provides drainage.
NELATON
CATHETER
 Nelaton catheter - The
catheters range in size from
12 Fr to 28 Fr.
 This is the preferred method
of drainage after PCNL.
FOLEY CATHETERS
 These are used for long term
drainage.
 Those patients which require
repeat tube changes.
 Disadvantage is, it is not
radiopaque.
MALLECOTS CATHETER
 These catheters have a flower at the
end of catheter as self-retaining
mechanism.
 They tend to fall out with firm pull.
 Not widely used as urethral catheters,
 Mainly used as nephrostomy catheter.
CIRCLE NEPHROSTOMY TUBES
 Less mucosal irritation when compared with foley catheters.
 It remained in the same position in the renal pelvis
 Better drainage of the renal pelvis and calyces when
compared with a foley catheter
 It was useful to irrigate the renal pelvis
 Easier to change in the office without requiring fluoroscopic
guidance
 It would not slide out if adequately secured.
Fundamentals of urinary tract drainage
Re-entry catheters
 Re-entry catheters are designed
to permit nephrostomy drainage
while ensuring access to the
ureter, should this be necessary.
ADVANTAGES
 Placement and exchange of the tube under local anesthesia.
 Nephrostomy tube offers better flow characteristics.
 In contrast to a DJ stent, the external drainage nephrostomy
tube can be easily unblocked by gentle irrigation in the
event of blockage.
 To administer therapeutic drugs to the upper urinary tract.
BCG or mitomycin C
 Chemolytic agents to achieve stone dissolution
 To obtain a nephrostogram
COMPLICATIONS
 Hemorrhage,
 Hematuria,
 Clot colic,
 UTIs
 Thoracic complications
Pneumothorax, hemothorax, hydrothorax, empyema
 Dislodgement and blockage
References
1. CAMPBELL-WALSH UROLOGY 11th edition
2. Urology Instrumentation A Comprehensive Guide Ravindra B Sabnis MS
MCh
3. Ureteric Stenting Edited by Ravi Kulkarni Ashford and St Peter’s Hospitals
NHS Foundation Trust, UK
4. Manual of Urology: Diagnosis and Therapy 2nd edition: By Mike B Siroky
MD, Robert D Oates MD, Richard K Babayan MD By Lippincott, Williams &
Wilkins
The surgeon responsible for stent insertion is
also accountable for its timely removal.
- CAMPBELL-WALSH UROLOGY
Thank you

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Fundamentals of urinary tract drainage

  • 1. FUNDAMENTALS OF URINARY TRACT DRAINAGE- CATHETERS, STENTS, PCN TUBES Dr. Prashant Kumar Chauhan Lucknow, India
  • 2. INDEX Lower urinary tract drainage Transurethral catheter Supra pubic catheter Upper urinary tract drainage Ureteric stents PCN tubes
  • 3. Transurethral catheter  History  Indications  Catheter selection  Catheter design  Types of catheters  Techniques of catheterization  Difficult catheterization  complications
  • 4. Brief History  The word “catheter” comes from Greek, meaning “to let or send down.  Catheters were used as early as 3,000 B.C. to relieve painful urinary retention.  In those times, many materials were used to form a hollow catheter shape, including straw, rolled up palm leaves, hollow tops of onions.  Malleable catheters were developed in the 11th century.
  • 5.  Coudé tip catheters were developed in the 18th and 19th centuries to facilitate male catheterization.  After World War II, Sir Ludwig Guttman introduced the concept of sterile intermittent catheterization in patients with with spinal cord injury after World War II.
  • 6. Benjamin the inventor of modern catheter  Benjamin Franklin, the inventor and colonial statesman, fashioned silver catheters for use by his older brother John.  John suffered from kidney stones and needed to undergo a daily ritual of placing a bulky metal catheter into his bladder.  Franklin worked with his local silversmith on his design for a flexible catheter.
  • 7. INDICATIONS Conveniently be divided into two categories: Diagnostic Therapeutic
  • 8. THERAPEUTIC Acute or chronic urinary retention neurological conditions, Bladder outlet obstruction Gross haematuria bladder irrigation and drainage of bloody urine and blood clots Urethral stricture Dilation with urethral catheters
  • 9. Intravesical therapy Dimethyl sulfoxide for interstitial cystitis Alum for intractable haematuria Mitomycin C or bacilli calmette-guérin solution for non-muscle invasive bladder cancer
  • 10. DIAGNOSTIC Monitor urinary output in critically ill or post-operative patients Postvoid residual urine volume  the most accurate method of measurement Intravesical and urethral pressure as in urodynamic studies
  • 11. Thermometer-tipped catheters during prolonged surgeries for thermometry and adequate drainage Retrograde cystography To opacify the urinary tract for diagnostic purposes
  • 12. CATHETER SELECTION A wide variety of catheters are available for transurethral catheterization. These vary in the following Differences in materials used in manufacture Variations in length Circumference Shape of the catheter tip Number of channels Varieties of coatings
  • 13. CATHETER DESIGN AND SIZE The choice depends on The indication for use Expected fluid requiring drainage Anticipated indwelling time Age Previous history Patient anatomy One should choose the smallest size available based on these variables.
  • 14. The golden rule is to use the smallest catheter size. The use of large-size catheters (18 Fr or larger) is not recommended more erosion of urethral mucosa stricture formation do not allow adequate drainage of periurethral gland secretions causing a build up of secretions that may lead to irritation and infection large catheters can cause pain and discomfort
  • 15. CATHETER DESIGN Single lumen : basic catheter design is constructed with a single lumen to allow for drainage or instillation. Double lumen : most frequently used retention mechanism is the retention balloon, which is inflated through a dedicated channel.
  • 16. CATHETER DESIGN Triple lumen : simultaneous instillation and drainage of fluids haematuria, clot retention and pyuria haemostasis after TURP compressing vessels at the bladder neck
  • 17. Three-way, two-way, and single-lumen catheters
  • 18. MATERIALS AND COATINGS Rubber Latex Silicone Polyvinylchloride (PVC) Silicone-coated latex catheters Hydrophilic-coated catheters Bacterial-coated catheters Antibiotic-impregnated catheters Silver Alloy-Coated Catheters
  • 19. Rubber Rubber catheter red in colour Contains high Sulphur Heat resistant Causes more irritation
  • 20. Latex Softer Smooth High stretch index Insoluble in urinary medium It can be kept for long time Increases in allergies -skin irritation,rashes, blisters Urethritis and urethral strictures
  • 21. Silicone Relatively inert Silicone catheters are thin-walled Rigid catheters Larger diameter drainage lumen
  • 22. Silicone-coated latex catheters Silicone-coated latex catheters have a chemically bonded coating of silicone elastomer.
  • 23. Hydrophilic-coated catheters Absorb water to produce a slippery outside surface Less discomfort Fewer traumatic catheterizations Decreased incidence of symptomatic urinary tract infections (UTIs) Decreased incidence of urethral strictures
  • 24. Antibiotic-impregnated catheters Antibiotic-impregnated catheters may delay bacteriuria in short term catheterization (<1 week).
  • 25. Bacterial-coated catheters Bacterial-coated catheters have the theoretical benefit of colonizing the urine with a nonvirulent strain of Escherichia coli.
  • 26. Silver alloy-coated catheters Silver alloy-coated catheters have a bacteriostatic effect because they reduce microbacterial adherence and migration of bacteria to the bladder. These catheters also minimize biofilm formation through their release of silver ions that prevent bacteria from settling on the surface. There appear to be few adverse effects and microbial resistance to the active agent is unlikely.
  • 27. TYPES OF URETHRAL CATHETERS • Simple rubber catheter (K90 = 14 Fr, K91 = 10 Fr, Teiman,Nelaton catheter). • Metallic catheters Simple catheters (Non indwelling) • Foley catheter • Gibbons catheter • Malecots catheter • Pig tail catheter Self- retaining catheters
  • 28. FOLEY CATHETER Foley catheter is a self-retaining catheter because of balloon mechanism at the end, balloon connected to a nozzle with a valve mechanism to the other end through a small tube running through the wall of catheter.
  • 30. Dr. Frederic Basil Foley The name came from the designer,Dr Frederic Basil Foley, a surgeon working in Boston, Massachusetts in the 1930s. His original design was adopted by C. R. Bard, Inc., who manufactured the first prototypes and named them in honor of the surgeon.
  • 32. Uses: Urinary drainage To irrigate the bladder To administer chemotherapy In urological surgery or other surgery on contiguous structures To obtain accurate measurements of urinary output in critically ill or post-operative patients To undertake urodynamic studies Other uses
  • 33. EXTRA-AMNIOTIC SALINE INFUSION  A foley catheter can also be used to ripen the cervix.  The balloon is inserted behind the cervical wall and inflated.  The catheter is pulled slightly taut and taped to the inside of the woman's leg.  As the cervix dilates over time, the catheter is readjusted to again be slightly taut and retaped to maintain pressure. When the cervix has dilated sufficiently, the catheter drops out.
  • 34. CONTROL OF EPISTAXIS They are also used in cases of severe epistaxis to block blood from freely flowing down the nasal passage into the mouth.
  • 35. ROBINSON CATHETER It is a straight rubber tube catheter. The tip of the Robinson catheter is rounded. with one or two drainage ports along the side. If a Robinson catheter is left indwelling, it must be secured to the glans penis by suture or tape. It is radiopaque due to lead oxide content. Available in 8–22 Fr size.
  • 37. USES :  short-term catheterization  as in measurement of residual urine and instillation of medication, chemotherapeutic or contrast material into the urinary bladder  intermittent self-catheterization  chronic urinary retention
  • 38. COUDE CATHETER Also known as Delinotte tip or Mercier tip This is curved at the tip (French word for “elbow”). Catheter is slightly stiffer than the Robinson catheter. Coude catheters are manufactured with and without retention balloons.
  • 40.  USES : Same as for Foley catheter (but typically used after failure of Foley placement) in a man with an enlarged prostate. Coude catheter navigates the S-shaped curve of the bulbous urethra, which is exaggerated in BPH. Hypertrophied or strictured bladder neck. The curved shape of the coude catheter is designed to guide it over the bladder neck. History of urethral strictures is contraindication - higher risk for false tracts
  • 41. PEZZER CATHETER This is self-retaining with a mushroom- shaped tip.
  • 43. USES : It is most commonly used for suprapubic cystotomy drainage. The catheter should be secured to the skin by suture or tape
  • 44. MALECOT CATHETER These catheters have a flower at the end of catheter as self-retaining mechanism. “Mandarin” keeps the tip flat during insertion and removal.  These catheters are less secure then Foley as they tend to fall out with firm pull.
  • 46. USES : Not used as urethral catheters, mainly used as nephrostomy catheter. Malecot's catheter can be kept for period of time (3 months) It drains fluid adequately Less infection rate Removal is easy
  • 47.  Suprapubic cystostomy (SPC)  In case of urinary retention when foley’s catheterization fails  Prostate or urethral surgeries  To drain abscess cavity  Perinephric abscess  Pyonephrosis  Subphrenic abscess  Amoebic liver abscess  Nephrostomy  Cholecystostomy  Gastrostomy and caecostomy
  • 49. WHISTLE- TIP CATHETER Also known as Couvelaire tip catheter This is a straight catheter with a beveled opening at the tip and another opening in the side.
  • 51. USES : It provides better irrigation and drainage than the Robinson catheter. This catheter is open at the end and allows drainage of large amounts of debris (e.g. blood, clots)
  • 52. COUNCILL CATHETER These are similar to Foley catheters, except that they have an opening at the end to allow use with a screw-tip stylet that can be attached to a filiform.  Councill catheters are especially useful when passage of any other type of catheter is difficult.
  • 54. USES : This type of catheter is most commonly used in bypassing a urethral stricture or false passage. After a stricture is dilated with filiforms and followers, the Councill catheter is attached to the filiform and guided into the bladder. The stylet and filiform (or guide wire) are then removed through the lumen of the Councill catheter.
  • 55. NELATON CATHETER Nelaton catheter is a simple tube with rounded tip which ensures an easier insertion Holes at side and a connecting piece at the opposite end to connect to a collecting bag. Most are made up of pvc (polyvinylchloride) Rigidity and radiopacity
  • 57. USES : Used to drain urine from the bladder temporarily in retention of urine. To find out residual urine. If it is more than 30-50 mL, it signifies obstruction. While doing cystography to infuse dye in to the Urinary bladder. To collect urine from the bladder for culture and sensitivity.
  • 58. Single gentle passage of the catheter is tried as a diagnostic method to identify the urethral/ bladder/ renal injuries. Haematuria signifies urinary tract injury. For administration of intravesical chemotherapy. To dislodge and push back the calculus impacted in the urinary meatus or in the urethra.
  • 59. Others For suction of throat/endotracheal tube/ tracheostomy tube. Can be used as tube drain.
  • 60. CATHETER STYLETS  are malleable metal guides that, when placed into a Foley or other type of catheter, can be used to provide stiffness and shape.  There are two type of stylets—one with a blunt tip, used with a Foley catheter, and one with a screw tip, used with a Councill catheter.  This procedure is useful to accomplish passage through a urethral stricture or tight bladder neck.
  • 61.  Catheter stylets also may be used following TURP to avoid undermining the bladder neck. When a catheter stylet is used, the bladder should always be full to avoid injuring the posterior bladder wall.
  • 62. TECHNIQUE OF URETHRAL CATHETERIZATION  After establishing the indication for catheterization, a medical and surgical history, focusing on position at the side of the patient corresponding to the physician’s dominant hand (if the physician is right handed, the position is on the right-hand side of the patient)
  • 63. All materials expected to be required should be readily available on the sterile drape. The patient should be in supine position at a comfortable height for the individual performing the catheterization. A frog-leg position is preferred for female patients. When an indwelling catheter is being placed, the balloon should be checked for integrity before catheterization.
  • 64. Lubrication of the catheter is advised for smooth catheterization and minimization of risk of urethral trauma.  Four categories of lubricants exist: Plain lubricant Lubricant-anesthetic Lubricant-disinfectant Lubricant-anesthetic-disinfectant
  • 65.  The systemic uptake of lidocaine through intact mucosa reaches a very low peak concentration that never reaches a toxic level. If toxicity occurs confusion lethargy seizures disorientation anaphylactic shock.
  • 66. The effect of lubricant can be enhanced by Cooling the lubricant to 4° C  a cryoanalgesic effect Slowly instilling (3 to 10 seconds) A minimum amount of 20 ml of cooled lubricant  Minimum of 15 minutes of exposure
  • 67. CATHETERIZATION IN MALE PATIENTS The true external urethral meatus is exposed by retracting the foreskin if present. In the presence of phimosis catheterization can be attempted blindly with a smaller-gauge flexible catheter meatal stricture or stenosis is apparent passing a catheter of a smaller size should be attempted first Gentle dilation of the stenosis with sounds can be attempted
  • 68. After skin and meatus preparation and sterile draping to be done.
  • 69. The initial maneuver is to grasp the penis with the nondominant hand, which is from then on regarded as no longer sterile.
  • 70.  The pendulous curvature of the penis is eliminated by pulling the shaft upward. The catheter is inserted into the meatus after lubrication and advanced approximately 7 to 12 cm.  The penis should be brought into a horizontal position, parallel to the patient. Some slight resistance can be appreciated at the membranous urethra, the most fragile segment.
  • 71. The entire catheter is introduced into the penis, up to the bifurcation of the catheter and balloon valve.
  • 72. After verifying the correct position of the catheter in the bladder, inflate the balloon with sterile water, which has been demonstrated to be the optimal filling solution.
  • 73. In uncircumcised patients, the foreskin is reduced to its normal position to avoid paraphimosis.
  • 74. The penis and catheter should be taped in an upright position to prevent pressure ulceration from occurring at the curve in the pendulous urethra and iatrogenic hypospadias at the urethral Meatus.
  • 75. Ideally, a closed circuit should be maintained with the catheter connected to a sterile closed bag system, positioned lower than the bladder to allow gravity to assist in bladder emptying.
  • 76. CATHETERIZATION IN FEMALE PATIENTS  nondominant hand is used to spread the inner labia to reveal the external urethral meatus.  This hand is now considered contaminated.  The urethral meatus should be found 1 to 2.5 cm inferior to the clitoris.  After the meatus has been cleaned and lubricated, the catheter is inserted into the meatus and gently advanced until approximately half the catheter has been inserted.
  • 77. CATHETERIZATION IN CHILDREN  Catheter use in children is predominantly for diagnostic purposes or postoperative drainage.  In infants, suprapubic puncture for obtaining a urine sample is often preferred over a bag sample because it is more likely to be sterile.  Bladder catheterization, however, is preferred over suprapubic aspiration because it is less painful and has a higher success rate in obtaining a satisfactory urine sample.
  • 78.  As in adults, it is useful to align the preputial opening with the meatus to facilitate catheterization.  Compared with women, the urethral orifice in young girls may be partly obscured behind the hymen. To reveal the meatus, it is useful to apply some downward pressure on the hymen.
  • 79. DIFFICULT CATHETERIZATION  This is commonly the result of an enlarged prostate or a closed striated sphincter.  The attempted catheter is retracted, and the catheter tip evaluated for the presence of blood.  If the catheter tip is clean, the next option is a 14-Fr or 16-Fr silicone catheter because it is somewhat stiffer and may pass the slight resistance more effectively.
  • 80.  If blood is present at the catheter tip, there is a possibility of a false passage and a coudé-tipped catheter should be used for the next attempt.
  • 81.  Although the female urethra is short, catheterization can be challenging because of inability to find the urethral meatus.  In obese patients or in patients unable to assume the frog-leg position, the use of stirrups and assistance for retraction to optimize visualization is advised and may be useful.
  • 83. COMPLICATIONS 1. Catheter-associated urinary tract infection 2. Inability to deflate the Foley balloon 3. Pericatheter urine leakage 4. Accidental removal 5. Catheter blockage 6. Hematuria 7. Bladder stones 8. Urethral stricture 9. Bladder cancer
  • 84. Catheter-associated urinary tract infection (CAUTI) From 15% to 25% of hospitalized patients undergo a urethral catheter placement at some point during their stay. UTIs account for approximately 35% of hospital- acquired infections.
  • 85. CAUTI is defined as significant bacteriuria in a patient with symptoms or signs indicating a UTI, whereas asymptomatic bacteriuria refers to significant bacteriuria in asymptomatic patients. Asymptomatic bacteriuria does not require antibiotic treatment The most important risk factor for developing CAUTI is prolonged catheterization(longer than 6 days)
  • 86. Guidelines for preventing CAUTI Avoidance of catheter use Maintenance of a closed drainage system Removal of a catheter as soon as possible. Catheters should be placed under antiseptic conditions Smallest possible catheter with adequate lubrication. Routine irrigation should be avoided.
  • 87. Inability to deflate the Foley balloon Instilling an extra 1 or 2 ml of fluid in the balloon and trying to repeat aspiration. Cutting off the inflation valve may assist if the valve is not functioning correctly. If the balloon still does not deflate one can pass a guidewire through the inflation channel to try and perforate the balloon.
  • 88. Ultrasound-guided needle puncture of the balloon is typically the final approach. Inability to remove a catheter with a fully deflated balloon can also be caused by catheter encrustation. The main causal factor of catheter encrustation is infection with proteus mirabilis.
  • 90. INDICATIONS Suprapubic catheterization is indicated (when transurethral catheterization is contraindicated or technically not possible Urethral injuries Urethral obstruction Bladder neck masses Benign prostatic enlargement Prostate cancer
  • 91. Short-term suprapubic catheter placement is often useful in postoperative situations after urogenital surgery to allow for bladder or urethral tissue healing. In patients requiring a long-term indwelling catheter in whom CIC is not feasible, a suprapubic catheter is often a better option than a transurethral catheter.
  • 92. CONTRAINDICATIONS Previous lower abdominal surgery resulting in unsafe percutaneous passage to the bladder Bladder cancer Uncorrected coagulopathies or anticoagulation Abdominal wall infection at the desired site Pelvic cancer with or without pelvic radiation (increased risk of adhesions)
  • 94. PERCUTANEOUS For suprapubic catheter placement, the patient should be placed in supine position at a comfortable height for the physician. In most patients the distended bladder displaces the intraperitoneal bowel loops out of the pelvis and away from the pubic symphysis. A minimum bladder volume of 300 mL on bladder scan is advised before suprapubic catheter placement is attempted
  • 95.  The patient’s infraumbilical abdomen should be prepared and draped in a sterile fashion. In performing blind puncture, the symphysis should be palpated and the access site should be chosen approximately one to two fingerbreadths above the symphysis.  In obese patients with an abdominal pannus, placement of the tract in a skin fold is avoided to prevent dermatitis.
  • 96.  Local anaesthetic is injected into the skin and along the preferred trajectory using a 10- to 20-mL syringe and an 18- gauge needle.  The tract should be almost perpendicular to the skin. Aspirating urine will confirm access to the bladder.  A midline 5- to 10-mm transverse incision is made at the injection site.
  • 97. SELDINGER TECHNIQUE  The safest technique for catheterization is the Seldinger technique.  A floppy-tip guidewire is advanced into the bladder through an 18-Fr access needle.  The percutaneous tract is dilated with coaxial dilators.  A Cope loop or Councill catheter can be placed over the guidewire into the bladder after the tract is dilated.
  • 99. TROCAR TECHNIQUE  The trocar technique employs a peel-away trocar that envelops the catheter.  The trocar should be advanced firmly but under steady control of the trocar.  Once entry into the bladder has been confirmed by urine flashback or aspiration, the catheter is advanced completely into the bladder, and the trocar is retracted and peeled away.  If the suprapubic catheter does not have a retention mechanism, the catheter is sutured to the skin.
  • 101. Open Suprapubic Cystostomy Open suprapubic catheter placement should be undertaken when a percutaneous technique cannot be performed safely. After the infraumbilical abdomen is prepared and draped, a small incision is made about one to two fingerbreadths above the pubic symphysis, providing access to the retroperitoneal space of Retzius.
  • 102. Two stay sutures are placed to stabilize the bladder, and a small incision is made through the bladder wall between the sutures, allowing for easy passage of a 16- to 18-Fr catheter.  The catheter should be introduced through the skin in line with the bladder incision to prevent kinking and should be secured in the bladder with a purse suture to prevent urine extravasation.
  • 103. COMPLICATIONS Haematuria Leakage of urine Accidental catheter loss Frequent blockage of a suprapubic catheter Excessive granulation tissue at the suprapubic tract
  • 105. URETERAL STENTS The first appearance of the term “stent” in the literature originated from a new dental impression material described by an English dentist, Charles T. Stent. The use of ureteral stents in surgery was described as early as the 19th century The first urologist to access the ureter endoscopically was Dr. James Brown at Johns Hopkins Hospital in 1893.
  • 106. Zimskind, however, in 1967 was the first to describe the cystoscopic placement of indwelling ureteral stents for obstructed ureters. Gibbons was the first to patent a barbed stent as a self-retaining mechanism. The first “double-J” (DJ) or double pigtail stent was developed almost simultaneously by Finney and Hepperlen.
  • 107. CHARACTERICTIS OF THE IDEAL STENT Easy to insert Ability to relieve intraluminal and extraluminal obstruction Has excellent flow characteristics Resistant to encrustation and infection Chemically stable after implantation in a urinary environment
  • 108. Stents should therefore have High tensile strength A low friction coefficient Memory A self-retainment mechanism Should be both biocompatible and affordable
  • 109. Biomaterials 1.Silicone Silicone is the most biocompatible material High friction coefficient and flexibility  More difficult to navigate through a tortuous or obstructed ureter.  Poor tensile strength  Susceptible for extrinsic compression
  • 110. 2. Polyethylene First plastic polymer Become brittle in urinary medium Encrustation Blockage Fragmentation
  • 111. 3.Polyurethane Good tensile strength Can be passed over guidewire Does not collapse on extrinsic pressure easily Rigidity causes more stent related discomfort Can damage ureter Prone to encrustation and colonization Ideally should be removed within 3 months.
  • 114. Hydrogel is a commonly applied stent coating composed of hydrophilic polymers that absorb water. This added surface water reduces friction and increases elasticity, rendering the stent easier to insert.  Hydrogel COATINGS
  • 115.  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP COATINGS
  • 116. Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer,and polyvinylpyrrolidone (PVP) are newer coatings that have been demonstrated to reduce  inflammatory response  encrustation  biofilm formation  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP COATINGS
  • 117.  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi) COATINGS
  • 118. Polyvinylpyrrolidone-iodine (PVPI) complex modified polyurethane Tecoflex stents appear to be  highly hydrophilic  Reduce encrustation  Reduce adherence of P. aeruginosa and S. aureus  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi) COATINGS
  • 119.  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi)  Diamond-like carbon (dlc) coating COATINGS
  • 120. Diamond-like carbon (DLC) coating  renders the stent surface ultra smooth  decreasing friction  Improving biocompatibility  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi)  Diamond-like carbon (dlc) coating COATINGS
  • 121.  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi)  Diamond-like carbon (dlc) coating  Oxalobacter Formigenes COATINGS
  • 122. Oxalate degrading enzymes  reduction in encrustation  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi)  Diamond-like carbon (dlc) coating  Oxalobacter Formigenes COATINGS
  • 123.  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi)  Diamond-like carbon (dlc) coating  Oxalobacter Formigenes  Triclosan-eluting Stents (triumph) COATINGS
  • 124. The Triumph stent  significantly reduced stent- related pain and urinary symptoms  reduced symptomatic UTI rate  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi)  Diamond-like carbon (dlc) coating  Oxalobacter Formigenes  Triclosan-eluting Stents (triumph) COATINGS
  • 125.  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi)  Diamond-like carbon (dlc) coating  Oxalobacter Formigenes  Triclosan-elutingStents (triumph)  Ketorolac-eluting stent (Lexington) COATINGS
  • 126. Ketorolac-eluting stent (Lexington) was developed with the goal of reducing stent-induced pain symptoms.  Hydrogel  Pentosan polysulfate (PPS), phosphorylcholine (PC) copolymer, and polyvinylpyrrolidone (PVP  Polyvinylpyrrolidone-iodine (pvpi)  Diamond-like carbon (dlc) coating  Oxalobacter Formigenes  Triclosan-elutingStents (triumph)  Ketorolac-eluting stent (Lexington) COATINGS
  • 127. NEWER COATINGS Drug-eluting and antiadhesive under investigation improving stent handling reducing biofilm formation preventing encrustation improving patient comfort silver coatings reducing biofilm adherence without the risk of inducing resistance
  • 128. Stent Design variations to the initial DJ stent developed by Finney include Different biomaterials as discussed Different diameters and lengths More or fewer side holes An open or closed tip
  • 129. 3F Microstent  The newly developed 3F Microstent uses a film anchor as a proximal retaining mechanism.  Once above the obstruction, the film anchor is deployed by retracting the integrated guidewire.  Flow characteristics of the 3F Microstent are equivalent to those of a 4.7-Fr DJ stent.  Because a smaller-caliber stent occupies less space in the ureter, stone passage may improve.
  • 130. THE DUAL-LUMEN STENT  It was developed with the goal of optimizing urinary drainage.  It significantly improved the flow in an ex vivo obstructed ureter model compared with a single 7-Fr stent and had similar flow rates compared with two ipsilateral 7-Fr stents.  Insertion of a dual-lumen stent has a practical advantage over insertion of two ipsilateral stents because it can be inserted in one pass.
  • 131. SPIRASTENT It is a DJ stent with helical metal ridges. It was designed to obtain better flow and easier stone fragment passage by theoretically increasing the distance between ureter wall and stent. Although in vitro study showed promising results, the stent appeared to allow less flow than the conventional DJ stent
  • 132. Open-Pass ureteral stent  The Open-Pass ureteral stent has 15 to 17 radially expanding baskets along its length.  It was developed for dilation of the ureter up to 20 Fr  stone fragments entrapment after SWL  Entrapped stone fragments are subsequently removed with the removal of the stent
  • 133. Stent with an antireflux valve Stents equipped with an antireflux valve mechanism at the intravesical portion of the stent demonstrate a significant decrease in reflux rate compared with a conventional DJ stent. Resulting in less flank and bladder pain and thus improved patient comfort.
  • 134. Stent with an antireflux valve
  • 135. DUAL DUROMETER The hypothesis that less or softer material in the bladder would result in fewer symptoms has influenced stent design toward variable diameter. Stents developed for use after endopyelotomy have a conventional 7-Fr proximal and distal coil and a broader body of 10 Fr.
  • 136. TAIL STENTS OR BUOY STENTS  Tail stents or buoy stents were developed to prevent stent-related lower urinary tract symptoms .  composed of a 7-Fr or 10-Fr upper body that tapers down to a 3-Fr distal tail rather than a coil.  Tail stents and buoy stents (10 Fr to 3 Fr) are reported to have significantly better drainage, reduced bladder inflammation, and reduced irritative.
  • 137. MAGNETIP STENT The Magnetip stent has been developed to avoid cystoscopic removal of the stent.  It has a metallic bead at the distal tip and can be removed with a magnetic-tipped urethral catheter.  Studies have demonstrated up to 100% successful retrieval in women and 75% to 97% in men.
  • 138. INDICATIONS INTRINSIC OBSTRUCTION Stones Tumours Strictures EXTRINSIC OBSTRUCTION compression by tumour overlying vessels Retroperitoneal fibrosis lymphadenopathies
  • 139. Absolute and usually emergent indication Bilateral obstruction Unilateral obstruction in the absence of a functional contralateral kidney Ureteral obstruction with hydronephrosis and urinary infection or sepsis. Intractable renal colic that cannot be controlled by analgesia
  • 140. Relative indications Stent placement before or after treatment of urolithiasis has been a subject of controversy. It is safer to place a ureteral stent in combination with SWL for a stone larger than 1.5 to 2 cm.
  • 141. Stenting a ureter post-URSL is, on the other hand, still advised if there are sizeable residual fragments, in the presence of an anatomically or functionally solitary kidney if the ureter has been balloon dilated if the patient has a UTI if a complication such as bleeding or perforation has occurred
  • 142.  Routine placement of an internal stent after uncomplicated percutaneous nephrolithotomy (PCNL) with a low tract is not necessarily required.  Stenting is, however, advised in the presence of Residual stone burden in the kidney Migration of residual fragments to the ureter Extensive edema Perforation of the collecting system High tract placement with risk of hydrothorax For performance of tubeless PCNL In the presence of persistent urinary leakage after nephrostomy tube removal
  • 143.  Stents are widely used in urologic reconstructive surgery for splinting the ureter.  Stents have a dual role in this setting the first being scaffolding the tissue to improve organized healing second being to allow urine to flow unhindered past the operated field.
  • 144. Stents have shown usefulness in Ureteral trauma treatment Ureteral realignment Pyeloplasty Ureteral reimplantation Ureteroureterostomy And other reconstructive procedures as renal transplantation.
  • 145.  Stents are often placed prophylactically before Gynecologic surgery Urologic surgery Abdominal surgery  This facilitates identification of the ureter during surgery and theoretically may reduce iatrogenic ureteral trauma.
  • 146. Others : Several authors have reported on the use of stents in the treatment of malignant pathology of the upper urinary tract with, BCG or Mitomycin C. After intravesical instillation of the agent, vesicoureteral reflux may permit the substance to reach the upper urinary tract.
  • 147. When a single ureteric stent is insufficient in relieving benign or malignant extrinsic ureteral compression, placing an additional ipsilateral stent has been reported to be successful in achieving adequate kidney drainage. Persistent urinary extravasation after blunt renal trauma can be treated by ureteral stent placement with high success rates.
  • 148. TECHNIQUES Stents can be placed using various techniques including Retrograde placement Antegrade placement During open surgery Laparoscopic surgery of the urinary tract
  • 149.  Stent placement in males supine position - flexible cystoscopy lithotomy position - rigid cystoscope  Stent placement in females frog-leg position - flexible cystoscopy lithotomy position- rigid cystoscopy  The distal end of the stent is positioned by advancing the radiopaque marker under fluoroscopic guidance at the middle of the pubic symphysis in male patients and the lower border of the pubic symphysis in female patients.
  • 150. Complications  Stent-associated symptoms can have a significant impact on patient quality of life. Hematuria urgency frequency dysuria  bladder and flank pain are the most prevalent symptoms related to indwelling ureteral stents.  Irritation of the bladder mucosa and especially the trigone by the distal portion of the stent, reflux of urine, and smooth muscle spasm are thought to contribute to stent-related symptoms.
  • 151.  Positioning the proximal coil in the upper pole of the kidney in contrast to in the renal pelvis appears to be better tolerated by stented patients.  Several authors have reported that stents crossing the midline of the bladder have a significant and deleterious influence on associated discomfort.
  • 152. IDEAL STENT LENGTH  Pilcher and Patel suggested a predictive model for ideal stent length based on patient height: shorter than 5 feet 10 inches  22-cm stent; 5 feet 10 inches to 6 feet 4 inches  24-cm stent; taller than 6 feet 4 inches  26-cm stent  straight linear measurement from PUJ to VUJ on preoperative intravenous pyelography correlated better with the actual ureteric length than the patient’s height
  • 153. Distance from xiphisternum to pubic symphysis Ideal stent length for children has been formulated as “child’s age + 10” cm
  • 154. Stent migration  Despite the self-retaining design of DJ ureteral stents, distal migration into the bladder or proximal into the ureter is possible.  Proximal stent migration into the ureter has been reported to occur in 1% to 8% of patients.  This can largely be prevented by choosing a sufficiently long stent and having an adequate loop both in the renal pelvis and in the bladder  Migration of the stent into the bladder can be treated by stent exchange.
  • 155. Urinary Tract Infection  Ureteral stents are inherently subject to bacterial colonization and therefore represent a source of UTI.  In chronically stented patients, bacterial colonization reaches 100%  Indwelling time, female sex, diabetes, and chronic kidney disease are factors influencing colonization of ureteral stents.
  • 156. Encrustation  Minor encrustation on stent surfaces is often present and usually does not result in stent blockage or resistance at stent removal.  More extensive and clinically significant encrustation can be a very challenging complication and often arises from a forgotten or retained stent.
  • 157.  The duration of indwelling time of ureteral stents is the most important risk factor for development of encrustation.  Additional risk factors for stent encrustation include pregnancy, UTI or urosepsis history of stone disease, metabolic or congenital abnormalities.
  • 158.  Calcium oxalate appears to be the major component of stent encrustation in the absence of UTI, pH values below 5.5, and hyperuricosuria.
  • 159. The forgotten or neglected stent is a multifactorial problem that originates from both poor patient compliance and health system issues related to patient follow-up.
  • 160. To prevent forgotten or neglected stents  Patient education  Several reminder mechanisms as Log books Card Web-based registries Computerized logs Software that arranges stent change or removal and sends reminder e-mails to patient and physician.
  • 162. HISTORIC NOTE Thomas Hillier reported on the first PCN for the drainage of a hydronephrotic kidney in a 4-year old boy in 1865. Fernström’s report on the first percutaneous stone extraction in 1976 initiated the PCNL era.
  • 163. INDICATIONS  Acute or chronic upper urinary tract obstruction in which access to the kidney is impossible from the lower urinary tract because of stones, infections, tumours, or anatomic anomalies.  patient's creatinine level is rising above the reference range and the urine cannot be drained through the ureter.  Renal pelvis disorders (UPJ obstruction, ureter duplex, ureter fissures, double renal collecting systems)  Hydronephrosis in renal transplant allografts
  • 164. Available Materials and Nephrostomy Tube Design Similar to ureteral stents An ideal nephrostomy tube is Biocompatible Has excellent flow characteristics Is easy to insert Resists Infection, encrustation, and dislodgement  And does not induce symptoms
  • 165. Councilman catheter This is a modified Foleys catheter, with a end on hole.  This type of nephrostomy drainage is useful if the nephrostomy tube requires frequent changes.
  • 166. Kaye’s Tamponade balloon  Originally the catheter was designed to arrest post-PCNL bleeding.  The tamponade is provided by the balloon and the central channel provides drainage.
  • 167. NELATON CATHETER  Nelaton catheter - The catheters range in size from 12 Fr to 28 Fr.  This is the preferred method of drainage after PCNL.
  • 168. FOLEY CATHETERS  These are used for long term drainage.  Those patients which require repeat tube changes.  Disadvantage is, it is not radiopaque.
  • 169. MALLECOTS CATHETER  These catheters have a flower at the end of catheter as self-retaining mechanism.  They tend to fall out with firm pull.  Not widely used as urethral catheters,  Mainly used as nephrostomy catheter.
  • 170. CIRCLE NEPHROSTOMY TUBES  Less mucosal irritation when compared with foley catheters.  It remained in the same position in the renal pelvis  Better drainage of the renal pelvis and calyces when compared with a foley catheter  It was useful to irrigate the renal pelvis  Easier to change in the office without requiring fluoroscopic guidance  It would not slide out if adequately secured.
  • 172. Re-entry catheters  Re-entry catheters are designed to permit nephrostomy drainage while ensuring access to the ureter, should this be necessary.
  • 173. ADVANTAGES  Placement and exchange of the tube under local anesthesia.  Nephrostomy tube offers better flow characteristics.  In contrast to a DJ stent, the external drainage nephrostomy tube can be easily unblocked by gentle irrigation in the event of blockage.  To administer therapeutic drugs to the upper urinary tract. BCG or mitomycin C  Chemolytic agents to achieve stone dissolution  To obtain a nephrostogram
  • 174. COMPLICATIONS  Hemorrhage,  Hematuria,  Clot colic,  UTIs  Thoracic complications Pneumothorax, hemothorax, hydrothorax, empyema  Dislodgement and blockage
  • 175. References 1. CAMPBELL-WALSH UROLOGY 11th edition 2. Urology Instrumentation A Comprehensive Guide Ravindra B Sabnis MS MCh 3. Ureteric Stenting Edited by Ravi Kulkarni Ashford and St Peter’s Hospitals NHS Foundation Trust, UK 4. Manual of Urology: Diagnosis and Therapy 2nd edition: By Mike B Siroky MD, Robert D Oates MD, Richard K Babayan MD By Lippincott, Williams & Wilkins
  • 176. The surgeon responsible for stent insertion is also accountable for its timely removal. - CAMPBELL-WALSH UROLOGY Thank you

Notas del editor

  1. Although ultrasound-based bladder scanners are widely used to estimate postvoid residual urine volume, the most accurate method of measurement is by emptying the bladder with transurethral catheterization.
  2. K90, K91 are now available as R90 and R91.
  3. He demonstrated this to the American Urologists Society in 1935, and published a paper describing it in 1937. While he was still developing his catheter, a patent was issued to Paul Raiche of the Davol Rubber Company of Providence, Rhode Island in 1936. Four months later, in October 1936
  4. The subgroup of patients with spinal cord injuries is at greater risk of complications
  5. Other risk factors include catheterization outside of the operating room, female sex, body mass index (BMI) greater than 30, diabetes, and other active site of infection
  6. Overinflation of the balloon with the intention of having it burst should be avoided because this may be painful and possibly result in retained fragments of the catheter balloon in the bladder.
  7. Frequent blockage of a suprapubic catheter can be caused by encrustation or bladder stones. Frequent catheter blockage should prompt consideration of cystoscopy to evaluate for the presence of bladder stones