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.
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
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
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
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.
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
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.
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.
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.
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
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
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.
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.
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
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
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.
K90, K91 are now available as R90 and R91.
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
The subgroup of patients with spinal cord injuries is at greater risk of complications
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
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.
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