Handbook for Ureteral Stenting

  • Shingo YamamotoEmail author


Ureteral stent is an essential item for surgical procedures and clinical examinations in the urological field, but the methods and protocols of insertion, withdrawal, and exchange, as well as the period before replacement are based on the experience of an individual practitioner. Ureteral stenting is frequently associated not only with stent-related symptoms but also complications such as urinary tract infections, encrustation, migration, knotting, and ureteroarterial fistula conditions, which are sometimes life -threatening.

The Japanese Society of Endourology (JSE) established a “the Section meeting for ureteral stenting” in order to establish consensus regarding the practice of the ureteral stenting in a handbook which was first published in Japan in 2017. Herein, we review and discuss about a variety of ureteral stent materials and configuration, indications for ureteral stenting, techniques for placement and exchange of ureteral stent, as well as ureteral stent-related adverse events for safe management of ureteral stenting.


Ureteral stent Ureteral catheterization Techniques Complications 



I express my appreciation to the members of the Section meeting for ureteral stenting of the Japanese Society of Endourology (JSE), including Drs. Kikuo Nutahara, Akito Yamaguchi, Soichi Mugiya, Hitoshi Yamada, Junichi Matsuzaki, Satoshi Takahashi, Mitsuru Yasuda, Koichiro Wada, and Jun Miyazaki, as of April 2017 when the first edition of this handbook was published.


  1. Abt D, Mordasini L, Warzinek E, et al. Is intravesical stent position a predictor of associated morbidity? Korean J Urol. 2015a;56:370–8.CrossRefGoogle Scholar
  2. Abt D, Warzinek E, Schmid HP, et al. Influence of patient education on morbidity caused by ureteral stents. Int J Urol. 2015b;22:679–83.CrossRefGoogle Scholar
  3. Agarwal MM, Singh SK, Mandal AK, et al. Endourologic management of forgotten encrusted ureteral stents: can ureteroscopic lithotripsy be avoided? Surg Laparosc Endosc Perctan Tech. 2009;19:72–7.CrossRefGoogle Scholar
  4. Althaus AB, Li K, Pattison E, et al. Rate of dislodgment of ureteral stents when using an extraction string after endoscopic urological surgery. J Urol. 2015;193:2011–4.CrossRefGoogle Scholar
  5. Ather MH, Talati J, Biyabani R. Physician responsibility for removal of implants: the case for a computerized program for tracking overdue double-J stents. Tech Urol. 2000;6:189–92.PubMedGoogle Scholar
  6. Billoud E, Savoye G, Hervé S, et al. Double J ureteral stent as an unusual endoscopic finding in a patient with rectal bleeding. Gastrointest Endosc. 2008;68:1239–40.CrossRefGoogle Scholar
  7. Braslis KG, Joyce G. Spontaneous knotting of a pigtail ureteric stent in the ureter requiring percutaneous removal. Aust N Z J Surg. 1992;62:825–6.CrossRefGoogle Scholar
  8. Breau RH, Norman RW. Optimal prevention and management of proximal ureteral stent migration and remigration. J Urol. 2001;166:890–3.CrossRefGoogle Scholar
  9. Bullock A, Andriole GL, Neuman N, et al. Renal autotransplantation in the management of a ureteroarterial fistula: a case report and review of the literature. J Vasc Surg. 1992;15:436–41.CrossRefGoogle Scholar
  10. Bultitude MF, Tiptaft RC, Glass JM, et al. Management of encrusted ureteral stents impacted in upper tract. Urology. 2003;62:622–6.CrossRefGoogle Scholar
  11. Cass AS, Odland M. Ureteroarterial fistula: case report and review of literature. J Urol. 1990;143:582–3.CrossRefGoogle Scholar
  12. Chung SY, Stein RJ, Landsittel D, et al. 15-year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents. J Urol. 2004;172:592–5.CrossRefGoogle Scholar
  13. van den Bergh RC, Moll FL, de Vries JP, et al. Arterioureteral fistulas: unusual suspects-systematic review of 139 cases. Urology. 2009;74:251–5.CrossRefGoogle Scholar
  14. El-Nahas AR, Tharwat M, Elsaadany M, et al. A randomized controlled trial comparing alpha blocker (tamsulosin) and anticholinergic (solifenacin) in treatment of ureteral stent-related symptoms. World J Urol. 2015;34:963–8.CrossRefGoogle Scholar
  15. Falahatkar S, Hemmati H, Monghaddam KG, et al. Intracaval migration: an uncommon complication of ureteral Double-J stent placement. J Endourol. 2012;26:119–21.CrossRefGoogle Scholar
  16. el-Faqih SR, Shamsuddin AB, Chakrabarti A, et al. Polyurethane internal ureteral stents in treatment of stone patients: morbidity related to indwelling times. J Urol. 1991;146:1487–91.CrossRefGoogle Scholar
  17. Farsi HM, Mosli HA, Al-Zemaity MF, et al. Bacteriuria and colonization of double-pigtail ureteral stents: long-term experience with 237 patients. J Endourol. 1995;9:469–72.CrossRefGoogle Scholar
  18. Flam TA, Thiounn N, Gerbaud PF, et al. Knotting of a double pigtail stent within the ureter: an initial report. J Urol. 1995;15:1858–9.Google Scholar
  19. Ganatra AM, Loughlin KR. The management of malignant ureteral obstruction treated with ureteral stents. J Urol. 2005;174:2125–8.CrossRefGoogle Scholar
  20. Ho CH, Chen SC, Chung SD, et al. Determining the appropriate length of a double-pigtail ureteral stent by both stent configurations and related symptoms. J Endourol. 2008;22:1427–31.CrossRefGoogle Scholar
  21. Ho CH, Chung SD, Huang KH, et al. Retrieval of a misplaced double-J ureteral stent in the renal pelvis: a novel technique. Surg Laparosc Endosc Percutan Tech. 2009;19:e24–2.CrossRefGoogle Scholar
  22. Ikeda A, Kawai K, Ando S, et al. Management of ureteral obstruction in advanced testicular tumor with lymph node metastasis. Jpn J Clin Oncol. 2012;42:748–52.CrossRefGoogle Scholar
  23. Ioannis C, Ioannis Z, Evangelos I, et al. Retrovesical migration of malpositioned double-j ureteral stent. Int Urol Nephrol. 2003;35:325–6.CrossRefGoogle Scholar
  24. Joshi HB, Stainthorpe A, Keeley FX, et al. Indwelling ureteral stents: evaluation of quality of life to aid outcome analysis. J Endourol. 2001;15:151–4.CrossRefGoogle Scholar
  25. Joshi HB, Newns N, Stainthorpe A, et al. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol. 2003;169:1060–4.CrossRefGoogle Scholar
  26. Karagüzel E, Kutku O, Karaz IO, et al. Knotted ureteral stent: a rare complication of ureteral stent usage. Urol Res. 2012;40:793–5.CrossRefGoogle Scholar
  27. Kawahara T. Choosing an appropriate length of loop type ureteral stent using direct ureteral length measurement. Urol Int. 2012a;88:48–53.CrossRefGoogle Scholar
  28. Kawahara T. Ureteral stent retrieval using the crochet hook technique in females. PLoS One. 2012b;7:e29292.CrossRefGoogle Scholar
  29. Kawahara T, Ito H, Terao H, et al. Changing to a loop-type ureteral stent decreases patients’ stent-related symptoms. Urol Res. 2012a;40:763–7.CrossRefGoogle Scholar
  30. Kawahara T, Ito H, Terao H, et al. Ureteral stent encrustation, incrustation, and coloring: morbidity related to indwelling times. J Endourol. 2012b;26:178–82.CrossRefGoogle Scholar
  31. Kehinde EO, Rotimi VO, Al-Awadi KA, et al. Factors predisposing to urinary tract infection after J ureteral stent insertion. J Urol. 2002;167:1334–7.CrossRefGoogle Scholar
  32. Keller FS, Barton RE, Routh WD, et al. Gross hematuria in two patients with ureteral-ileal conduits and double-J stents. J Vasc Interv Radiol. 1990;1:69–77.CrossRefGoogle Scholar
  33. Kondo N, Yoshino Y, Shiono Y, et al. A case demonstrating knot formation at the upper end of a ureteral stent. Hinyokika Kiyo. 2005;51:385–7.PubMedGoogle Scholar
  34. Kouba E, Wallen EM, Pruthi RS. Management of ureteral obstruction due to advanced malignancy: optimizing therapeutic and palliative outcomes. J Urol. 2008;180:444–50.CrossRefGoogle Scholar
  35. Krambeck AE, DiMarco DS, Gettman MT, et al. Ureteroiliac artery fistula: diagnosis and treatment algorithm. Urology. 2005;66:990–4.CrossRefGoogle Scholar
  36. Kwon JK, Cho KS, Oh CK, et al. The beneficial effect of alpha-blockers for ureteral stent-related discomfort: systematic review and network meta-analysis for alfuzosin versus tamsulosin versus placebo. BMC Urol. 2015;15:55.CrossRefGoogle Scholar
  37. Lamb AD, Vowler SL, Johnson R, et al. Meta-analysis showing the beneficial effect of α-blockers on ureteric stent discomfort. BJU Int. 2011;108:1894–902.CrossRefGoogle Scholar
  38. Lee BK, Paick SH, Park HK, et al. Is a 22 cm ureteric stent appropriate for Korean patients smaller than 175 cm in height? Korean J Urol. 2010;51:642–6.CrossRefGoogle Scholar
  39. LeRoy AJ, Williams HJ Jr, Segura JW, et al. Indwelling ureteral stents: percutaneous management of complications. Radiology. 1986;158:219–22.CrossRefGoogle Scholar
  40. Liatsikos E, Kallidonis P, Kyriazis I, et al. Ureteral obstruction: is the full metallic double-pigtail stent the way to go? Eur Urol. 2010;57:480–6.CrossRefGoogle Scholar
  41. Lim KT, Kim YT, Lee TY, et al. Effects of tamsulosin, solifenacin, and combination therapy for the treatment of ureteral stent related discomforts. Korean J Urol. 2011;52:485–48.CrossRefGoogle Scholar
  42. Lingeman JE, Preminger GM, Goldfischer ER, et al. Assessing the impact of ureteral stent design on patient comfort. J Urol. 2009;181:2581–7.CrossRefGoogle Scholar
  43. Lojanapiwat B. Colonization of internal ureteral stent and bacteriuria. World J Urol. 2006;24:681–3.CrossRefGoogle Scholar
  44. McCullough MC, Oh EE, Lucci JA 3rd, et al. Ureteroarterial fistula. J Obstet Gynaecol. 2012;32:617–20.CrossRefGoogle Scholar
  45. Michalopoulos AS, Tzoufi MJ, Theodorakis G, et al. Acute postoperative pulmonary thromboembolism as a result of intravascular migration of a pigtail ureteral stent. Anesth Analg. 2002;95:1185–8.CrossRefGoogle Scholar
  46. Mohan-Pillai K, Keeley FX Jr, Moussa SA, et al. Endourological management of severely encrusted ureteral stents. J Endourol. 1999;13:377–9.CrossRefGoogle Scholar
  47. Moltzahn F, Haeni K, Birkhäuser FD, et al. Peri-interventional antibiotic prophylaxis only vs continuous low-dose antibiotic treatment in patients with JJ stents: a prospective randomised trial analysing the effect on urinary tract infections and stent-related symptoms. BJU Int. 2013;111:289–95.CrossRefGoogle Scholar
  48. Monsky WL, Molloy C, Jin B, et al. Quality-of-life assessment after palliative interventions to manage malignant ureteral obstruction. Cardiovasc Intervent Radiol. 2013;2013(36):1355–63.CrossRefGoogle Scholar
  49. Park J, Yoo C, Han DH, et al. A critical assessment of the effects of tamsulosin and solifenacin as monotherapies and as a combination therapy for the treatment of ureteral stent-related symptoms: a 2 × 2 factorial randomized trial. World J Urol. 2015;33:1833–40.CrossRefGoogle Scholar
  50. Paz A, Amiel GE, Pick N, et al. Febrile complications following insertion of 100 double-J ureteral stents. J Endourol. 2005;19:147–50.CrossRefGoogle Scholar
  51. Quillin SP, Darcy MD, Picus D. Angiographic evaluation and therapy of ureteroarterial fistulas. AJR Am J Roentgenol. 1994;162:873–8.CrossRefGoogle Scholar
  52. Richards MM, Khalil D, Mahdy A. Successful treatment of stent knot in the proximal ureter using ureteroscopy and holmium laser. Case Rep Med. 2011;2011(2011):50219.Google Scholar
  53. Riedl CR, Plas E, Hübner WA, et al. Bacterial colonization of ureteral stents. Eur Urol. 1999;36:53–9.CrossRefGoogle Scholar
  54. Robert M, Boularan AM, El Sandid M, et al. Double-J ureteric stent encrustations: clinical study on crystal formation on polyurethane stents. Urol Int. 1997;58:100–4.CrossRefGoogle Scholar
  55. Sancaktutar AA, Tepeler A, Söylemez H, et al. A solution for medical and legal problems arising from forgotten ureteral stents: initial results from a reminder short message service (SMS). Urol Res. 2012;40(3):253–8.CrossRefGoogle Scholar
  56. Shalaby E, Ahmed AF, Maarouf A, et al. Randomized controlled trial to compare the safety and efficacy of tamsulosin, solifenacin, and combination of both in treatment of double-j stent-related lower urinary symptoms. Adv Urol. 2013;2013(2013):752382.PubMedPubMedCentralGoogle Scholar
  57. Sighinolfi MC, De Stefani S, Micali S, et al. A knotted multi-length ureteral stent: a rare complication. Urol Res. 2005;33:70–1.CrossRefGoogle Scholar
  58. Singh I, Gupta NP, Hemal AK, et al. Severely encrusted polyurethane ureteral stents: management and analysis of potential risk factors. Urology. 2001;58:526–31.CrossRefGoogle Scholar
  59. Sivalingam S, Streeper NM, Sehgal PD, et al. Does combination therapy with tamsulosin and tolterodine improve ureteral stent discomfort compared with tamsulosin alone? A double-blind, randomized, controlled trial. J Urol. 2015;195:385–90.CrossRefGoogle Scholar
  60. Slaton JW. Proximal ureteral stent migration: an avoidable complication? J Urol. 1996;155:58–61.CrossRefGoogle Scholar
  61. Slaton JW, Kropp KA. Proximal ureteral stent migration: an avoidable complication? J Urol. 1996;155:58–61.CrossRefGoogle Scholar
  62. Tang VC, Gillooly J, Lee EW, et al. Ureteric stent card register—a 5-year retrospective analysis. Ann R Coll Surg Engl. 2008;90:156–9.CrossRefGoogle Scholar
  63. Tehranchi A, Razaei Y, Khalkhali H, et al. Effects of terazosin and tolterodine on ureteral stent related symptoms: a double-blind placebo-controlled randomized clinical trial. Int Braz J Urol. 2013;39:832–40.CrossRefGoogle Scholar
  64. Veenstra GM, Fossion LMCL, Debonnaire G, et al. Endovascular treatment of a right-sided ureteroiliac fistula in a patient with a simultaneous left-sided ureteroileal fistula. Case Rep Urol. 2011;2011:284505.PubMedPubMedCentralGoogle Scholar
  65. Wall I, Baradarian R, Tangorra M, et al. Spontaneous perforation of the duodenum by a migrated ureteral stent. Gastrointest Endosc. 2008;68:1236–8.CrossRefGoogle Scholar
  66. Weedin JW, Coburnt M, Link RE. The impact of proximal stone burden on the management of encrusted and retained ureteral stents. J Urol. 2011;185:542–7.CrossRefGoogle Scholar
  67. Wong LM, Cleeve LK, Milner AD, et al. Malignant ureteral obstruction: outcomes after intervention. Have things changed? J Urol. 2007;178:178–83.CrossRefGoogle Scholar
  68. Zhou L, Cai X, Li H, et al. Effects of α-blockers, antimuscarinics, or combination therapy in relieving ureteral stent-related symptoms: a meta-analysis. J Endourol. 2015;29:650–6.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Department of Urology, Kidney Transplant CenterHyogo College of MedicineNishinomiyaJapan

Personalised recommendations