A simple technique for retroperitoneal laparoscopic JJ stenting of the ureter
Version of Record online: 16 APR 2003
Volume 91, Issue 7, pages 725–726, May 2003
How to Cite
Gaur, D.D., Joshi, N.R., Dubey, M. and Acharya, U.P. (2003), A simple technique for retroperitoneal laparoscopic JJ stenting of the ureter. BJU International, 91: 725–726. doi: 10.1046/j.1464-410X.2003.04184.x
- Issue online: 16 APR 2003
- Version of Record online: 16 APR 2003
- Accepted for publication 28 January 2003
JJ stenting of the ureter is required after ureterolithotomy or uretero-ureterostomy and is usually undertaken cystoscopically before a laparoscopic procedure. However, this involves an additional procedure, and the indwelling stent can make manipulation and laparoscopic suturing of a transected ureter difficult. Moreover, cystoscopic retrograde stenting of the ureter may not be possible in all patients. Therefore, sometimes the ureter is stented at the end of a laparoscopic procedure, using a previously placed open-ended catheter lying just distal to the point of ureteric obstruction.
During open surgery a stent is usually inserted towards the end of the procedure and it is logical that the same be done during a laparoscopic procedure. Although laparoscopic JJ stenting of the ureter has been described previously it requires much dexterity and therefore was not subsequently reported . We herein describe a simpler technique of laparoscopic JJ stenting of the ureter, which was successfully used in five patients undergoing retroperitoneal laparoscopic ureterolithotomy for impacted upper ureteric stones.
PREPARING THE STENT
An appropriate JJ stent is selected and placed over the plain X-ray of the patient with the closed end lying over the bladder and the open end over the kidney region. The part of the stent overlying the stone is marked. A stylet is made by cutting a guidewire at its stiff end, using a wire-cutting scissors or a chisel, to ≈ 2 cm shorter than the total length of the JJ stent. The smooth uncut end is passed down to the closed end through a hole in the JJ stent next to the mark. The cut end is then passed towards the other end through a hole in the JJ stent on the other side of the mark. By holding 5 cm of the exterior part of the stylet, it is adjusted so that its ends fall short by 5 and 15 mm at the open and the closed ends, respectively. The JJ stent with its open end almost straight and the closed end slightly curved is now ready for laparoscopic insertion (Fig. 1).
INSERTING THE STENT
Retroperitoneal laparoscopic upper ureterolithotomy is performed with the patient in a lateral position using a renal angle, a mid-axillary and an anterior axillary port. The closed end of the stent is lubricated and passed through a 3 or 5 mm working port at the renal angle. It is manipulated into the distal ureter through the ureterotomy using the other working port, and is pushed down into the bladder until its upper end snaps into the ureter (Fig. 2a). The stent easily coils up into the bladder during this manoeuvre. The upper end is then slowly pushed into the renal pelvis with a curved 5 mm grasper until ≈ 2 cm of the ex-dwelling part of the stylet has gone beyond the ureterotomy incision.
The stylet is now grasped with a 5-mm grasper and is extracted, leaving the JJ stent in position. During this manoeuvre, the incised ureter with the stent is steadied with a 5-mm ureteric forceps to prevent extrusion of the stent (Fig. 2b). The correct positioning of the stent is confirmed by fluoroscopy and adjustments made if required.
COMPARISON WITH OTHER METHODS
There is only one report of laparoscopic JJ stenting of the ureter ; the procedure did not become popular because it was complex, and involved passing two guidewires proximally and distally through the ureterotomy, followed by pushing down a folded JJ stent through a 5-mm or a smaller port. The procedure is cumbersome as it involves laparoscopic passage of two guidewires up and down the ureter through the same port. These wires can become entangled and create problems when the folded JJ stent is being pushed down. Moreover, the introduction of the two ends of the folded stent through the ureterotomy in opposite directions might damage the ureter.
The new technique does not involve the use of guidewires and only one end of the stent is introduced into the ureter. The other end of the stent is easily placed through the ureteric incision. However, the stent needs to be pushed up into the renal pelvis, but being a simple up and down movement it is not so difficult.
ADVANTAGES AND DISADVANTAGES
The method is simple, and was successful in all five patients, with a mean stenting time of 12 min. Its main advantage is that it avoids the need for previous cystoscopy, but also avoids the difficulties of exposing the peritoneum of the patient during the laparoscopic procedure to insert the stent when a previous cystoscopic attempt has failed. This often requires some change in the position of the patient, and moving the instrument tray placed over the hip of the patient, to obtain the proper alignment of the guidewire.
The present procedure is reasonably safe; there is little risk of ureteric perforation as the ends of the stent are floppy, because the stylet is 5 and 15 mm shorter at the ends. There is little strain on the ureter as the stent is only passed down the ureter into the bladder to form a coil. The formation of the coil by the stent in the bladder is atraumatic, and none of the patients had postoperative haematuria. Indeed, the springing action of the coil makes the introduction of its upper end into the renal pelvis easier.
The technique allows perfect placement of the stent, and in none of the five patients was there any need to adjust the position of the stent after a fluoroscopic check. The other advantage of the method is that if such a stent becomes commercially available, it could also be used for an open procedure.
The most difficult part of the procedure was the initial introduction of the closed end of the stent into the ureter. However, this was solved once the closed end was angled by about 30°, by making the stylet 15 mm shorter at this end. Care should be taken to avoid submucosal or subserosal dissection during initial insertion into the ureter. Nevertheless, this normally should not happen as the stent tip is flexible. Also, the ureter and the stent should be held with a ureteric or Fallopian tube-holding forceps (Fig. 2b) while the stylet is being extracted, and a grasper should not be used, to avoid inadvertent ureteric damage.