Facilitation of difficult percutaneous ureteral stent insertion.

Attempts to convert percutaneous nephrostomies into internal ureteral stents were done by antegrade techniques in 26 patients in whom a retrograde approach for stent placement previously had been unsuccessful. There appeared to be complete obstruction of the ureter on antegrade urography in 8 patients but the area of the obstruction was traversed and a ureteral stent was inserted. Dilation of malignant or benign ureteral strictures followed by ureteral stent placement was done in 15 patients. The major difficulties in antegrade ureteral stent placement were marked ureteral tortuosity and ureteral kinking. The tortuosity was managed by insertion of a pigtail catheter in these instances. The pigtail catheter was wedged in the region of the kink and passed through the area of difficulty by manipulation of the catheter and guide wire under fluoroscopy. Another problem encountered was coiling and kinking of the catheter in a dilated renal pelvis. This problem was resolved by the transparenchymal approach for percutaneous nephrostomy and application of torque guide wires and stiffer torque control catheters. We herein demonstrate that apparent complete obstruction of the ureter on pyelography does not preclude consideration of ureteral stent insertion and that an antegrade approach often is successful when a ureteral stent cannot be placed by a retrograde technique.