Arab Journal of Urology (2013) 11, 148–151 Arab Journal of Urology (Ofﬁcial Journal of the Arab Association of Urology) www.sciencedirect.com STONES/ENDOUROLOGY ORIGINAL ARTICLE Double-J ureteric stenting in pregnancy: A single-centre experience from Iraq a b c d Ho-Yin Ngai , Hawre Qadir Salih , Ayad Albeer , Ismaeel Aghaways , e, Noor Buchholz Department of Urology, Queen Elizabeth Hospital, Hong Kong, China Consultant Urologist, Shorsh Hospital, Sulaimani, Iraq Department of Urology, Medical City Hospital, Baghdad, Iraq Department of Surgery, University of Sulaimani, Sulaimani, Iraq Department of Urology, Bartshealth NHS Trust, The Royal London Hospital, London, UK Received 26 January 2013, Received in revised form 12 February 2013, Accepted 15 February 2013 Available online 25 March 2013 KEYWORDS Abstract Objectives: To evaluate the safety and effectiveness of ureteric stenting with a JJ stent in pregnant women, to relieve renal obstruction and intractable ﬂank Hydronephrosis; pain. Pregnancy; Patients and methods: All pregnant patients presenting with intractable ﬂank Stent pain, with or without complications, to a tertiary national teaching hospital in Kurd- istan/Iraq, and necessitating ureteric stenting with a JJ stent, were prospectively ABBREVIATION assessed for this study between March 2008 and March 2010. US, ultrasonography Results: In all, 30 pregnant patients presented with intractable ﬂank pain necessi- tating JJ ureteric stenting during the 25 months. Intractable ﬂank pain (23 patients, 77%) was the most common indication for ureteric stenting, followed by ﬂank pain with clinical sepsis (six, 20%). All pregnant women had hydronephrosis on ultraso- nography (US), and 12 (40%) had evidence of coexisting renal stones on US. All ureteric stents were inserted successfully. The mean (range) indwelling time was 47.4 (3–224) days. Radiologically, 14 (47%) and 15 (50%) had complete resolution of the hydronephrosis on follow-up US in late pregnancy and in the early postnatal Corresponding author. Tel.: +44 2035942662. E-mail address: email@example.com (N. Buchholz). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. http://dx.doi.org/10.1016/j.aju.2013.02.002 JJ in pregnancy 149 period, respectively. Two-thirds of patients had a clinical improvement immediately (15, 50%) and soon after (ﬁve, 17%) surgery. Stent encrustation (three, 10%), stent migration (three, 10%) and stent irritation (ﬁve, 17%) were reported as complica- tions. The post-natal evaluation conﬁrmed that half the patients had urinary calcu- lus disease. Conclusion: Ureteric stenting during pregnancy can be safe, with no intraopera- tive imaging and even under local anaesthesia. It provides good symptom relief and has a low complication rate. We therefore advocate it as a ﬁrst-line treatment in pregnant women with therapy-resistant ﬂank pain. ª 2013 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. Introduction The ureter was stented either under local, spinal or general anaesthesia, using pregnancy-approved antibi- Pregnant women can have some degree of hydronephro- otic prophylaxis. The procedure was conducted using a sis, as a result of the physiological changes in pregnancy. 22-F rigid cystoscope. A 4.7-F 26-cm JJ ureteric stent It is not uncommon to have pregnant women with (Flexater ureteric stent, Gallini Medical Devices, Italy) intractable ﬂank pain resulting from renal obstruction was inserted retrogradely over a guidewire. The posi- and who thus require hospital admission, and the condi- tioning of the ureteric stent was assumed to be correct tion is more complicated if associated with stone disease. after a smooth insertion, observation of stent markings The incidence of symptomatic urinary calculi in preg- and the adequate distal coiling of the stent inside the nancy is 1/244 to 1/3300 [1–4], and it is estimated that bladder. Immediate US was used for proximal coil posi- the incidence of urinary calculus disease in pregnant wo- tioning. No ﬂuoroscopy was used during the procedure. men is similar to that in nonpregnant women of the The patient’s clinical signs and symptoms were clo- same age . sely monitored after the procedure. Patients were dis- Managing ﬂank pain during pregnancy can be chal- charged when the ﬂank pain subsided, or when the lenging. Standard radiographic investigations and surgi- sepsis and the acute renal failure were resolved. Antibi- cal treatments, as used in nonpregnant women, cannot otic prophylaxis was maintained in all stented patients be applied easily due to concerns about ionising radia- to minimise bacteriuria and stent colonisation through- tion and the potential harm to the fetus. out the remaining course of pregnancy. A follow-up Thus we present data from a single institution in Iraq, with renal function tests and US was arranged weekly assessing the safety and effectiveness of ureteric stenting in the ﬁrst month, then monthly throughout pregnancy. with a JJ stent in pregnant women to relieve renal After delivery, patients had a plain abdominal ﬁlm, obstruction and intractable ﬂank pain. US and/or IVU to assess the continued presence of renal obstruction and/or stone disease, and consequently the Patients and methods need for further treatment. Data were prospectively collected from the Department Results of Urology of a tertiary national teaching hospital in Iraq, from March 2008 to March 2010. All pregnant pa- In all, 30 patients were enrolled into the study during the tients presenting with intractable ﬂank pain, with or 25-month period. Their baseline values are shown in Ta- without complications in the form of kidney infection ble 1. Intractable ﬂank pain (23 patients, 77%) was the and deterioration of renal function, and necessitating most common indication for ureteric stenting, followed JJ ureteric stenting, were enrolled in the study. Intracta- by ﬂank pain with clinical sepsis (six, 20%). Only one ble ﬂank pain was deﬁned as ﬂank pain that could not case (3.3%) presented with anuria and acute renal fail- be relieved by conservative management comprising ure due to bilateral ureteric obstruction. bed rest, hydration and the use of paracetamol. All pregnant women had hydronephrosis on US, and Patients were assessed with a complete medical 12 (40%) had evidence of coexisting renal stones on US. history and comprehensive physical examination. A All ureteric stents were inserted successfully. Local mid-stream urine sample was collected for microscopy, anaesthesia (27, 90%) was the predominant form of culture and sensitivity testing. Blood tests included a anaesthesia. No percutaneous nephrostomy was needed. complete blood count and a renal function assessment. The mean (range) indwelling time was 47.4 (3–224) Trans-abdominal ultrasonography (US) provided evi- days. Radiologically, 14 (47%) and 15 (50%) of the wo- dence of hydronephrosis and, where possible, urinary men had complete resolution of the hydronephrosis on calculus disease. follow-up US in late pregnancy and the early postnatal 150 Ngai et al. one level, leading to ureteric dilatation . Urinary sta- Table 1 The baseline demographic data of the 30 patients. sis, as a result, might have a role in urinary calculus Variable Mean (range) or n (%) formation and renal colic in these women. Age (years) 27.2 (18–38) Although pain from renal colic is the most common non-obstetric reason for hospital admission during preg- Trimester on presentation First 5(17) nancy , the timely diagnosis and subsequent manage- Second 15(50) ment in pregnant women can be challenging. It was Third 10(53) reported that 28% of pregnant women having obstruct- Parity ing stones were initially misdiagnosed as having other Primiparous 11(37) pathologies, such as appendicitis and placental abruption Multiparous 19(63) . While ﬂank pain (23, 77%) was the most common Positive history of urinary calculus 11(37) presenting symptom in this series, ﬂank pain with sepsis Preoperative US ﬁndings (six, 20%) also features as an important presentation . Presence of hydronephrosis 30(100) However, the clinical presentation might not always Left 11(37) be reliable in predicting stone disease in pregnant wo- Right 14(47) Bilateral 5(17) men with ﬂank pain . The role of radiographic inves- Presence of stones in kidneys 12(40) tigations in various trimesters of pregnancy has been the Left 6(20) subject of a long-standing and ongoing debate, in view Right 3(10) of the potential exposure to ionising radiation of the Bilateral 3(10) developing fetus. The potential sequelae of foetal radia- Indications for ureteric stenting tion exposure are teratogenesis, mutagenesis and carci- Intractable ﬂank pain 23(77) nogenesis . Limited IVU has been used in the past Flank pain with clinical sepsis 6(20) during later pregnancy, presuming the teratogenic effect Acute renal failure 1(3) was related to the high radiation sensitivity of the em- Presumed aetiologies bryo in the ﬁrst trimester. However, mutagenic and car- Urinary calculus 12(40) Physiological 18(60) cinogenic effects in second and third trimesters cannot be neglected. As there is no well-deﬁned safe radiation dose, it is deemed safer not to use radiographic investi- period, respectively. Two-thirds of patients had a clinical gations in pregnant women . improvement in pain relief immediately (15, 50%) and Consequently, US becomes the ﬁrst-line investigation soon after (ﬁve, 17%) surgery. Three patients (10%) re- to evaluate ﬂank pain in pregnant women. While the ported no difference with ureteric stenting, and seven advantages of US are its non-invasiveness, lack of ionis- (23%) had a worsening of symptoms, with either an in- ing radiation and ready availability, it has a limited sen- creased analgesic requirement or the development of sitivity , and is further limited for accurately detecting new symptoms related to stent placement, i.e. frequency, stones, visualising the ureter, and differentiating be- urgency and haematuria. Three patients (10%) had a tween different causes of renal obstruction . Neverthe- stent migration and required subsequent revision of the less, the accuracy of US in detecting stones can be ureteric stent. Stent encrustation was found in three improved signiﬁcantly (up to 71.9%) by closely observ- (10%) patients on stent removal, and stent irritation ing the features of upper tract obstruction and interpret- (ﬁve, 17%) causing haematuria and LUTS were likewise ing them correctly, such as a hydroureter extending reported as complications (Table 2). below the pelvic brim, the asymmetric absence of ure- The postnatal evaluation conﬁrmed that half the pa- teric jets, or an elevated resistive index . tients had urinary calculus disease (Table 2). ESWL (in As renal colic in pregnant patients can be compli- eight of the 15) was used as the main treatment, while cated by severe upper-tract infection and premature la- percutaneous nephrolithotripsy (two), ureteroscopy bour , unrecognised pyonephrosis is potentially (one) and open ureterolithotomy (one) were also used life-threatening for both the mother and fetus. Given as deﬁnitive treatments. that most patients will recover with analgesia, antibiot- ics and hydration, the initial treatment should be conser- Discussion vative. However, some authors advocate early Physiological hydronephrosis and hydroureter begin in intervention after the analgesia has been shown to be the ﬁrst trimester of pregnancy. By the third trimester, ineffective . Drainage of the obstructed and infected system is indicated in patients who have symptoms up to 90% of pregnant women can have upper urinary refractory to conservative measures, i.e. ongoing sepsis tract dilatation . It is known that these physiological despite antibiotics (>48 h) and the worsening of any changes are the result of mechanical obstruction of the of renal function, pain, obstruction or hydronephrosis ureters by an enlarged uterus at the pelvic brim, as well . as the muscle-relaxing effect of an increased progester- JJ in pregnancy 151 most cases can be inserted under local anaesthesia. It Table 2 The complications of ureteric stenting with a JJ stent, provides good symptom relief and has a low complica- and the results of postnatal investigations. tion rate. We therefore advocate it as the ﬁrst-line treat- Variable n (%) ment in pregnant women with therapy-resistant ﬂank Complication pain. Stent migration 3 (10) Stent encrustation 3 (10) Bothersome LUTS 3 (10) Conﬂict of interest Gross haematuria 2 (7) None. Post-natal investigations No stone 12 (40) Renal stones 6 (20) Funding Ureteric stones 5 (17) Both ureteric stone and renal stones 4 (13) None. Not known 3 (10) References It was reported that JJ ureteric stenting can be difﬁ- cult in the third trimester due to the tortuosity of the  Butler EL, Cox SM, Eberts EG, Cunningham FG. Symptomatic nephrolithiasis complicating pregnancy. Obstet Gynecol ureter . However, others did not conﬁrm this [9– 2000;96:753–6. 12,14–16]. All patients in our series had successful  Stothers L, Lee LM. Renal colic in pregnancy. 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Arab Journal of Urology
– Taylor & Francis
Published: Jun 1, 2013
Keywords: Hydronephrosis; Pregnancy; Stent; US, ultrasonography