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Annals
of
the
Royal
College
of
Surgeons
of
England
(1988)
vol.
70
168
doubleJ
(pigtail)
uretericcatheter
insertions:
a
retrospective
review
FRANK
H
SMEDLEY
MS
FRCS
SurgicalRegistrar
JOHNRIMMER
FRCS
SurgicalRegistrar
Westminster
Hospital,
London
MARTIN
TAUBE
FRCS
Senior
SurgicalRegistrar
LYNN
EDWARDS
MChir
FRCS
Consultant
Urologist
Key
words:
URETER,
STENT
Summary
The
medical
records
of
116
patients
who
had
168
ureteric
doubleJ
(pigtail)
cathetersinserted
over
a
6-year
period
between
1981
and
1987
were
reviewed.
Eighty-five
patients
had
pigtails
insertedfor
benign
conditions
and
31
for
malignant
disease.
The
pigtail
catheters
were
inserted
cystoscopically
in
88
patients,
percutaneously
in
7
patients
and
by
open
surgery
in
21
patients.
Of
168
pigtail
catheters
used,
147
were
soft(silicone,
multilength)
and
21
hard
(polyurethane).
No
mortality
was
attributable
to
the
use
of
these
catheters
but
certain
complications
were
commonly
encountered.
Loin
discomfort
occurred
after
32
(19%)
insertions;
27
of
147
(18%)
soft
catheters
and
5
of
21
(24%)
hard
catheters.
Trigonal
irritation,
confirmed
cystoscopi-
cally
was
reported
in
26
of
147
(18%)
insertions
of
soft
catheters
and
in
6
of
the
21
(29%)
with
hard
catheters
(y,
P=0.37).
Urinary
tract
infection
(confirmed
by
urine
microscopy
and
cul-
ture)
occurred
after
46
(31%)
soft
catheter
insertions
and
after
13
oJ
21
(61%)
hard
catheter
insertions
(2
test,
P=0.O1).
Stent
migration
occurred
in
five
patients
and
obstruction
in
two.
Pigtail
catheters
are
safe
uretericstents
which
areeasy
to
insert
and
their
use
is
supported
by
this
study.
The
complications
of
associated
infection,
trigonal
irritation
and
loin
discomfort
are
relatively
common
and
still
occureven
with
soft
catheters.
Careful
monitoring
of
all
patients
with
pigtail
catheters
in
position
is
recommended.
Introduction
In
1967
Zimskind
etal.
(1)
reported
on
the
long-term
use
of
silicone
tubing
to
bypass
ureteral
obstruction
and
for
the
treatment
of
ureterovaginal
fistula.
Marmar
(2)
and
Orikasa
et
al.
(3)
improved
the
techniques
for
passing
these
stents
in
a
retrograde
fashion.
McCullough
(4)
initially
described
the
use
of
a
polyethylene
stent
with
a
'memory'
such
that
a
shepherd's
crook
configuration
reformed
after
the
tube
was
properly
placed
with
its
proximalend
in
the
renal
pelvis.
Hepperlen
et
al.
(5)
modified
a
standard
single
pigtail
polyethyleneangio-
graphic
catheter,
allowing
passage
by
a
Seldinger
tech-
Correspondence
to:
Mr
F
H
Smedley
MS
FRCS,
Westminster
Hospital,
Dean
Ryle
Street,
London
SW
1
P
2AP
nique
and
preventing
distal
but
not
proximal
dislodge-
mentFinney
(6)
completed
the
evolutionof
the
stent
with
additions
of
'Js'
or
'pigtails'
to
each
end
of
the
silicone
tubing
preventingmigration
in
either
direction.
Pigtailcatheters
are
now
widelyused
in
urological
practice.
While
the
more
rigid
polyurethane
stents
are
easier
to
advance
through
stenoses
and
occlusions
they
more
oftenlead
to
symptoms
of
bladder
irritation
(7)
and
may
be
more
prone
to
breakageand
obstruction
(8,9).
The
softersilicone
catheters
are
now
manufactured
with
an
extra
turn
on
their
lower
ends
adding
a
multilength
capability.
An
incidence
of
urinary
tract
infection
in
the
presenceof
a
foreign
body
in
the
urinary
tract
is
inevit-able.
Other
complications
include
encrustation,
renalpelvicperforation,
erosion
through
ureteral
wall
into
blood
vessels
and
bowel,
stent
breakageand
migration
(10).
Opinions
differ
on
how
long
to
leave
pigtail
stentsin
position.
There
is
also
disagreement
as
to
when
they
should
be
used
and
regarding
which
sort
of
catheter
to
choose.
Thisstudy
analyses
ourexperienceof
168
soft
and
hard
pigtail
catheter
insertions.
Patients
andmethods
The
medical
records
of116consecutive
patientstreated
at
the
Westminster
and
St
Stephen's
Hospitals
between
the
years
of
1981
and
1987werereviewed.
They
had
a
total
of
168
pigtail
catheters
successfully
inserted.
The
typeof
pigtail
catheters
used
were
either
soft
(silicone-
multilength
(Cook
International))
or
hard
(polyure-
thane-single
length
(Cook
International)).
A
tabulatedrecordof
sex,
age,
number
and
type
of
catheter
for
each
patient
was
prepared.
Also
the
indica-
tionfor
insertion,
method
of
insertion,
length
oftime
in
position,
length
of
hospital
stay,
diagnosis,
complica-
tions,
reason
for
removal
and
outcome
were
recorded.
A
urinary
tract
infection
was
defined
as
a
positive
urine
culture
at
any
time
when
a
catheter
was
inposi-
tion.
Trigonal
irritation
was
said
to
be
present
when
symp-
tomsof
suprapubic
pain
or
urinary
frequency
(in
the
 
378
F
H
Smedley
et
al.
absence
of
infection)
were
associated
withredness
and
oedema
of
the
trigone,
noted
cystoscopically
at
the
timeof
change
or
removal
of
the
catheters.
Early
patients
tended
to
havehard
catheters
inserted
as
these
were
the
only
type
of
catheter
available
at
the
time.
However,
even
when
soft
multilength
catheters
became
available
we
elected
to
use
hard
catheters
to
negotiateparticularly
tight
ureteric
strictures.
With
all
insertions
X-ray
visualisation
usingan
image
intensifier
wasemployed
to
ensure
correct
stent
placement.
Results
Of
the
116
patients
there
were
74
men
and
42
women.
A
total
of
168
pigtail
catheters
were
inserted
and
of
these
147
were
soft
and
21
hard.
The
mean
age
was
50.3
years
(range
21-83
years).
The
mean
age
of
thepatients
(59
males,
36
females)
with
soft
catheters
was
41.6
years
(range
21-74
years)
and
the
mean
age
of
the
patients
(15
males,
6
females)
with
hard
catheters
was
53.4
years
(range
23-83
years).
Eighty-eightpatients
had
catheters
inserted
by
the
cystoscopic
route,
21
by
open
operation
and
7
percu-
taneously.
A
total
of132
pigtail
catheters
was
insertedcystoscopically,
29
at
open
operation
and
7
percu-
taneously.
Thirty-one
patients
had
cathetersinserted
for
malignant
obstruction
and
85
for
benign
conditions
(Table
I).
The
mean
length
of
hospital
stay
for
the
entire
group
was
15.9
days
(range
2-63
days).
For
the
soft
pigtails
the
mean
length
of
hospital
stay
was
15.3
days
and
for
the
hard
pigtails
17.5
days(P>0.1,
Student's
t
test).
The
mean
length
of
time
the
pigtails
were
left
insitu
was
79
days
(range
1-366
days).
In
the
hardgroup
the
mean
time
was
51
days
(range
5-180
days).
The
softstents
remained
in
position
for
a
mean
of
83
days
(range
1-366
days).
We
failed
to
insert
pigtail
catheters
in
14
by
the
cystoscopic
route,
a
failure
rate
of
14%
(14
of
99
pati-
ents)
and
in
12
of
these
we
proceeded
to
open
surgery.Fifteen
of
the
29
(52%)
open
insertions
were
performed
electively.
The
conditions
from
which
the14
patients
who
had
failed
cystoscopic
insertions
were
suffering
are
summarised
in
Table
II.
TABLE
i
Indications
for
insertion
of
168
pigtail
catheters
(116
patients)
Mode
of
insertion
Type
C
O
P
H
S
Malignant
obstruction
45
37
44
7
38
Benign
and
postoperative
stricture
22
21
1
-
4
18
Ureterostomies
3
-
-
3
1
2
Functional
obstruction
17152
-
0
17
Postoperative
urinary
fistula
13
12
1
-
-
13
Urinary
fistula
as
a
result
of
RTA
3
1
2
-
-
3
Postoperative
splinting
17
-
17
-
3
14
Stones
(surgery
or
ESWL)
48
46
2
-
6
42
Total
168
13229
7
21
147
C=cystoscopic,
O=Open
S=Soft
surgery,
P=Percutaneous,
H=Hard,
TABLE
II
Causes
of
obstruction
in
the
14
patients
who
had
failed
insertion
of
pigtail
catheters
Cause
of
obstruction
n=14
Tuberculosis
of
ureter
1
Retroperitoneal
fibrosis
(benign)
4
Stone
in
ureter
2
Malignant
strictures
4*
Urinary
fistula
following
accident2t
Postoperativeurinary
fistula
1+
*
One
transitional
cell
carcinoma
of
ureter,
two
carcinoma
of
cervix,
one
carcinoma
of
rectum
t
Road
traffic
accidents
with
multiple
injuries
including
ruptured
ureters
+
Following
repair
of
ureterafter
hysterectomy
TABLE
III
Complications
associated
with
insertion
of
pigtail
cathetersn
Soft
Hard
No.
of
insertions
168
147
21
Loin
discomfort32
(19%)
27
(18%)
5
(24%)
Trigonal
irritation(at
cystoscopy)
32
(19%/)
26
(18%)
6
(29%)
Stent
migration
5
(3%)
5
(3%)
0
Stent
obstruction
2
(1.0%)
1
(0.7%)
1
(5%)
Urinary
tract
infection
(positive
MSU)
59
(35%)
46
(31%)
13
(62%)
Stent
breakage
1
(0.6%)
1
(0.7%)
0
Complications
are
summarised
in
Table
III.
No
mor-
tality
was
attributable
to
the
useof
pigtail
catheters.
Loin
discomfort
wasnoted
in
32
(19%)
of
the
168
insertions.
Trigonal
irritation
noted
cystoscopically
wasfound
in
26
of
147
(18%)
insertions
of
soft
catheters
and
in
6
of
the
21
(29%)
with
hard
catheters
(X2
test,
P=0.37).Urinary
tract
infection
occurred
after
46
(31%)
of
the
147
soft
catheter
insertions
and
after13
of
21
(61%)
hard
catheter
insertions
(X2
test,
P=0.012).
Stent
migration
occurred
infive
patients
and
obstruction
in
two.
Discussion
Double
J
(pigtail)
uretericcatheters
must
be
soft
enough
to
avoid
problems
of
urinary
tract
irritation
and
stent
breakage,
but
must
be
rigid
enough
to
permit
introduc-
tion
by
axialforce
through
strictures
and/or
neoplasms
involving
the
ureter
(6-9).
It
has
been
reported
that
silicone
stents
do
not
cause
bladder
irritation
and
that
they
have
superior
durability
to
other
stents
(6,8,11).
With
the
addition
of
an
extra
curl
in
the
lower
end,
soft
stents
have
the
ability
to
adapt
to
differentureteral
lengths.
Our
experience
suggests
that
bladder
irritation
and
loin
discomfort
still
occur
frequently
even
when
soft
multilength
catheters
are
used.
Urinary
tract
infection
was
more
common
in
patients
with
hard
catheters.
We
did
not
use
postoperative
or
peroperative
prophylactic
antibiotics
routinely,
but
some
authors
have
suggested
that
this
practice
may
decrease
the
high
incidence
of
urinary
tract
infectionthat
tends
to
be
associated
with
of 00

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