Clinical Radiology (2002) 57: 5962 doi:10.1053/crad.2001.0737, available online at http://www.idealibrary.

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Choosing the Correct Length of Ureteric Stent: A Formula Based on the Patient's Height Compared with Direct Ureteric Measurement
J . M . P I L C H E R , U . PAT E L Department of Radiology, St George's Hospital, London, U.K.
Received: 20 September 2000 Revised: 29 January 2001 Accepted: 6 February 2001

AIM: To evaluate a formula based on the patient's height for choosing the correct length of ureteric stent and to compare its accuracy with that of direct ureteric length measurement. METHODS: Thirty-ve patients (41 ureters) with ureteric obstruction were prospectively studied. All received Percuex 8F double pigtail ureteric stents. Stent lengths were chosen according to patient height: 5 5 ft 10 in (5178 cm) 22 cm; 5 ft 10 in to 6 ft 4 in (178193 cm) 24 cm; 4 6 ft 4 in (4193 cm) 26 cm. The nal stent position was graded using a 5-point scale (0 representing ideal length, with 2 and 2 being too short and too long respectively). Stent length acceptability using direct ureteric measurement was then estimated using the same 5-point scale; and the results compared. RESULTS: Patient's height correctly predicted stent length in the majority of ureters (grade 0 61%), with no stent being too short. In comparison, direct ureteric measurement oversized the stent in 83%, correctly predicting stent length in only 17%. CONCLUSION: Patient's height is a more reliable guide to ureteric stent length than direct ureteric measurement, particularly in the dilated and tortuous ureter. This may be because the redundant ureter is capable of signicant shortening under the inuence of the ureteric stent. Pilcher, J. M. and Patel, U. # 2002 The Royal College of Radiologists (2002) Clinical Radiology 57, 5962. Key words: ureter, stent, ureteric stent, stent length, ureteric obstruction.

Choosing the correct length of ureteric stent is important to ensure trouble-free drainage. Too long a stent can result in trigonal irritation, too short a stent may retract, necessitating its replacement. Methods described to determine the correct length of ureteric stent are: (1) direct measurement of the ureter itself using a guidewire [1]; or (2) endocatheter ruler [2]; (3) a formula that calculates the stent length from a pre-procedure intravenous urogram (IVU) [3]. In the authors' experience, the third method is often impractical, as not all patients will have an IVU, while direct ureteric measurement is of poor reliability. Many antegrade stents are now inserted as a primary procedure, without initial nephrostomy to reduce ureteric redundancy, and we have found that direct measurement tends to overestimate stent length. We have therefore developed a formula based on the patient's height to determine ureteric stent length; its performance against that of direct ureteric measurement by guidewire was formally assessed in a prospective study.
Author for correspondence: J. M. Pilcher, Department of Imaging, Hammersmith Hospital, Du Cane Road, London W12 0HS, U.K. Fax: 44 (0) 20 8383 3121; E-mail: pilmac@waitrose.com Guarantor of study: U. Patel 0009-9260/02/010059+04 $35.00/0

METHOD

Thirty-ve patients (41 ureters) were studied. There were 17 women and 18 men, with an age range of 1889 years. The underlying cause of ureteric obstruction was malignancy in 33 ureters ( primary pelvic tumour or metastatic disease) and benign disease in 8 (1 retroperitoneal brosis, 2 ischaemic stricture and 5 renal calculi). The duration of obstruction prior to stenting varied from 1 day to months, and all had dilated ureters of varying degrees. In 39 cases antegrade ureteric stenting was successfully carried out as a primary procedure while the remaining two ureters were stented following 48 hours of external drainage. All procedures were carried out with the patient positioned prone or prone-oblique. Having accessed the pelvicalyceal system, a guidewire (0.35-inch standard J-wire or angled hydrophilic wire) was manipulated down into the bladder and the ureteric length measured as follows: A 6.5F single end-hole catheter was passed over the guidewire into the bladder and the tip of the guidewire positioned within the bladder just beyond the vesicoureteric junction (VUJ). A kink was made in the wire at
# 2002 The Royal College of Radiologists

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Table 1 Length of stent used according to patient height Patient height (Feet and inches) 55 ft 10 in 5 ft 10 in6 ft 4 in 46 ft 4 in (cm) 5178 178193 4193 22 24 26

CLINICAL RADIOLOGY

Stent length (cm)

This formula does not apply if there has been an alteration in either of the two xed points (the pyelo-ureteric junction or the vesicoureteric junction), e.g. by large bladder tumour or an ileal conduit.

(Table 2 and Fig. 1). To assess whether direct measurement would have achieved better results, stent position grades were then estimated as if the stent had been chosen according to the measured ureteric length using the same grading system. If direct ureteric length indicated the use of a stent one size shorter or longer than that inserted, the estimated grade was decreased or increased by one respectively. Likewise two changes in stent size from that actually inserted led to a corresponding increase or decrease in the estimated position grade by two. For easy comparison, the results of the two stent choices were incorporated into a bar chart (Fig. 2).

the catheter hub and the guidewire was then withdrawn until its tip reached the renal pelvis. A second kink was made in the guidewire at the catheter hub and the distance between the two kinks taken to be the actual ureteric length. This information was not used to select the stent length, but recorded for later comparison. The length of ureteric stent was then chosen according to the patient's height (Table 1), this formula being based upon previous (unpublished) experience in our department. In all cases an 8F Percuex ureteral stent (Medi-tech1, Boston Scientic, Natwick, MA, U.S.A.) of 22 cm, 24 cm, or 26 cm was inserted. On six occasions an alternative length of stent to that indicated by the patient's height was used; in four cases this was because the correct choice of stent was unavailable; in two cases patients had large bladder tumours centred around the VUJ. Once the stent had been deployed, its nal position on uoroscopy was subjectively graded, using a ve-point scale
Table 2 Grading system to score nal ureteric stent position Grade 2 1 0 1 2 Stent position Unacceptably short Acceptably short Ideal Acceptably long Unacceptably long

RESULTS

The range of patient height was 5 ft 0 in to 6 ft 1 in (152 cm185 cm; mean 169.4 cm) and the measured ureteric length varied from 22 cm to 35 cm (mean 27.4 cm). Of the 41 stents inserted, more were graded as ideal (n 25, 61%) using patient's height than by direct ureteric measurement (n 7, 17%) (see Fig. 2). Direct measurement overestimated stent size in the vast majority of cases (83%), and in no case did it improve the stent grade (i.e. grade moved towards 0). Furthermore, none of the inserted stents were too short (grade 2, requiring replacement), with only 3 (7%) being graded as 1. Although three (7%) stents were deemed unacceptably long in position, none of these was replaced as the patients did not complain of any immediate discomfort.

Position of the stent pigtails Stent drainage holes beyond PUJ proximally or above VUJ distally Stent drainage holes above PUJ proximally and beyond VUJ distally but pigtails poorly formed Proximal pigtail formed within PUJ Distal pigtail formed and projecting just beyond VUJ Distal pigtail formed beyond VUJ but up against bladder trigone Distal pigtail crossing bladder midline/coiling within bladder

PUJ pelvi-ureteric junction. VUJ vesico-ureteric junction.

GRADES: 2

+1

+2

PUJ

VUJ

Fig. 1 Fluoroscopic grading system used for nal stent position. See Table 2 for description of grades. PUJ pelvi-ureteric junction; VUJ vesico-ureteric junction.

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Table 3 Exceptions to height determined stent length Number (total 6) 2 2 1 1 Size of stent used (cm)/size of stent indicated by patient height (cm) 22/24 24/22 24/22 26/24 Reason for exception Stent availability Large bladder tumour Final position grade 1 1 1 1

30 25 25

29

Number of stents

20

Patient height

15 10 10 7

Direct ureteric measurement

5 5 0 0 2 0 3 0 1 0 Grades
Fig. 2 Position grades for height determined stents and estimated grades for stents as if chosen by direct ureteric measurement. See Table 2 for explanation of grading system.

Of the four cases in which an alternative stent size was used because the correct length was unavailable, two received stents one size longer and two received stents one size shorter than that indicated by their height. Interestingly their nal stent position scores reect this (Table 3). Both cases with large bladder tumours at the VUJ received stents one size longer than indicated by their height in order to allow the distal pigtail of the stent to form within the bladder. Again this was reected in their nal stent position scores (Table 3). In all cases the discrepancy seen between ureteric length and stent size according to patient height was independent of the underlying disease process, side of ureteric obstruction, or calyx of entry (upper/mid/lower pole).

DISCUSSION

Ureteric stents are manufactured in a variety of lengths ( from 20 cm to 28 cm) and the choice needs to be individualized for each patient. Although antegrade multilength stents are marketed, these use softer polymers to allow the pigtail to unfurl to the required length and in our experience upper pigtail positioning is often dicult. Direct ureteric length measurement to determine the correct size of

stent seems logical and two methods have been described: the rst is the guidewire technique [1,5] as used in this study; the second is by the use of an endocatheter ruler (a catheter with radio-opaque markings at set intervals) [2]. However, there are no published data of clinical performance of either method beyond the initial descriptive papers [1,2]. Our experience of direct measurement has been disappointing. As shown in this study, it tends to oversize the ureteric stent, particularly in those with tortuous ureters; sometimes the measured length was over 32 cmlonger than any commercially available stent. The mean ureteric length in this study was over 27 cm, and direct ureteral measurement would have resulted in the majority of stents being long (83%). In comparison, patient height accurately predicts stent length in the majority, with no stent being so unacceptably short as to require exchange. That a stent shorter than the actual length of the ureter should be a better choice appears counterintuitive but may reect the physical properties of the tortuous, redundant ureter. Its elevated resting tone [6] confers a latent contractility, enabling the ureter to reduce its dimensions following the relief of obstruction [7,8]. However, the rapid return of the ureter to an apparently normal length seen on screening nal stent position cannot be attributed solely to its latent contractility. It may be that the stent xed

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CLINICAL RADIOLOGY

between two points, namely the pelvi-ureteric junction (PUJ) and VUJ, causes the ureter to `bunch up' over it, so appearing to return to its pre-obstructed length. This `bunching up' has been described when initially negotiating the tortuous ureter with a guidewire [4], although in our experience the guidewire, if anything, appears to exaggerate ureteric redundancy. In criticism, the grading system we used to assess ideal stent position was subjective, based solely upon the nonblinded, uoroscopic appearances. To conrm that a stent position graded as 0 is indeed an ideal length, trouble-free stent would clearly require some period of patient followup. Likewise with stents deemed unacceptably long, no delayed assessment was made as to whether patients experienced trigonal irritation. Additionally, the performance of direct measurement was estimated rather than formally tested, but a prospective study comparing the two methods, by sequential patient recruitment, would not be possible as some patients would require stents of 4 26 cm according to direct measurement. Finally, it is possible that the ndings of this study only apply if the relatively sti 8F stents of Percuex, or sti polyurethane or polyethylene stents are used. Despite these shortfalls, we believe we have shown that patient height reliably predicts the correct length of ureteric stent and this is now our routine method. Although a minority of the stents inserted will be slightly short, none will require replacement and most will be of the correct

length. Exceptions to the height rule do occur when there is an alteration in either of the xed points (namely the PUJ and VUJ), such as large bladder or renal pelvic tumours and patients with re-implanted ureters (e.g. ileal conduits). Finally, the ndings of this study apply to the tortuous ureter. With non-redundant ureters, such as those decompressed by prior nephrostomy, direct measurement and patient height are equally reliable in our experience.
REFERENCES 1 Pollack HM, Banner MP. Percutaneous nephrostomy and related pyeloureteral manipulative techniques. Urol Radiol 1981;2:147154. 2 Herrera M, Brawerman S, Castaneda WR, Kotula F, Amplatz K. The endocatheter ruler: a useful new device. AJR Am J Roentgenol 1982;139:828829. 3 Wills MI, Gilbert HW, Chadwick DJ, Harrison SC. Which ureteric stent length? . Br J Urol 1991;68:440. 4 Bigongiari LR. The Seldinger approach to percutaneous nephrostomy and ureteral stent placement. Urol Radiol 1981;2:141145. 5 Mitty HA, Train JS, Dan SJ. Placement of ureteral stents by antegrade and retrograde techniques. Radiol Clin North Am 1986;24: 587600. 6 Weiss RM, Bassett AL, Homan BF. Dynamic length-tension curves of cat ureter. Am J Physiol 1972;222:388393. 7 Lennon GM, Ryan PC, Fitzpatrick JM. Recovery of ureteric motility following complete and partial ureteric obstruction. Br J Urol 1993;72:702707. 8 Biancani P, Hausman M, Weiss RM. Eect of obstruction on ureteral circumferential force-length relations. Am J Physiol 1982;243:204210.