Prolene Suture-Assisted Cystoscopic Removal of Ureteral Stents in Infants

Abstract

Double J (DJ) ureteral stents are a critical instrument in pediatric urology, particularly for the management of postoperative urinary drainage in infants with congenital urological abnormalities, ureteral obstruction, or vesicoureteral reflux. Yet, removal of the stents in infants is a technically challenging task because of the narrow caliber of the lower urinary tract, restricted cystoscopic maneuverability, and risks associated with anesthesia exposure. Conventional methods of DJ stent retrieval in infants can be cumbersome, involving general anesthesia, fluoroscopy, or larger equipment that is not optimally designed for infants.

The Prolene suture-assisted cystoscopic stent removal procedure has developed as a safe, minimally invasive, and effective alternative to stent retrieval in infants. This technique utilizes the attachment of a Prolene suture to the distal coil of the stent at placement as an easy mechanism for recognition and stent retrieval upon cystoscopy. This review delves into the rationale, technique, clinical outcomes, and future implications of this novel method, highlighting its use in minimizing procedural risks and maximizing postoperative care in pediatric urology.

Introduction

Double J ureteral stents are invaluable in the treatment of many pediatric urological disorders. The most basic function of these stents is to provide free urinary drainage from the kidney to the bladder, especially following reconstructive procedures like pyeloplasty, ureteral reimplantation, or endoscopic correction of congenital ureteropelvic junction obstruction. Nonetheless, the removal of DJ stents in infants, particularly those younger than 12 months, poses considerable technical and logistical challenges.

Newborns possess small urethral diameters, necessitating ultra-thin cystoscope use, which restricts available working space for standard graspers or retrieval tools. Urethral trauma, anesthesia risks, and procedure failure threaten DJ stent removal in this context, making it a precise procedure. The Prolene suture-assisted method offers an easy yet efficient solution with enhanced procedural safety and efficiency.

Rationale for the Prolene Suture-Assisted Approach

The concept of affixing a Prolene suture to the distal coil of the DJ stent during its initial placement offers several advantages:

• Enhanced Visibility: The Prolene tail can be left protruding slightly from the urethra or easily located within the bladder on subsequent cystoscopy.

• Simplified Retrieval: The suture provides a clear grasping point, minimizing the need for intricate cystoscopic manipulation.

• Reduced Instrumentation: A smaller-caliber cystoscope can be used, as retrieval can be accomplished with forceps or a simple snare without requiring a dedicated stent grasper.

This technique is particularly valuable in infants, where minimizing procedural complexity and reducing anesthesia duration is crucial.

Indications for Double J Stent Placement in Infants

DJ stents are commonly placed in infants for:

• Post-pyeloplasty drainage.

• Management of vesicoureteral reflux (VUR) following endoscopic injection therapy.

• Relief of ureteral obstruction from congenital anomalies.

• After ureteral reimplantation surgery.

• Temporary drainage after urolithiasis treatment.

The timing and method of stent removal are essential for ensuring successful recovery and preventing complications such as stent encrustation, infection, or migration.

Traditional Stent Removal Techniques in Infants

In larger children and adults, DJ stent removal is commonly performed in the outpatient setting using flexible or rigid cystoscopy with direct grasper retrieval. However, in infants, these techniques present several limitations:

• Narrow urethral caliber restricts cystoscope size.

• Limited bladder capacity complicates maneuverability.

• Traditional graspers are often too large for infant cystoscopes.

• Increased need for general anesthesia, as awake cystoscopy is not feasible in infants.

Fluoroscopic Removal

In some cases, particularly for stents with poor visualization during cystoscopy, fluoroscopy-guided retrieval can be attempted. However, this exposes the infant to unnecessary radiation and still requires anesthesia.

Ultrasound-Guided Techniques

Non-radiation techniques using ultrasound guidance have been explored but require operator expertise and specialized equipment, limiting their accessibility.

Prolene Suture-Assisted Cystoscopic Removal: Technique Overview

Step 1: Prolene Suture Attachment at Placement

At the time of DJ stent placement, a 4-0 or 5-0 Prolene suture is attached to the distal coil of the stent, leaving a trailing end extending into the bladder or slightly into the urethra. This serves as a retrieval handle.

Step 2: Cystoscopic Visualization

When it is time to remove the stent, a small-caliber cystoscope (typically 6-8 Fr) is introduced under general anesthesia or deep sedation. The Prolene suture tail is visualized in the bladder, either floating free or looped around the stent coil.

Step 3: Simple Grasping and Retrieval

The Prolene suture is grasped with either fine cystoscopic forceps or a retrieval snare, depending on the available instruments. The stent is gently pulled out along with the suture, avoiding the need for excessive manipulation or repositioning of the cystoscope.

Advantages of the Prolene Suture-Assisted Method

Minimized Urethral Trauma

The small-caliber cystoscope and the absence of large grasping devices protect the fragile urethral mucosa in infants.

Reduced Procedure Time

The suture provides a direct retrieval handle, avoiding prolonged cystoscopic searching and manipulation.

Improved Success Rates

The visual cue provided by the suture ensures that even partially encrusted stents can be removed with greater ease.

Lower Anesthesia Exposure

Shorter procedures mean reduced anesthesia duration, lowering potential complications.

Potential Challenges and Limitations

While the Prolene suture-assisted technique offers substantial benefits, certain challenges should be considered:

• Suture Loss or Migration

  • In some cases, the suture may retract into the bladder or become encrusted, making retrieval difficult.

  • Careful placement and appropriate stent dwell times mitigate this risk.

• Suture Fragmentation

  • Rarely, the Prolene suture could break during retrieval, requiring additional maneuvers for complete stent removal.

• Operator Learning Curve

  • Urologists unfamiliar with this technique may require some initial experience to optimize suture placement and cystoscopic retrieval.

Clinical Outcomes and Published Experience

Success Rates

In several small case series, Prolene suture-assisted stent removal has demonstrated:

• Successful retrieval in >95% of cases.

• Reduced procedural times by 30-50% compared to traditional cystoscopic techniques.

• Minimal complications, including rare cases of transient hematuria.

Complication Profile

• Transient hematuria (5-10%).

• Urethral irritation in <5%.

• Failure requiring alternative retrieval techniques (1-3%).

Long-Term Outcomes

• No long-term urethral strictures or bladder injuries have been directly attributed to this technique in published series.

Future Directions and Innovations

Suture-Integrated Stents

Future DJ stent designs could incorporate pre-attached retrieval sutures, reducing procedural variability and ensuring optimal placement.

Smart Cystoscopes with Enhanced Visualization

Advances in fiber-optic cystoscopes may further improve visualization in small infant bladders, making suture retrieval even more efficient.

Refining Noninvasive Retrieval Methods

Ongoing innovation in magnetic and ultrasound-guided retrieval techniques may eventually offer alternative noninvasive options for selected cases.

Conclusion

The Prolene suture-assisted cystoscopic removal procedure provides a secure, effective, and efficient method of DJ stent retrieval in infants. By using easy suture attachment with minimal invasive cystoscopy, this technique surpasses much of the technical limitations inherent in conventional methods in this difficult group of patients. As pediatric urology progresses, methods that are focused on safety, efficiency, and minimizing procedural trauma will be at the pinnacle of maximized infant care.

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