Annals of the Royal College of Surgeons of England (1988) vol. 70

168 doubleJ (pigtail) ureteric catheterinsertions: a retrospective review

FRANK H SMEDLEY MS FRCSSurgical RegistrarJOHN RIMMER FRCSSurgical RegistrarWestminster Hospital, London

MARTIN TAUBE FRCSSenior Surgical RegistrarLYNN EDWARDS MChir FRCSConsultant Urologist

Key words: URETER, STENT

SummaryThe medical records of 116patients who had 168 ureteric doubleJ(pigtail) catheters inserted over a 6-year period between 1981 and1987 were reviewed. Eighty-five patients had pigtails insertedforbenign conditions and 31 for malignant disease.

The pigtail catheters were inserted cystoscopically in 88patients, percutaneously in 7 patients and by open surgery in 21patients. Of 168 pigtail catheters used, 147 were soft (silicone,multilength) and 21 hard (polyurethane). No mortality wasattributable to the use of these catheters but certain complicationswere 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 ofsoft cathetersand 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 13oJ 21 (61%) hard catheter insertions (2 test, P=0.O1). Stentmigration occurred in five patients and obstruction in two.

Pigtail catheters are safe ureteric stents which are easy to insertand their use is supported by this study. The complications ofassociated infection, trigonal irritation and loin discomfort arerelatively common and still occur even with soft catheters. Carefulmonitoring of all patients with pigtail catheters in position isrecommended.

IntroductionIn 1967 Zimskind et al. (1) reported on the long-term useof silicone tubing to bypass ureteral obstruction and forthe treatment of ureterovaginal fistula. Marmar (2) andOrikasa et al. (3) improved the techniques for passingthese stents in a retrograde fashion. McCullough (4)initially described the use of a polyethylene stent with a'memory' such that a shepherd's crook configurationreformed after the tube was properly placed with itsproximal end in the renal pelvis. Hepperlen et al. (5)modified a standard single pigtail polyethylene angio-graphic catheter, allowing passage by a Seldinger tech-

Correspondence to: Mr F H Smedley MS FRCS, WestminsterHospital, Dean Ryle Street, London SW 1P 2AP

nique and preventing distal but not proximal dislodge-ment Finney (6) completed the evolution of the stentwith additions of 'Js' or 'pigtails' to each end of thesilicone tubing preventing migration in either direction.

Pigtail catheters are now widely used in urologicalpractice. While the more rigid polyurethane stents areeasier to advance through stenoses and occlusions theymore often lead to symptoms of bladder irritation (7) andmay be more prone to breakage and obstruction (8,9).The softer silicone catheters are now manufactured withan extra turn on their lower ends adding a multilengthcapability. An incidence of urinary tract infection in thepresence of a foreign body in the urinary tract is inevit-able. Other complications include encrustation, renalpelvic perforation, erosion through ureteral wall intoblood vessels and bowel, stent breakage and migration(10).

Opinions differ on how long to leave pigtail stents inposition. There is also disagreement as to when theyshould be used and regarding which sort of catheter tochoose. This study analyses our experience of 168 softand hard pigtail catheter insertions.

Patients and methodsThe medical records of 116 consecutive patients treatedat the Westminster and St Stephen's Hospitals betweenthe years of 1981 and 1987 were reviewed. They had atotal of 168 pigtail catheters successfully inserted. Thetype of pigtail catheters used were either soft (silicone-multilength (Cook International)) or hard (polyure-thane-single length (Cook International)).A tabulated record of sex, age, number and type of

catheter for each patient was prepared. Also the indica-tion for insertion, method of insertion, length of time inposition, 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 in posi-tion.

Trigonal irritation was said to be present when symp-toms of suprapubic pain or urinary frequency (in the

378 F H Smedley et al.

absence of infection) were associated with redness andoedema of the trigone, noted cystoscopically at the timeof change or removal of the catheters.

Early patients tended to have hard catheters insertedas these were the only type of catheter available at thetime. However, even when soft multilength cathetersbecame available we elected to use hard catheters tonegotiate particularly tight ureteric strictures. With allinsertions X-ray visualisation using an image intensifierwas employed to ensure correct stent placement.

ResultsOf the 116 patients there were 74 men and 42 women. Atotal of 168 pigtail catheters were inserted and of these147 were soft and 21 hard. The mean age was 50.3 years(range 21-83 years). The mean age of the patients (59males, 36 females) with soft catheters was 41.6 years(range 21-74 years) and the mean age of the patients (15males, 6 females) with hard catheters was 53.4 years(range 23-83 years).

Eighty-eight patients had catheters inserted by thecystoscopic route, 21 by open operation and 7 percu-taneously. A total of 132 pigtail catheters was insertedcystoscopically, 29 at open operation and 7 percu-taneously. Thirty-one patients had catheters inserted formalignant 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 themean length of hospital stay was 15.3 days and for thehard pigtails 17.5 days (P>0.1, Student's t test).The mean length of time the pigtails were left in situ

was 79 days (range 1-366 days). In the hard group themean time was 51 days (range 5-180 days). The softstents remained in position for a mean of 83 days (range1-366 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 performedelectively. The conditions from which the 14 patientswho had failed cystoscopic insertions were suffering aresummarised in Table II.

TABLE i Indications for insertion of 168 pigtail catheters (116patients)

Mode of insertion TypeC O P H S

Malignant obstruction 45 37 4 4 7 38Benign and postoperative

stricture 22 21 1 - 4 18Ureterostomies 3 - - 3 1 2Functional obstruction 17 15 2 - 0 17Postoperative urinary

fistula 13 12 1 - - 13Urinary fistula as a

result of RTA 3 1 2 - - 3Postoperative splinting 17 - 17 - 3 14Stones

(surgery or ESWL) 48 46 2 - 6 42Total 168 132 29 7 21 147

C=cystoscopic, O=OpenS=Soft

surgery, P=Percutaneous, H=Hard,

TABLE II Causes of obstruction in the 14 patients who hadfailed insertion ofpigtail catheters

Cause of obstruction n=14

Tuberculosis of ureter 1Retroperitoneal fibrosis (benign) 4Stone in ureter 2Malignant strictures 4*Urinary fistula following accident 2tPostoperative urinary fistula 1+

* One transitional cell carcinoma of ureter, two carcinoma of cervix,one carcinoma of rectumt Road traffic accidents with multiple injuries including rupturedureters+ Following repair of ureter after hysterectomy

TABLE III Complications associated with insertion of pigtailcatheters

n Soft Hard

No. of insertions 168 147 21Loin discomfort 32 (19%) 27 (18%) 5 (24%)Trigonal irritation

(at cystoscopy) 32 (19%/) 26 (18%) 6 (29%)Stent migration 5 (3%) 5 (3%) 0Stent 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 use of pigtail catheters.Loin discomfort was noted in 32 (19%) of the 168insertions. Trigonal irritation noted cystoscopically wasfound in 26 of 147 (18%) insertions of soft catheters andin 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 after 13 of 21(61%) hard catheter insertions (X2 test, P=0.012). Stentmigration occurred in five patients and obstruction intwo.

DiscussionDouble J (pigtail) ureteric catheters must be soft enoughto avoid problems of urinary tract irritation and stentbreakage, but must be rigid enough to permit introduc-tion by axial force through strictures and/or neoplasmsinvolving the ureter (6-9). It has been reported thatsilicone stents do not cause bladder irritation and thatthey have superior durability to other stents (6,8,11).With the addition of an extra curl in the lower end, softstents have the ability to adapt to different ureterallengths.Our experience suggests that bladder irritation and

loin discomfort still occur frequently even when softmultilength catheters are used. Urinary tract infectionwas more common in patients with hard catheters. Wedid not use postoperative or peroperative prophylacticantibiotics routinely, but some authors have suggestedthat this practice may decrease the high incidence ofurinary tract infection that tends to be associated with

DoubleJ (pigtail) ureteric catheter insertions 379

these catheters (12). It is possible that the higher inci-dence of postoperative complications associated withhard catheters in our study may be related to our inex-perience, as more hard catheters were inserted early inthe series (when soft catheters were not available).Some complications associated with the use of these

stents are mechanical. We found that stent occlusionoccurred in only 2 of 116 patients (1.7%). Encrustationof the stents was present in both these cases and bothwere treated by simple exchange of catheter. Stentmigration occurred in five patients and only one catheterbroke, and this was on insertion. Spontaneous fracture ofan indwelling polyethylene or polyurethane stent is rare,but because it has been known to occur stent exchangeevery 6 months is recommended by the manufacturers.Stent exchange at 1 year is recommended for siliconecatheters.We have found that difficult stenoses or strictures can

sometimes be more easily negotiated if the ureter isdilated before insertion. When the guidewire is passedinto the ureter of a difficult case it is helpful to ensurethat the tip of the inserting cystoscope is very close to theureteric orifice. The minimises 'bowing' of the guidewirewithin the bladder. The most difficult strictures that wehave encountered have been caused by tuberculosis,malignancy and retroperitoneal fibrosis. If, when thepigtail catheter is changed, there is concern that theremay be difficulty with reinsertion we often partiallywithdraw the catheter so that the distal tip just protrudesfrom the urethra. In this way the guidewire can bepassed through the catheter and stricture more readily,particularly if it is in the lower ureter. If the ureter hasbeen obstructed for some time it may become verydilated and the upper end becomes tortuous. It may bedifficult to pass a guidewire into the renal pelvis cysto-scopically becanse of this tortuosity. Under these cir-cumstances it may be more sensible to decompress thekidney by performing a percutaneous nephrostomy andattempting to introduce the pigtail catheter some weekslater either via the nephrostomy or from below.

Accidental perforation of a ureter with the guidewireor pigtail catheter probably occurs infrequently, butperhaps more frequently than is generally recognised.On the few occasions that we were aware of this com-

plication, we administered antibiotics and observed thepatients closely. No serious problems occurred.

This study confirms the safety of pigtail catheters withno deaths or serious complications directly attributableto their use. Careful monitoring of all patients withpigtails in position is important. Although urinary tractinfection may be eradicated if diagnosed and treatedearly, there may be a role for prophylactic antibiotics.Early removal may be required for severe loin pain,trigonal irritation or urinary tract infection. Althoughthe complications associated with the use of pigtailcatheters should not be underestimated, it is now pos-sible in many cases to avoid open surgery or externalurinary drainage.

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Received 6 Apnil 1988