Endoscopic Placement of Ureteral Stents 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
 
Ureteral stent placement is one of the most 
common procedures performed by urologists 
worldwide. It is indicated for ureteral obstruction, 
which can be caused by intraluminal pathology like 
a kidney stone or ureteral stricture, or extraluminal 
compression from malignancies or retroperitoneal 
fibrosis. Stents can also be placed for partial ureteral 
injuries, especially when they are recognized 
endoscopically or in a delayed fashion. 
 
Stents are available in different sizes and can 
be tailored to the measured length of the ureter, based 
on CT or plain pyelography. In adults the following 
values can also be used to estimate the stent length:  
 
Height (adult) 
Stent length 
<178cm 
22cm 
179-192cm 
24cm 
>193cm 
26cm 
 
 
Stents provide temporary relief of obstruction 
and can remain in place for between 3 and 12 months 
depending on the stent, after which they should be 
exchanged, or the ureteral pathology definitively 
treated. Regardless of the material, stents can cause 
a great deal of discomfort. Patients should be 
counseled that flank pain, urinary frequency and 
urgency are common with indwelling stents. 
Regardless of the indication for stent placement, 
fluoroscopy or ultrasound must be available for 
endoscopic stent placement. Ultrasound allows 
confirmation of the position of the guidewire and 
distal curl of the stent: a retrograde pyelogram, as 
described here, can not be done without fluoroscopy. 
See Introduction to Ultrasonography. 
 
Steps:  
1. The patient is positioned in Lithotomy position 
(See  Chapter.)  
2. A cystoscope is inserted into the bladder via the 
urethra (See Chapter, Cystourethroscopy.) 
3. After careful inspection of the urethra and 
bladder, the affected ureteral orifice should be 
identified. 
 
The ureteral orifice can be subtle (left) or more obvious (right.) 
 
4. A retrograde pyelogram should be performed to 
characterize the site and severity of the injury or 
obstruction. This is done by atraumatically 
placing a hydrophilic-tipped wire into the 
ureteral orifice about 3-4 cm up the ureter. 
 
 
 
The 5 Fr ureteral catheter can be used to direct the wire into 
the ureteral orifice. 
 
5. A 5 or 6 Fr open-ended ureteral catheter can then 
be advanced 2-3 cm up the ureter, over the wire 
under direct vision. 
6. The wire can then be withdrawn leaving the 
catheter in the distal ureter. Radio-opaque 
contrast material is instilled into the ureter and 
kidney while fluoroscopic images are obtained. 
For a system without hydronephrosis, only 5-8 cc 
Endoscopic Placement of Ureteral Stents 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
of contrast should be necessary. For a 
hydronephrotic system, up to 30 cc of contrast 
may be needed to fully characterize the ureter, 
renal pelvis and calyces. 
 
Endoscopic placement of a 5 Fr ureteral catheter (Red arrow) 
into the right ureteral orifice. 
 
 
Right retrograde pyelogram showing a mildly dilated renal 
pelvis. 
 
7. The wire can then be passed via the ureteral 
catheter to the renal pelvis under fluoroscopic 
guidance. If fluoroscopy is not available, 
ultrasound can be used to confirm that the wire 
reaches the renal pelvis; a pyelogram is not done 
in this circumstance. 
 
A hydrophilic-tipped wire placed into the right renal pelvis- 
note that the tip of the wire is coiled (Red arrow,) indicating 
that it has reached the pelvis. 
 
8. A double-J ureteral stent should then be 
advanced over the wire to the renal pelvis under 
direct vision. This is done on most stents by 
advancing the stent until a thick black marker is 
visible at the ureteral orifice. Once all of the stent 
is within the scope, you will need to use the stent 
pushing catheter, along the guidewire, to 
continue to advance the stent into position.  
Endoscopic Placement of Ureteral Stents 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Stent being advanced over the wire, up the ureter. 
 
 
Stop advancing the stent when the thick black marker reaches 
the ureteral orifice. 
 
9. The wire should then be partially withdrawn so 
that its tip is distal to the ureteropelvic junction, 
this releases the proximal curl within the renal 
pelvis, which can be confirmed with fluoroscopy 
or ultrasound. Note that the wire should remain 
within the distal stent, which allows you to 
continue using the stent-pushing catheter. 
 
Double-J stent curl (Red arrow) deployed in the right renal 
pelvis. Note that the curl is fully open, indicating that it is within 
the renal pelvis 
 
 
Ultrasound of the kidney shows the curl of the stent within the 
renal pelvis. Source: Bardapure M, Sharma A, Hammad A. 
Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2022 
Jun 13];25:109-12. Available from:  
https://www.sjkdt.org/text.asp?2014/25/1/109/124514  
 
10. The scope should be pulled back to the bladder 
neck, using the stent-pushing catheter to maintain 
the stent in position until the stent pushing 
catheter is just barely visible at the bladder neck. 
The wire can then be completely withdrawn, 
which deploys the distal curl of the stent in the 
bladder. 
Endoscopic Placement of Ureteral Stents 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
Stent pushing catheter (Black arrow) just visible at the bladder 
neck. 
 
 
Once the position of the stent is acceptable, the guidewire is 
withdrawn. The proximal stent then assumes a curl, as seen 
here. The stent pusher is still visible at the bladder neck. 
 
 
Distal stent curl deployed in the bladder. 
 
Pitfalls:  
● Real-time imaging is essential for endoscopic 
management and may be a limitation in some 
settings. Placement of a stent without imaging 
can lead to misplaced stents outside of the 
collecting system and devastating ureteral  or 
renal pelvis injuries. It is possible to use 
ultrasound to confirm guidewire and stent 
placement in the renal pelvis, but this adds 
complexity to the case and requires a skilled 
ultrasound operator.  
● Placing the stent with the distal curl proximal to 
the ureteral orifice (in the ureter but not in the 
bladder) leads to very difficult stent removal and 
may even cause paradoxical obstruction. This 
should be avoided by careful and methodical 
stent placement under direct  vision as described 
in Step 10 above. 
● Patients 
must 
be 
counseled 
about 
stent 
symptoms. These include flank pain, hematuria, 
and urinary frequency and urgency. These 
symptoms can mimic both urinary tract infection 
and obstruction and are distressing to patients 
who are not offered appropriate anticipatory 
guidance. Hematuria is inevitable and generally 
harmless. Flank pain can be treated with 
acetaminophen, non-steroidal anti-inflammatory 
Endoscopic Placement of Ureteral Stents 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
medications and alpha-adrenergic blockers. 
Frequency and urgency can be treated with 
anticholinergics or beta-3 agonists. 
● One of the most devastating complications of 
stent placement is loss to follow-up with an 
indwelling stent. Stents encrust over time and 
this can lead to ureteral stricture and obstruction, 
sometimes requiring lithotripsy or percutaneous 
surgery for removal. Without intervention, stent 
encrustation can lead to loss of the renal unit. 
 
George E. Koch MD  
Vanderbilt University Medical Center 
USA 
 
Niels V. Johnsen MD, MPH 
Vanderbilt University Medical Center 
USA 
 
 
 
