If you have undergone a recent kidney stone surgery or have had urgent advice given about a kidney or ureteric blockage, you may have heard about the placement of a ‘DJ stent’. The term ‘stent’ inside your uteri may be strange for many. Such situations may lead to a lot of concerns.
This page is very helpful as it explains everything you need to know about DJ stents, the reasons for the placement, and what to anticipate with the basic information about its removal. The placement of a DJ stent is a quick, basic, and easy procedure and learning about it helps lower the stress levels of the patient and allows the patient to effectively manage their recovery.
Dr. Vikas Singh is a Senior Consultant Urologist at the Kokilaben Dhirubhai Ambani Hospital, Nipania, Indore and places DJ stents for the therapeutic and management procedures of kidney stones, post-operative stent protection from the urinary tract, easing the obstruction of the ureter, and care of kidney transplants. His team focuses on providing as much information in clear terms as possible to the patient about the management of the stents.
A Double-J stent, also known as a DJ stent, ureteric stent, or internal ureteral stent, is about 25 to 30 centimeters long, about 2 to 3 millimeters wide, and made from soft, flexible, and hollow plastic. These stents travel from a person’s kidney, through the ureter, and finally, into the bladder.
The purpose of a stent is to cut down on blockage and swelling within the ureter and to give urine a pathway to freely flow from the kidney to the bladder. After ureter surgery, blockage and swelling create a dam, and urine will back up and enlarge the kidney and cause damage and infection.
Stents made from flexible medical-grade polymers, that are biocompatible and pose little risk after insertion, create a pathway for urine to flow from the kidneys to the bladder. There are 26 cm to 32 cm DJ stents, that vary from 4.7 to 7 F (French units), and Dr. Vikas Singh chooses the stent size and length for the patient based upon the patient height, anatomy, and the clinical situation.
Stent insertion and removal are performed via urethra. A telescope, a cystoscope, is used to access the bladder. This process is performed with the body’s natural openings, so there are no external scares.
Double “J” or “DJ” refers to the J-shape at each end of the stent. When the stent is positioned correctly in the body, each end of the stent assumes the shape of the letter “J”. It is referred to as a Double J, as one end of the “J” is positioned at the kidney and the other end is positioned at the bladder.
The double “J” shape are not solely for nomenclature. They fulfill an important purpose. The coiled end at the kidney blocks the stent from being pushed out of the kidney from the natural flow of urine. The coiled end at the bladder helps prevent the stent from moving out of place and into the ureter. The double coiled ends keep the stent in the correct position without the need of external stitches or fixation.
The coiled ends straighten out when the stent is under tension from the guidewire. This allows the stent to slide into the ureter during the insertion and also to be removed. The guidewire is pulled out of the stent and the coiled ends instantly re-form. The stent has shape-memory properties and the coiled ends lock the stent in place.
The most common reason DJ stents are placed is a routine practice in clinical settings after kidney stone surgery. The ureter is usually stretched and worked on for stones after RIRS, Laser URSL, and PCNL. The ureteral lining temporarily becomes edematised, narrowing the ureter and causing a damming effect when the ureteric outflow is obstructed
The stents maintain the outflow of urine from the kidney passed the obstructions to and from the stent modularly, also allowing for the passage of stone that was left as residual to the procedure. The procedure is fast as the DJ is in for about 1 to 4 weeks. with a single stone and fast outpatient procedure the stents are also usually removed within an outpatient procedure done through a cystoscopy.
A stone that gets lodged in the ureter and completely or almost completely obstructs the ureter prevents urine from exiting the kidney, causing it to be retained within the body. If the stone is not treated, the stone and urine will cause the kidney to swell and damage its tissues. This is referred to as obstructive nephropathy. The stone can be bypassed with a double-J stent (DJ stent) to drain urine from the kidney and alleviate pain. This protects the kidney from further damage and allows time until the stone can be treated with a ureterorenscopic laser surgery (URSL) or retrograde intrarenal surgery (RIRS) in a non-emergency setting.
There is the possibility of a stone obstructing the ureter and causing a kidney infection, in which case it is critical to place the DJ stent as in this case, the obstructed and infected kidney can pose a significant risk to the patient’s life. If an infection develops in the urine that is trapped in the swelling an obstructed kidney, the urosepsis is life threatening and the blood infection can cause rapid deterioration. The obstruction can be relieved with a DJ stent to alleviate the pressure in the kidney, which allows circulation of antibiotics.
Hydronephrosis describes an abnormal swelling of a kidney due to an outflow obstruction of urine, caused by different conditions such as a kidney stone, ureteric stricture, ureteric compression by a tumor, a ureteric occluding blood clot, etc. Significant hydronephrosis that causes kidney damage or hydronephrotic pain warrant the placement of a double-j stent to relieve the obstruction and decompress the kidney.
The response of the kidney to double-j stenting is generally quite remarkable. The swelling is typically reduced within 24 to 72 hours after the stent is placed. The pain due to stretching and distention of the kidney also subsides. In the case of acute obstruction, the blood tests show improvement of kidney function (declining creatinine) after the stent is placed, typically within a few days.
The donor kidney in a kidney transplant is hooked up to the recipient’s blood vessels and bladder. This surgery, and creation of the transplant urinary connection, requires a DJ stent to be placed in a transplanted ureter. This stent remains in place until the surgical connection of ureter to donor urinal bladder is complete. This UVA connection, and broader surgical context, is intricate and must heal without interruptions.
After 4 to 6 weeks, the stent is removed, as this cystoscopy occurs after sufficient healing of the connection. Particular to his field, kidney transplant and post-transplant urology, Dr. Vikas Singh, is a qualified, competent surgeon and manages operations for stent insertion and removal.
All forms of ureteric injury tend to result in the same consequence of either loss of urine or development of a ureteral stricture. In the case of a ureteric injury related to DJ ureteric stenting, a DJ stenting catheter will provide a drain from the site of injury, and the ureteral injury can be treated by either a surgical or a conservative approach. Urinary tract obstruction due to ureteric strictures can also be managed by temporary ureteral diversion using a DJ ureteric stenting catheter, that will be removed while the strictured segment of the ureter is further evaluated and treated.
Severe renal colic is perhaps the most traditional sign of a need for urgent DJ stenting. Renal colic is a cramping pain caused by a stone or other blockage in the ureter. When the pain is unmanageable or poorly controlled with pain medications, and/or renal colic is associated with kidney infection or renal parenchymal damage, a DJ stent is placed to relieve the pain. The stone is removed providing a permanent solution during a planned surgical intervention.
Urgent DJ stenting or percutaneous nephrostomy is performed in cases of complete ureteric obstruction to prevent irreversible damage to the kidney by relieving the obstruction. While total obstruction of kidney drainage is conditionally survivable for some time, the kidney will progressively lose function in an irreversible manner the longer the obstruction persists. A patient is considered to require an urgent urological assessment if they have a ureteric stone or other related condition and demonstrate considerable reduction or total absence in urine output from the affected kidney.
In cases of recurrent febrile urinary tract infections with a history of kidney stones, ureteric strictures, or hydronephrosis, DJ stenting is highly recommended. When the ureter is obstructed, bacteria recirculates into the kidney and stagnant urine is retained. In instances such as these, an infection may not be permanently cured with antibiotics because the obstruction must first be resolved. DJ stenting resolves stagnation and allows antibiotics to cure the infection.
An increase in creatinine levels from blood tests (or renal function deterioration from a MAG3 renogram) in a patient with a ureteric stone or obstruction demonstrates that renal obstruction is progressively damaging the kidney. This indicates that urgent decompression is needed to reduce further loss of the kidney’s functional parenchyma. DJ stenting is a temporary measure with a definitive stone removal or obstruction management plan.
Unexpected changes such as swelling, pain, or a rise in creatinine levels after a procedure such as a PCNL, RIRS, ureteral reimplant, or kidney transplant could mean that a urine leak or other obstruction has formed. A DJ stent, placed at a subsequent cystoscopy if not already in place, will allow the obstruction, and thus the stress from the urine, to be taken away from the leak site, and will allow the obstruction to be taken away.
A common type of DJ stent used for post stone surgery, management of acute ureteric obstruction, or as a short-term protective stent for the ureter, is intended for an indwelling time of 4 to 6 weeks for most common clinical applications. That’s long enough for the ureters to heal after surgery or for definitive management of the stone, but short enough to avoid complications and encrustation (deposits of minerals on the surface of the stent) associated with stents prolonged over time.
Once the planned time for stenting is over (normally 2 to 6 weeks), Dr. Vikas Singh takes the patients for an outpatient procedure of cystoscopy for stents to be taken out. In over 90% of patients, stent related symptoms such as increased frequency of urination, urinary urgency, and flank pain drastically improve within 24 hours.
A DJ stent can stay in place for 3 to 6 months in the following situations: ureteric strictures that are pending surgical repair, management of a large or complex ureteral injury, or patients with malignant ureteral obstruction and are currently receiving treatment for the cancer. Frequent exchange of the stent in these situations is paramount, because prolonged stent placement results in a higher risk of stent failure and encrustation.
For ongoing management of a large or complex ureteral injury, Dr. Vikas Singh has designed a stent recall system so patients with a stent for long-term ureteral management are guaranteed to have an exchange reminder at a designated time to ensure that a stent is never left in place for longer than the designated indwelling time.
Leaving a DJ stent inside the body for longer than the planned duration is associated with several significant complications that patients and their families must understand:
The most important advantage of DJ stenting is that it protects the kidney from obstruction-related injury. When the ureter is obstructed, urine refluxes into the kidney, and the collecting system and renal parenchyma become edematous and injured. A DJ stent can decompress the kidney in hours. Protection of the kidney after obstruction can make the kidney recover. In obstruction cases, stenting can determine the kidney’s prognosis.
Each of the endoscopic kidney stone procedures (RIRS, PCNL, or Laser URSL) result in the ureter being worked through, stretched, and use of laser energy. The ureter must be given time to heal in an open and functional position, as opposed to compressed and narrowed caused by swelling that occurs post-operatively. A DJ stent is used to position the ureter in an open diameter and proper orientation, and after healing occurs in that position. The stent is removed in a window of 2 to 4 weeks, and the ureter is expected to be healed in a proper caliber and function.
In spite of any ureteral compromise – whether by injury, stone suppression, surgical insult, or stricture rupture has to remain continually unobstructed from the kidney to protect renal function and stope the infection from ascending. A DJ stent provides this functionality, even when the ureter cannot and thus bridges the gap from the acute insult to either surgical intervention or natural healing of the ureter. In the cases where concern of renal function is even greater, such as a patient having only one kidney, or a patient with chronic renal insufficiency, the situation becomes even more acute.
Both DJ stent placement and removal are done through the urethra using a cystoscope, with no incisions. Due to the minimal invasiveness, life disruption to the patient is minimal. The placement procedure lasts about 5 to 15 minutes and is done using local anesthesia. The stent can be removed within only 2 to 5 minutes and can be done with or without anesthesia. Most patients are stented then discharged, all within about an hour.
Most patients will experience some effects from the DJ stent like increased urinary frequency and discomfort, but cannot specifically feel the stent inside of their body. The stent is placed inside of the ureter, and the ureter does not have direct nerves. What patients will experience is the bladder discomfort (caused from the irritation of the coiled bladder end) and discomfort from the stent refluxing into the kidney. Also, some patients that have the string extension of the stent, may feel the string at the urthreal opening. This string is not to be removed unless the physician says otherwise.
Patients who engage in only desk or light type-work usually can return shortly after stent placement, usually in the range of a few days after the placement, as long as they are past the more acute post-op pain. Frequent breaks will be needed for their increased urinary frequency and urgency. After stent placement, increased movement and violence of the body are more likely to cause and worsen stent-related pain and the stent-related blood, and thus, will worsen the body’s stent-related lacerations and blood. This is a strong motivator to return, or to completely avoid physical work.
Yes, with some precautions. Schedule your stent removal appointment before your trip. Bring stent information (placement date, type, size) along with Dr. Vikas Singh’s contact information. Keep yourself very well hydrated. Take plenty of bathroom breaks, as long stent-related urinary frequency can make travel uncomfortable. Dr. Vikas Singh can give you a letter explaining the stent, which is useful for air travel and imaging at security.
This is actually very common and expected. Blood in urine can be common with DJ stenting. It is usually worse in the first few days after the insertion of the DJ stent, after physical activities, and towards the end of stenting. Staying hydrated can help. Drinking 2.5 to 3 L of water should help. It is not common if the urine contains clots and the urine is dark with clots. Other things that require emergency evaluation are the complete inability to urinate or blood in the urine with a high fever. These require urgent evaluation and you should contact the clinic immediately.
DJ stent extraction is done through a quick ambulatory cystoscope. A local anesthetic is applied first to the urethra. After a short duration of up to ten minutes to allow the anesthetic to set, the cystoscope is introduced. The doctor then removes the stent end from the bladder using the grasping forceps through the scope. The procedure is said to take about 5 minutes. The procedure is not particularly painful. It is best described as the removal of a urinary catheter. As an option for extremely anxious patients, mild oral sedation can be used.
One of the serious but entirely avoidable complications in urology is the leaving of a DJ stent in for an extended period of time after the removal is due. When stents are in the body for too long they get mineral deposits that encase the stent and make it very difficult to remove. In addition to the stent encasement, the stents have the potential to fracture and splinter and could require extensive surgery in order to remove. Dr. Vikas Singh provides a record of the stent removal date to each of his patients and his office will also send a reminder of the date. Although the office clears up possible complications, it is the patient’s responsibility to come for the appointment, and the patient is highly encouraged to do so because the procedure to remove the stone will be a similar time and effort to the procedure to remove the stent.
Stent migrations do happen, but they are rare. The most serious type is distal migration, where the stent moves downward, and the coil at the end of the stent exits the bladder into the urethra. This causes the patient to experience searing, sharp pain during urination. If that happens, you should contact the office of Dr. Vikas Singh as soon as possible to replace or remove the stent. Stents may also migrate proximally into the kidney, which usually requires an endoscopic procedure to remove the stent from the kidney.
Having a DJ stent doesn’t alter the safety of sexual intercourse, however discomfort can occur, such as flank pain, increased hematuria, and/or discomfort. If a retrieval string is attached to the stent, care should be taken to avoid embarrassing stent retrieval during sexual intercourse. For those who do not have discomfort, sexual intercourse can be resumed 1 to 2 weeks after stent placement. Dr. Vikas Singh can better advise based on individual circumstances.
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