POINT OF TECHNIQUE
|Year : 2001 | Volume
| Issue : 2 | Page : 191-192
Antegrade JJ-stenting after percutaneous renal procedures: The reverse zebra technique
Pankaj N Maheshwari, Mukund G Andankar, Rakesh Khera, Sunil Hegde, Manish Bansal
R. G. Stone Urological Research Institute and B.Y.L. Nair Medical College and Hospital, Mumbai, India
Pankaj N Maheshwari
Chief Urologist, R.G. Stone Urological Research Institute, 14-A Road, Khar (W), Mumbai - 400 052
Source of Support: None, Conflict of Interest: None
| Abstract|| |
JJ stent is placed in many patients of calculus disease after percutaneous nephrolithotomy (PCNL). It is also used after Endopyelotomy or ante grade ureteroscopy. Presented here is a simple technique of placing JJ stent antegrade over a stiff Zebra guide wire.
Keywords: J J Stent; Double J Ureteric Stent; PCNL; Renal Calculus Disease; Endopyelotomy
|How to cite this article:|
Maheshwari PN, Andankar MG, Khera R, Hegde S, Bansal M. Antegrade JJ-stenting after percutaneous renal procedures: The reverse zebra technique. Indian J Urol 2001;17:191-2
|How to cite this URL:|
Maheshwari PN, Andankar MG, Khera R, Hegde S, Bansal M. Antegrade JJ-stenting after percutaneous renal procedures: The reverse zebra technique. Indian J Urol [serial online] 2001 [cited 2020 May 27];17:191-2. Available from: http://www.indianjurol.com/text.asp?2001/17/2/191/20279
| Indications|| |
JJ stent is the most frequently used endo-prosthesis in urological practice. Usually JJ stent is placed retrograde over a guide wire using cystoscopy and fluroscopy guide.
JJ stent is placed in many patients of calculus disease after percutaneous nephrolithotomy (PCNL). It is also used after Endopyelotomy or antegrade ureteroscopy. In these patients placing stent retrograde after completion of percutaneous surgery may necessitate making the patient supine and an additional cystoscopic procedure. Placing the stent antegrade on a through-and-through guide wire also has difficulties. Proper placement of the lower end of the stent is difficult and it frequently needs readjustments.
We present a simple technique of placing JJ stent antegrade over a stiff guide wire (like a Zebra guide wire). We find this technique simple, safe and very successful.
| Technique|| |
Puncture and dilatation of the PCNL tract is done using fluoroscopic guidance. For opacification of the pelvicalyceal system an open-ended ureteric catheter is placed prior to placing the patient in prone position. At the end of PCNL if JJ Stern is needed, the renal end of the open-ended catheter is grasped with the nephroscopic forceps and brought in the Amplatz sheath. With the renal end of the open-ended catheter under vision secured in the Amplatz sheath, the reverse end of the Zebra guide wire (stiff end) is threaded in the ureteric catheter retrograde. This wire is withdrawn through the Amplatz sheath as a through-and-through wire.
Under fluoroscopic control, the Zebra wire is then pulled out through the Amplatz sheath till the radio-opaque marker at the lower floppy end of the Zebra wire is seen at the level of the ischeal spine. At this stage the open-ended ureteric catheter is removed keeping the Zebra wire antegrade. The Zebra wire is now advanced to coil the floppy end of the wire in the bladder. Over this wire the JJ stent can be placed antegrade under fluoroscopy guidance. Nephrostomy tube is placed to complete the procedure.
Zebra wire is a stiff guide wire with a floppy end. The floppy end has a radio-opaque marker. Due to the Zebra wire's stiffness, it is quite simple to place the stent antegrade, without the wire being through-and-through. The radioopaque floppy end helps in proper placement of the wire and later the JJ stent.
| Difficulties and Complications|| |
In last 3 years in over 150 patients of PCNL, Endopyelotorny and antegrade ureteroscopy there has been no difficulty or complications in JJ stent placement due to this technique. In none of these patients did we have to use a through-and-through guide wire or make the patient supine to place the stent.
| Discussion|| |
Normally antegrade stenting is done over a through-and through guide wire.  During PCNL, the guide wire is placed through the open-ended catheter. It can also be placed antegrade and coiled in the bladder, retrieved from the urinary bladder using a transurethral snare under fluoroscopic guidance, or by simultaneous cystoscopy.  Rigid or flexible cystoscopy can be done. For rigid cystoscopy the patient has to be turned supine, while flexible cystoscopy adds another procedure. Retrieving the guide wire by flexible cystoscopy may sometimes be difficult.
Placing the stent antegrade on a through-and-through guide wire also has difficulties. Proper placement of the lower end of the stent is difficult. It commonly gets pushed in the prostatic urethra or an excess length gets coiled in the bladder. The position of the lower end frequently needs readjustments.
The major advantage of the `Reverse Zebra' technique is that JJ-stenting can be done satisfactorily in prone position. Additional rigid or flexible cystoscopy is avoided. There is no need to make the patient supine for retrograde stent placement. The use of a stiff Zebra wire makes the procedure easy and fast. Operation theater time is not spent on the readjustment of the stent position.
| References|| |
|1.||Lumerman J, H, Smith AD. Technique of endopyelotomy. In: Yachia D (ed.). Stenting the Urinary System. Isis Medical Media, Oxford, 1998; 181-189. |
|2.||Lu D, Papanicolaou N, Girard N. Percutaneous internal ureteral stent placement: review of technical issues and solutions in 50 consecutive cases. Clin Radio] 1994; 49: 256-261. |