Surgical Treatment 7421

Ureteral Stents

When a urinary calculus requires surgery during pregnancy, the classical attitude is to ensure urine flow, with the definitive treatment undertaken after the child is born (Denstedt and Razvi 1992). Placing a double-J ureteral stent easily removes the obstruction. In very septic patients, the stent can be placed without sedation. When urine is thick, it is preferable to first position an open ureteral stent, which can be replaced after a few days with a double-J stent when the sepsis is under control and the urine more liquid (Dore 2004). The double-J stent presents several advantages. It can be placed under local anesthesia and presents no radiation to the patient, as the procedure is guided by ultrasound (Jarrard et al. 1993). It allows the patient to return to normal activities rapidly and permits vaginal delivery. It is not always easy to place, especially during the 3rd trimester, when the bladder is pushed back by the uterus, the trigone deformed, and the mucous membrane of the bladder rendered hyperemic by pelvic hypervascularization. In addition, the stent carries a certain number of disadvantages: bladder irritation by the lower J that may cause urinary frequency, increased micturition urge or hematuria, risk of displacement due to dilatation of the excretory tract, and vesi-

corenal reflux, which can cause lower back pain or acute pyelonephritis (Zwergel et al. 1996).

Many authors have reported the risk of incrustation secondary to hypercalciuria of pregnancy (Borboroglu and Kane 2000; Goldfarb et al. 1989; Loughlin 1994). This risk is reduced by increasing fluid intake, controlling calcium intake, and treatment of UTI if necessary (Biyani and Joyce 2002b). To avoid incrustations, some authors advise changing the double-J stent every 4-8 weeks (Denstedt and Razvi 1992; Loughlin and Bailey 1986), thus multiplying hospitalizations and the risks related to endoscopic procedures. Other authors prefer to avoid the double-J stent at the beginning of pregnancy and reserve its use for after the 22nd week (Denstedt and Razvi 1992; Goldfarb et al. 1989; Loughlin and Bailey 1986; Stothers and Lee 1992).

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