Ureteric stent

This guideline describes the rationale for insertion as well as the care and management of a child/young person requiring ureteric stents, including their removal.

NOTE: We review our guidelines regularly and this guideline is now past its review date. The content of the guideline below may not reflect the most recent evidence based practice. Please use with caution.

While this guideline refers to the 'child' throughout, all activities are applicable to young people.

Background

A ureteric stent catheter directly drains the kidney via the ureter. It usually exits the abdomen via the bladder wall in the suprapubic region and may, in older children, be attached to a drainage bag. In young children who have not been toilet trained it may drain into double nappies.

The two most commonly used stents at GOSH are the Blue Stent™ and PVC feeding tubes.

A ureteric stent may be used to:

  • assist in accurately measuring fluid output from the affected kidney following major nephro-urological surgery, eg bladder augmentation and re-implantation of ureters

  • support an anastamosis of the ureter

  • promote wound healing

  • minimise pressure and thus prevent urine leakage following surgery to the bladder (Fillingham & Douglas, 2004)

Ureteric stent catheters should only be used for the minimum amount of time (3-10 days) (Rationale 1).

They are inserted under a general anaesthetic using an aseptic technique and are managed on the ward using an aseptic non-touch technique (Rationale 2). The stent is usually stitched at skin level (Rationale 3).

It is recommended that the smallest gauge stent should be used. This is determined at the time of surgery by the surgeon (Rationale 4). It is recommended that all catheters and securing devices are latex free (Rationale 5).

Inform child and family

The medical team will inform the child and family of the need for a ureteric stent when explaining the surgery, in order to obtain consent (Rationale 6 and 7). They will be informed of the following:

  • why the ureteric stent is necessary (Rationale 7)

  • the anticipated duration of the stent being in situ

Ensure the child has been appropriately prepared for the procedure by the play specialist (Rationale 9).

Catheter care: exit site

  • The stent should be sutured to the child’s skin, at the exit site, until the desired removal date (Rationale 10). 

  • The catheter must be secured to the child’s abdomen using hypoallergenic, latex free adhesive strapping eg Mefix™. However, care must be taken not to obstruct the flow of urine (Rationale 11).

  • The strapping and suture should be checked whenever the bag or nappy are changed (Rationale 12).

Depending on the age of the child normal nappy care/hygiene routines should be maintained. However, care should be taken to keep the stent exit site dry. Shallow baths or washes are appropriate.

The exit site should be observed for signs of trauma or infection. Doctors need to be informed of any bleeding, discharge or inflammation (Rationale 13). Record these observations in the child’s health care records (Rationale 14).

If an infection of the exit site is suspected a swab should be taken for microbiological examination (Rationale 15).

Stent exit site cleaning should only be performed if there is bleeding or discharge (Rationale 16). If cleansing is necessary the exit site should be cleaned using an aseptic non-touch technique (Rationale 17).

The following equipment should be gathered:

  • non-sterile gloves and plastic apron (Rationale 18)

  • dressing pack

  • additional sterile lint free gauze (Rationale 19)

  • sachet sterile 0.9 per cent Sodium Chloride (Rationale 20)

  • hypo-allergenic, latex free strapping eg Mefix™

To clean a bleeding or infected ureteric exit site:

  • explain the procedure to the child and family and ensure privacy (Rationale 21)

  • place a sachet of 0.9 per cent Sodium Chloride in a bowl of warm water (Rationale 22)

  • put on a plastic apron

  • perform a hand wash and dry hands thoroughly

  • open the dressing pack and sterile gauze

  • dry the sachet of saline and pour the appropriate amount into the container of the dressing pack

  • apply alcohol-based gel to hands rubbing thoroughly until dry and put on gloves (Rationale 23)

  • with non-dominant hand, hold catheter

  • using gauze soaked in 0.9 per cent Sodium Chloride wipe once around exit site

  • repeat, using clean gauze each time until the exit site is clean

  • dry around exit site using new piece of gauze (Rationale 24)

  • resecure the stent to the child’s abdomen (Rationale 11)

  • dispose of equipment, gloves and apron in an appropriate waste bag in line with the Trust's waste management policy (Rationale 18 and 25)

  • perform a hand wash and dry hands thoroughly (Rationale 18)

  • record the procedure in the child’s health care records (Rationale 14)

Removal of the ureteric stent

The child will require adequate analgesia prior to the stent being removed (Rationale 27). This must be prescribed and administered according to the Trust’s medicine administration policy.

In certain circumstances the stent should be clamped for several hours prior to removal, the doctor will advise if this is necessary (Rationale 28).

The stent must be removed by, or under the supervision of a competent nurse or doctor.

Standard precautions and an aseptic non-touch technique must be used (Rationale 17).

To remove a stent the following equipment should be gathered (Rationale 29):

  • non-sterile gloves

  • plastic apron

  • sterile gauze

  • sterile stitch cutter

  • hypo-allergenic strapping, eg Mefix™

  • adhesive removal

To remove the stent:

  • explain the procedure to the child and family and ensure privacy (Rationale 8)

  • thirty minutes prior to the procedure, administer analgesia as prescribed (Rationale 27)

  • put on an apron and safety glasses (Rationale 18 and 30)

  • perform a social hand wash, dry hands thoroughly and put on gloves

  • remove strapping with adhesive remover

  • if present, cut retaining suture

  • hold stent at entry site (Rationale 31 and 32)

  • encourage the child to take deep breaths (Rationale 33)

  • gently pull on the stent in one steady motion, whilst the child exhales, until the stent is completely removed (Rationale 34)
  • contact the child’s doctor if the stent cannot be removed (Rationale 35)

  • following removal, apply pressure (using gauze) for one minute to the exit site to promote closure of the bladder and abdominal wall (Rationale 36)

  • place a small dressing over the exit site

  • measure the volume of urine in the catheter bag/nappy (Rationale 14)

  • dispose of any urine and equipment, gloves and apron in an appropriate waste bag in line with the Trust's waste management policy (Rationale 18 and 25)

  • remove safety glasses

  • perform a hand wash and dry hands thoroughly

  • record the procedure and volume of urine in the child’s health records (Rationale 14)

The child and family must be reminded that pain may be experienced as the kidney pelvis fills up and during the first micturition.

  • The child’s first micturition must be documented on the fluid balance chart and in the child’s health care record (Rationale 14).
  • The child's doctor must be informed if the child:
    • has dysuria or loin pain
    • if the entry site leaks on their first micturition (pressure should be applied) (Rationale 39)

The dressing should be removed after 24 hours (Rationale 40). Once the site is healed a dressing will no longer be required.

Discharge

The child’s parents should be advised to contact the ward if, once discharged, they have concerns about the wound site (Rationale 41).

The family must be told to contact the ward if the child experiences any of the following problems:

Rationale

Rationale 1: Duration of catheterisation is strongly associated with risk of infection ie the longer the catheter is in place, the higher the incidence of urinary tract infection (Parry et al, 2013).
Rationale 2: To reduce the risk of introducing infection (Pratt et al, 2007).
Rationale 3: To prevent it from slipping out before the desired removal date.
Rationale 4: Smaller gauge catheters minimise trauma and mucosal irritation, which can predispose a child to catheter-associated infection (Pratt et al, 2007).
Rationale 5: The use of latex catheters and securing devices is a risk factor in acquiring latex allergy (Woodward, 1997).
Rationale 6: To obtain informed consent.
Rationale 7: To alleviate parental and child anxiety by the giving of information.
Rationale 8: To encourage carer involvement.
Rationale 9: To assist in the psychological preparation of the child.
Rationale 10: To prevent trauma to the ureter and exit site.
Rationale 11: To prevent accidental removal. To ensure the tape is not so tight it obstructs the flow of urine.
Rationale 12: To maintain the security of the catheter.
Rationale 13: To ensure appropriate management.
Rationale 14: To maintain an accurate record and enhance communication.
Rationale 15: To enable identification of micro-organisms (Higgins, 2013).
Rationale 16: Routine cleansing may cause an exit site infection due to manipulation and the introduction of skin commensals into the surrounding tissue.
Rationale 17: To minimise the risk of introducing infection.
Rationale 18: To minimise the risk of cross-infection (Pratt et al, 2007; National Institute for Clinical Excellence (NICE) 2014).
Rationale 19: Cotton wool should not be used as it can deposit fibres in the exit site, increasing the risk of infection.
Rationale 20: There is no advantage in using antiseptic preparations for cleansing (Pratt et al, 2007).
Rationale 21: To promote co-operation and involvement and reduce anxiety.
Rationale 22: Warm solution causes less discomfort.
Rationale 23: To prevent the spread of infection and ensure efficient cleansing.
Rationale 24: A dry environment is less conducive to the growth of micro-organisms.
Rationale 25: To prevent cross infection and adhere to the Trust’s waste policy.
Rationale 26: To provide an accurate record and enhance communication.
Rationale 27: To relieve any discomfort the child may experience.
Rationale 28: To ensure the stent is no longer required and the kidney is draining adequately.
Rationale 29: To enable the procedure to be performed safely and effectively.
Rationale 30: To minimise the risk of cross infection and splash back into the eyes (Pratt et al, 2007; NICE, 2014).
Rationale 31: To reduce trauma.
Rationale 32: To enabled stent to be gently pulled.
Rationale 33: To relax the abdominal wall.
Rationale 34: If the stent gets caught it can cause muscular/bladder spasms.
Rationale 35: The internal suture may still be intact or it may be caught on oedematous tissue.
Rationale 36: To prevent the leakage of urine and bleeding.
Rationale 37: The bladder or urethra may be oedematous causing pain or obstruction.
Rationale 38: Increased bladder pressure may cause a leak.
Rationale 39: If the bladder bleeds or leaks urine, a haematoma or urinoma may form creating a risk of infection (Fillingham and Douglas, 2004).
Rationale 40: To promote healing.
Rationale 41: To provide appropriate advice and reassurance.

References

Reference 1:
Fillingham S, Douglas J (2004) Urological Nursing (3rd ed). London, Bailliere Tindall

Reference 2:
Parry MF, Grant B, Sestovic M (2013) Successful reduction in catheter-associated urinary tract infections: Focus on nurse-directed catheter removal. American Journal of Infection Control 41: 1178-1181

Reference 3:
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, McDougall C, Wilcox M (2007) Epic2: National evidence-based guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 65(1): 1-64

Reference 4:
Woodward A (1997) Complications of allergies to latex urinary catheters. British Journal of Nursing 6(14): 786-790

Reference 5:
Higgins C (2013) Understanding laboratory investigations: A text for healthcare professionals. 3rd ed. Oxford, Blackwell Science

Reference 6:
National Institute for Health and Care Excellence (2014) Standard principles of prevention and control of healthcare-associated infections in primary and community care. Manchester, NICE

Document control information

Lead Author(s)

Helen Ingall, CNS, Urodynamics

Additional Author(s)

Karen Ryan, CNS Urodynamics

Document owner(s)

Helen Ingall, CNS, Urodynamics

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
21 July 2004
Date approved: 
19 December 2014
Review schedule: 
Three years
Next review: 
19 December 2017
Document version: 
4.0
Previous version: 
3.0