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Double-J (DJ) Ureteral Stent

The double-J (DJ) ureteral stent is one of the most commonly used devices in all of urology — the standard tool for internal urinary drainage across an enormous range of benign and malignant conditions. First described by Finney in 1978,[1] the characteristic "J" pigtail curl at each end has remained the fundamental design principle for nearly five decades.

History & Development​

  • 1967 — Zimskind described the first indwelling silicone ureteral tubing for internal drainage; early stents suffered from frequent migration.[2]
  • 1972 — Robert Gibbons (Virginia Mason) developed the first commercially available ureteral stent — the Gibbons stent — with "wings" to prevent distal migration, a barium-impregnated proximal tip, a distal flange to reduce trigonal irritation, and a removal tail. Established CPT code 52332, still used today.[2][3][4]
  • 1978 — Roy Finney introduced the double-J ureteral catheter stent — a self-retaining silicone stent with a J-hook at each end preventing both proximal and distal migration. Designed for both open surgical and endoscopic placement.[1]
  • 1984 — Andriole 87-patient series confirmed ease of endoscopic insertion, exceptional tolerance, and improved encrustation resistance vs prior designs.[5]
  • 1990s–present — Evolution in materials (polyurethane, silicone, C-Flex, Percuflex), coatings (hydrophilic, antibacterial, anti-encrustation), and designs (metallic, biodegradable, drug-eluting).[6][7][8]

Design & Specifications​

Hollow, flexible tube with side holes along its length and a pigtail curl at each end — one coiling in the renal pelvis and one in the bladder. Self-retaining; prevents both proximal and distal migration.

Diameter​

  • Range 4.7–8.5 Fr; 6 Fr is most common.
  • Smaller stents reduce symptom burden without compromising subsequent URS — Nestler 2020 showed 4.7 Fr had significantly fewer urinary symptoms, less pain, and better general health vs 7 Fr.[9]

Length​

  • Standard adult range 22–28 cm (24 / 26 cm most common); 16–18 cm pediatric; up to 32 cm for unusually long ureters.
  • Three selection methods:
    1. Patient-height formulas — < 178 cm → 22 cm; 178–193 cm → 24 cm; > 193 cm → 26 cm (Pilcher).[10]
    2. CT measurement of ureteral length — correlates better with actual length than height alone; 100% ideal positioning vs 71% for height-based mismatched lengths (p = 0.006).[11]
    3. Intraoperative measurement with calibrated ureteric catheter — most accurate.

Materials​

MaterialProsConsUse
PolyurethaneTunable stiffness; excellent radiopacityStiffer → more symptoms; encrusts fasterShort-medium term
SiliconeSofter; lower encrustation; better tolerated long-termHigher friction; lower radial strengthLonger-term / sensitive patients
C-Flex / Percuflex / PolarisHybrid copolymers; better flexibility + encrustation resistanceCostGeneral use
Metallic (Resonance, Memokath, Allium, Uventa)Resist extrinsic compressionCost; specialized placementMUO
Biodegradable (PLGA, PCL, PLA, PDO)Self-degrading — no removal procedureLargely investigationalEmerging

Stent biocompatibility — particularly resistance to encrustation and biofilm — is the dominant determinant of long-term performance.[6][7]

Indications​

Stone Disease (Most Common Indication)​

Stenting follows ~60% of ureteral stone and ~80% of renal stone URS cases.[12] Other stone uses: pre-stenting for large / impacted calculi, decompression with sepsis or renal failure, and post-PCNL drainage.

Ureteral Obstruction​

Malignant extrinsic compression (gynecologic, colorectal, bladder, prostate, retroperitoneal cancers), benign stricture, retroperitoneal fibrosis, UPJ obstruction (post-pyeloplasty).

Post-Surgical Drainage​

Ureteral reimplantation / UNC, ureteral repair after iatrogenic or traumatic injury,[13] kidney transplant prophylaxis, endopyelotomy.

Urinary Fistula​

Upper urinary tract fistulas (ureteral, renal) — approximately 50% heal with stenting alone.[5]

Kidney Transplantation​

  • Cochrane 2024 (12 RCTs, n = 1,960): prophylactic stenting reduces urine leakage (RR 0.25) and ureteral obstruction / stricture (RR 0.42); UTI rate increases (RR 1.41).[14]
  • Yin 2026 confirmatory meta.[15]
  • DJ stents superior to single-J in transplantation (PCN needed in 4.5% vs 14.5%, p = 0.003) — Oudmaijer 2025.[16]
  • Patel 2017 RCT: early removal at 5 days significantly reduces stent-related complications vs 6-wk removal (7.6% vs 28.6%, p < 0.05).[17]
  • Amara NSQIP 2026 (n = 3,407): stenting is associated with higher UTI (OR 2.22, p < 0.05).[18]

Stenting vs No-Stenting After Uncomplicated URS​

The Cochrane Ordonez 2019 review and subsequent RCTs:[12][19][20][21]

  • Stenting is mandatory after complicated URS (ureteral injury, infection, renal failure).
  • Stent omission reduces dysuria but increases unplanned medical visits (OR 1.63, 95% CI 1.15–2.30) — Pais 2016 SR.[19]
  • Proximal ureteral / renal stones (Allam 2023 RCT): unstented patients had significantly fewer irritative symptoms.[20]
  • Distal ureteral stones < 1 cm (Reddy 2022 RCT): stent omission feasible with selective use.[21]

Optimal Dwell Time & Removal​

Dwell Time​

Katsimperis 2026 SR (32 studies, 4,373 patients): 10–14 days appears optimal in uncomplicated cases to balance healing and prevent encrustation.[22]

  • < 5 days — increased ED visits at removal (Ghani 2023).[23]
  • 3 vs 7 days RCT (Heidenberg 2023): 3-day removal had better USSQ symptoms / pain / general health with no increase in complications.[24]
  • Encrustation remains low < 4 mo (1.3% non-stone) but rises after 4–6 mo (Legrand 2021, Maxim 2025).[25][26]

Removal Methods[22][27][28][29]​

MethodFrequencyProsCons
Rigid cystoscopy48.7%Standard, reliableProcedure, discomfort
Flexible cystoscopy19.9%Less painful, office-basedEquipment cost
Extraction strings (SOS)23.5%Patient self-removal at home; cost savings; less pain3–10% dislodgement risk
Device-assisted (magnetic)7.9%NovelLimited availability

Stent-on-String​

Harrison 2024 SR (22 studies, n = 8,382): shorter dwell time, less pain on removal, significant cost savings; > 90% of patients willing to self-remove at home.[28][27][29] Inoue 2019 controlled trial: string removal significantly less painful than cystoscopic removal in men (VAS 2.73 vs 5.67).[30] Particularly valuable in pediatrics where it avoids GA for removal (Juliebø-Jones EAU YAU 2022 SR).[31]

Affects ~60–90% of patients. Bosio 2019 prospective USSQ study (n = 232):[32]

  • Urinary frequency ≥ 1/hr: 59.1%
  • Nocturia ≥ 1: 90.1%
  • Urgency: 86.6%; Dysuria: 82.3%
  • Pain (any): 83.2% — kidney 67.9%, bladder 31.3%; pain during activity 72.9%, micturition 77.0%
  • Pain interfered with everyday life in 92.2%
  • 62% would be dissatisfied if further stenting were proposed
  • Younger patients and females are more affected.

A new validated questionnaire — Canadian Endourology Group Stent Symptom Score (CEGSSS) (Bhojani 2026) — was developed specifically for short-term dwell times (< 30 days).[33]

Pathophysiology[34]​

  • Mucosal irritation by stent body and curls (trigonal irritation by bladder curl).
  • Vesicoureteral reflux through the stent lumen during voiding (loin-with-voiding pain).
  • Ureteral spasm and irregular peristalsis.

Pharmacologic Management​

Hinojosa-Gonzalez 2023 Bayesian network meta-analysis of 26 RCTs identified the most effective strategy by domain:[35]

Symptom domainMost effective
Urinary symptomsSilodosin 8 mg + solifenacin 10 mg
PainSilodosin 8 mg + solifenacin 10 mg
Sexual performanceTadalafil 5 mg
General healthSilodosin + solifenacin + tadalafil
Work performanceα-blocker + anticholinergic; PDE5i
  • α-blockers — Lamb 2011 meta: mean ↓ 8.4 points USSQ urinary score; pain RR 0.59 (95% CI 0.47–0.71). EAU strong recommendation.[36][37]
  • Anticholinergics / mirabegron — significant benefit for irritative symptoms; additive with α-blockers.[37]
  • Combination (solifenacin 10 mg + tamsulosin 0.4 mg) — most effective for pain in Pricop 2024 RCT (p = 0.001).[38]

Complications​

ComplicationIncidenceNote
Stent-related symptoms (LUTS / pain)60–90%Most common
Hematuria14–25%Usually self-limited
Bladder irritation4–10%Frequency, urgency, dysuria
UTI / bacteriuria6–42%Increases with dwell time; biofilm
Encrustation2–76% (time-dependent)Major long-term risk
Migration1.5–10%Proximal or distal
Stent fractureRareProlonged dwell
Ureteral perforationRareUsually iatrogenic at placement
Forgotten stentVariablePreventable but potentially devastating

Encrustation — Time-Dependent​

Legrand 2021 European multicenter (n = 473):[25]

  • < 4 mo: 1.3% non-stone / 8% stone indication.
  • 4–6 mo: 5.2% non-stone / ~17% stone.
  • > 6 mo: rising thereafter.
  • One-third of stents in routine practice were indwelling > 6 mo, 9% > 1 yr — highlighting the gap between recommendation and reality.

Maxim 2025: indwelling > 90 d significantly associated with higher encrustation grade.[26] Risk factors: prolonged dwell, urolithiasis history, UTI (especially Proteus mirabilis), pregnancy, cystinuria, alkaline urine.[39][40]

Forgotten Stent​

Preventable but potentially devastating. Zhang 2020 case: DJ retained 6 years → 4.2 cm bladder stone requiring pneumatic lithotripsy.[41] Management depends on encrustation severity:[42][40][43]

  • None — simple extraction.
  • Minimal — SWL or percutaneous.
  • Moderate — retrograde URS + holmium laser lithotripsy ± stent cutting (Thomas 2017: 98% success with retrograde approach alone).[44]
  • Severe (> 3 mm throughout) — combined antegrade / retrograde, PCNL, rarely open surgery.[43][42]

Computerized stent tracking is strongly advocated.[40]

Metallic Ureteral Stents​

Critical advance for malignant ureteral obstruction (MUO) where polymeric DJ stents have high failure rates from extrinsic compression.[45][14][15]

StentDesignSuccessMigrationKey feature
Resonance (Cook)NiTi coiled88–95%1% (lowest)Longest functional duration; resists compression[46][47]
Memokath 051Thermo-expandable NiTi65%HigherSelf-expanding, removable
UventaSelf-expanding meshVariableVariableLowest obstruction rate
Allium URSSelf-expanding, covered88%VariableCovered, prevents ingrowth
CMS (silicone-covered)Self-expanding70–95%2.3%Better patency than DJ for MUO[48][49]

Resonance — Most-Studied Metallic Stent​

  • Mean 4-month longer functional duration vs polymeric stents (p < 0.0001).[46]
  • Median functional duration 14 months vs shorter for 6 / 8 Fr polymeric (p = 0.012).[50]
  • Annual exchange schedule feasible.[51]
  • Effective for both malignant and benign chronic obstruction; reduces stent changes from 6.3/yr to 1.4/yr.[52]

Covered Metallic Stent vs DJ for MUO​

Kim 2018 prospective RCT: CMS overall patency significantly higher than DJ (p = 0.041); median patency 239 days vs 80 days; 3-mo patency 90% vs 35%; 6-mo patency 57% vs 21%.[49][48][53]

Biodegradable Ureteral Stents​

Self-degrade after a predetermined period — eliminate retrieval procedure. Materials under investigation: PLGA, PCL, PLA, PDO and copolymers.[13][54]

Advantages: no second procedure, no forgotten-stent risk, potential controlled drug delivery, lower preclinical UTI / encrustation rates than standard DJ.

Limitations: degradation timing hard to control precisely; limited clinical data (mostly preclinical); mechanical strength may be insufficient; degradation products may transiently obstruct.

Wang 2023 modified biodegradable mesh: complete biodegradation at 3–5 mo in animal models with lower UTI and less encrustation than DJ.[54]

Drug-Eluting & Surface-Modified Stents​

Surface modifications[8]:

  • Hydrophilic — reduce friction and mucosal irritation.
  • Antibacterial — silver, propolis, triclosan reduce biofilm and UTI.
  • Anti-encrustation — heparin, diamond-like carbon, zwitterionic coatings.

Specific drug-eluting designs:

  • Triclosan-eluting (Triumph) — Mendez-Probst RCT showed significant reductions in flank pain during activity (58.1%, p = 0.017), abdominal pain (42.1%, p = 0.042), and urethral pain on urination (31.7%, p = 0.049), without significant biofilm / encrustation impact.[55]
  • Antimicrobial — ciprofloxacin (Ma 2016); moxifloxacin / dual-drug silk fibroin / PDO (Duan 2025).[56][57]
  • Anti-stricture — rapamycin and paclitaxel for post-laser-lithotripsy stricture prevention (Hu 2023).[58]
  • Anti-tumor drug-eluting — for local chemotherapy in UTUC.[59]
  • Propolis-coated — eliminated > 90% of bacterial biofilms; bacteriostatic up to 3 mo in preclinical work.[60]

Reconstructive-Urology Relevance​

DJ stent is integral to reconstructive practice as an intraoperative scaffold:

  • UNC / Boari flap / psoas hitch — 4–6 wk dwell typical.
  • Pyeloplasty — 4–6 wk.
  • Renal transplant ureteral anastomosis — early removal at ~5 days reduces complications (Patel 2017).[17]
  • BMG ureteroplasty / appendiceal interposition — 6–8+ wk.
  • After ureteral injury during pelvic / colorectal / gynecologic surgery — see ACS Best Practices for GU Injuries.[13]

See also: Nephrostomy Tube, Nephroureteral Stent, Metal / Long-Term Ureteral Stents, The Ureters.

References​

1. Finney RP. Experience With New Double J Ureteral Catheter Stent. The Journal of Urology. 1978;120(6):678-681. doi:10.1016/s0022-5347(17)57326-7

2. Donahue RP, Stamm AW, Gibbons RP, et al. Evolution of the Ureteral Stent: The Pivotal Role of the Gibbons Ureteral Catheter. Urology. 2018;115:3-7. doi:10.1016/j.urology.2018.02.007

3. Smith AD, Lange PH, Miller RP, Reinke DB. Introduction of the Gibbons Ureteral Stent Facilitated by Antecedent Percutaneous Nephrostomy. The Journal of Urology. 1978;120(5):543-544. doi:10.1016/s0022-5347(17)57265-1

4. Danoff DS. The Gibbons Indwelling Silicone Ureteral Stent Catheter. The Journal of Urology. 1977;117(1):33. doi:10.1016/s0022-5347(17)58326-3

5. Andriole GL, Bettmann MA, Garnick MB, Richie JP. Indwelling Double-J Ureteral Stents for Temporary and Permanent Urinary Drainage: Experience With 87 Patients. The Journal of Urology. 1984;131(2):239-241. doi:10.1016/s0022-5347(17)50324-9

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