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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2015  |  Volume : 26  |  Issue : 4  |  Page : 747-750
Retained fragmented double J ureteric stent: A report of four cases with review of the literature


1 Department of Urology, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India
2 Department of Urology, Bankura Sammilani Medical College, Bankura, West Bengal, India

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Date of Web Publication8-Jul-2015
 

   Abstract 

Polyurethane double-J ureteral stents are widely used in the field of urology. Postoperatively, patient education about the ureteral stent and making sure it is removed at the prescribed time is an utmost necessity. Forgotten ureteral stent is not only disastrous for the patient but also fraught with serious medico-legal implications for the urologist. Herein, we present four cases of long-term retained part of ureteral stent with its varied presentation and subsequent management.

How to cite this article:
Goel HK, Kundu AK, Maji TK, Pal DK. Retained fragmented double J ureteric stent: A report of four cases with review of the literature. Saudi J Kidney Dis Transpl 2015;26:747-50

How to cite this URL:
Goel HK, Kundu AK, Maji TK, Pal DK. Retained fragmented double J ureteric stent: A report of four cases with review of the literature. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2020 Sep 27];26:747-50. Available from: http://www.sjkdt.org/text.asp?2015/26/4/747/160199

   Introduction Top


Polyurethane ureteral stents are widely used in the field of urology since 1967. [1] Pain, bladder irritation and fever are signs of early complications related to ureteral stents; late complications such as encrustation, infections and fragmentation are more troublesome. [2],[3],[4] Cases of fragmented ureteral stents [5],[6] and vanishing mid-shaft of ureteral stent [7] are rarely reported. We present four cases of long-term forgotten and fragmented ureteral stents with their varied presentation and subsequent management.


   Case Reports Top


Case 1

A 47-year-old male presented with complaints of lower urinary tract symptoms, predominantly frequency, urgency and dysuria. He had a past history of right open pyelolithotomy seven years earlier and was subsequently lost to follow-up. He was normoglycemic, with normal renal function tests. Urinalysis showed microscopic hematuria and pyuria. Urine culture was sterile. On ultrasound, a double-J ureteric stent was visualized in the right renal system. X-ray of the kidney, ureter and bladder (KUB) region showed a fragmented double-J ureteric stent in the right renal region with lower coil present in the bladder and extending into the urethra [Figure 1]. Intravenous urography (IVU) confirmed normal function of both the kidneys. Under cystoscopic guidance, the lower fragment of the stent was pushed back in the bladder and then removed en masse with the cystoscopic sheath in situ to prevent any urethral trauma due to encrustations. The upper fragment was then removed under ureteroscopic guidance with the help of a foreign body grasper. Post-operative recovery was uneventful.
Figure 1: X-ray KUB region showing fragmented double-J ureteric stent in the right renal region with lower coil present in the bladder and extending into the urethra.

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Case 2

A 59-year-old male presented with complaints of lower urinary tract symptoms and right flank pain. He had a past history of right ureteroscopic lithotripsy four years earlier. He had normal renal function tests with pyuria on urinalysis. Urine culture showed growth of proteus species. On ultrasound, a double-J ureteric stent was seen in the right renal system extending into the upper ureter; additionally, echogenic material (? calculi) was seen in the bladder region. X-ray KUB [Figure 2] showed fragmented double-J ureteric stent in the right renal region with the lower coil, surrounded by encrustation/calcification, present in the bladder. IVU confirmed normal function of both kidneys. Because of severe encrustation, per urethral removal of the lower fragment was considered unsafe. The lower fragment was therefore removed by percutaneous cystotomy and the upper fragment removed by ureteros copy. Post-operative recovery was uneventful.
Figure 2: X-ray KUB showing fragmented double-J ureteric stent in the right renal region with lower coil present in the bladder, with encrustation/calcification around the lower part of the coil.

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Case 3

A 43-year-old male presented with complaints of right flank pain and fever. He had a past history of right open ureterolithotomy nine years earlier. He had normal renal function tests with pyuria and microscopic hematuria on urinalysis. Urine culture showed growth of E. coli. On ultrasound, there was suspicion of calculi in the right renal pelvis. Xray KUB [Figure 3] showed the coiled upper part of a double-J ureteric stent in the right renal pelvic area with absence of the remaining part of the stent. There was no history of any instrumentation after the previous surgery. IVU confirmed normal functioning kidneys. Culture-specific antibiotics were administered. A right renal percutaneous access was created and the stent was removed with the help of a foreign body grasper. A double-J ureteric stent was placed, which was removed after three weeks. Post-operative recovery was uneventful.
Figure 3: X-ray KUB showing the coiled upper part of the double-J ureteric stent in the right renal pelvic area with absence of the remaining part of the stent.

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Case 4

A 49-year-old male presented with left renal colicky pain that was relieved by analgesics. He had a past history of left open ureterolithotomy four years earlier. He was diabetic, controlled on oral anti-diabetic medication, and with normal renal function tests. Urinalysis showed microscopic hematuria and pyuria. Urine culture showed growth of E. coli and proteus. On ultrasound, multiple calculi (1.5 cm) were seen in the left renal pelvis with mild hydronephrosis. X-ray of the KUB [Figure 4] showed presence of calculi in the left renal region surrounding the uppermost part of the double-J ureteric stent. IVU confirmed the findings of X-ray KUB; mild left hydronephrosis was seen. There was no history of instrumentation after prior surgery. Culture-specific antibiotics were administered. Left percutaneous nephrolithotomy was performed and the system was cleared. A nephrostomy drain and double-J ureteric stent were placed, which were removed on the 3 rd and 21 st post-operative days, respectively. Post-operative recovery was uneventful.
Figure 4: X-ray of KUB showing part of the upper end of the double-J stent in the left renal pelvis with calculi around it.

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   Discussion Top


Double-J ureteral stents are widely used in modern urology practice. The ideal biomaterial characteristics include biological inertia, chemical stability in the urine, resistance to infection and encrustation, long-term urinary flow, stability, no discomfort and affordability. [8] Currently, biomaterials commonly used in the urinary tract include polyurethane, silicone, Silitek, C-Flex, Percuflex and metals, and have their own inherent advantages and drawbacks. [8],[9] The optimal indwelling period is eight to 16 weeks, which has been further reduced to two to 12 weeks more recently. [3] Forgotten ureteral stents are observed in urologic practice because of poor compliance or failure of the physician to adequately counsel the patient. El-Faqih et al demonstrated that the rate of complication for indwelling polyurethane stents was 9.6% if removed in less than six weeks. This rate increased to 47.5% for stents left for six to 12 weeks and to 76.3% for stents left for 12 weeks. [3] These findings were supported by Kumar et al, who reported that stents had fragmented into multiple pieces after a mean indwelling time of only 14 weeks. [10] This occurs because the stent is exposed to different factors in the urine and the urothelium for a long time, which may lead to loss of its strength, elasticity and flexibility. [10]

Various mechanisms have been proposed to explain ureteral stent fragmentation. In most fractured stents, many leukocytes were identified in the urine, with or without infection; this might lead to depolymerisation of biomaterials. [11] Polyurethane stents are especially prone to encrustation due to their higher tensile strength that may encourage stasis with periluminal and endoluminal encrustation. Encrustations are often composed of calcium oxalate, which is enhanced by rough surfaces, catheter holes and edges (major characteristics of polyurethane stents). [8] Because of encrustations, the ends of the stent may be retained in situ while the central shaft may get degraded and vanish due to urinary infections. [7]

On inspection of fragmented stents, these fracture lines generally pass across the stent side holes. [10] Therefore, the incidence of ureteral stent fracture can be decreased by eliminating these holes. [9]

Generally, cystoscopic intervention is enough to remove the bladder stents. Utmost care should be taken to prevent any urethral trauma while retrieving an encrusted double-J stent. A percutaneous cystoscopic approach should be preferred when there is risk of urethral injury. Retrieving a proximally fragmented double-J ureteral stent can be frustrating and technically challenging, and may require ureteroscopic, percutaneous or open approach.

Prevention is better than cure. Timely cystoscopic removal or replacement of the ureteral catheter would minimize stent calcification and fragmentation. Complete removal of the stent should be confirmed by examining the stent after removal. Poor compliance is the most important risk factor for stent fragmentation. This can be prevented by using a computerized registry system to track patients, using a distal traction suture to a ureteral stent and/or using a ureteral catheter. [12]

 
   References Top

1.
Zimskind PD, Fetter TR, Wilkerson JL. Clinical use of long-term indwelling silicone rubber ureteral splints inserted cystoscopically. J Urol 1967;97:840-4.  Back to cited text no. 1
[PUBMED]    
2.
Damiano R, Oliva A, Esposito C, De Sio M, Autorino R, D'Armiento M. Early and late complications of double pigtail ureteral stent. Urol Int 2002;69:136-40.  Back to cited text no. 2
    
3.
el-Faqih SR, Shamsuddin AB, Chakrabarti A, et al. Polyurethane internal ureteral stents in treatment of stone patients: Morbidity related to indwelling times. J Urol 1991;146:1487-91.  Back to cited text no. 3
    
4.
Schulze KA, Wettlaufer JN, Oldani G. Encrustation and stone formation: Complication of indwelling ureteral stents. Urology 1985;25: 616-9.  Back to cited text no. 4
[PUBMED]    
5.
Zisman A, Siegel YI, Siegmann A, Lindner A. Spontaneous ureteral stent fragmentation. J Urol 1995;153:718-21.  Back to cited text no. 5
    
6.
Kilciler M, Erdemir F, Bedir S, et al. Spontaneous ureteral stent fragmentation: A case report and review of the literature. Kaohsiung J Med Sci 2006;22:363-6.  Back to cited text no. 6
    
7.
Gupta R, Modi P, Rizvi J. Vanishing shaft of a double-j stent. Urol J 2008;5:277-9.  Back to cited text no. 7
    
8.
Beiko DT, Knudsen BE, Watterson JD, Cadieux PA, Reid G, Denstedt JD. Urinary tract biomaterials. J Urol 2004;171:2438-44.  Back to cited text no. 8
    
9.
Gorman SP, Jones DS, Bonner MC, Akay M, Keane PF. Mechanical performance of polyurethane ureteral stents in vitro and ex vivo. Biomaterials 1997;18:1379-83.  Back to cited text no. 9
    
10.
Kumar M, Aron M, Agarwal AK, Gupta NP. Stenturia: An unusual manifestation of spontaneous ureteral stent fragmentation. Urol Int 1999;62:114-6.  Back to cited text no. 10
    
11.
Ilker Y, Türkeri L, Dillioglugil O, Akdas A. Spontaneous fracture of indwelling ureteral stents in patients treated with extracorporeal shock wave lithotripsy: Two case reports. Int Urol Nephrol 1996;28:15-9.  Back to cited text no. 11
    
12.
Ahallal Y, Khallouk A, El Fassi MJ, Farih MH. Risk factor analysis and management of ureteral double-j stent complications. Rev Urol 2010;12:e147-51.  Back to cited text no. 12
    

Top
Correspondence Address:
Hemant Kumar Goel
Department of Urology, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata 700 020, West Bengal
India
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DOI: 10.4103/1319-2442.160199

PMID: 26178549

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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