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| Year : 2012 | Volume
: 23
| Issue : 5 | Page : 1043-1045 |
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| Forgotten long-term indwelling double "J" stent |
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Bhushan Wani, Rohit Upadhey, Vishal Rathod, Anil Bhole
Department of Surgery, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India
Click here for correspondence address and email
| Date of Web Publication | 13-Sep-2012 |
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 Abstract | | |
A poor, uneducated patient from a rural background presented to us with burning micturition and colicky pain in the loin. He had undergone surgery for pelvi-ureteric junction (PUJ) obstruction on the right side four years earlier. Following surgery, the patient was irregular in his follow-up and, as such, he did not get the double "J" (DJ) stent, which was placed during surgery, removed. Ultrasonography performed during the present admission revealed mild hydronephrosis of the right kidney with a tiny calculus in the urinary bladder. Intravenous urography revealed mild hydronephrosis with the DJ stent in situ in the right kidney. After an unsuccessful attempt with cystoscopy, the stent was removed successfully by suprapubic cystostomy. The postoperative course was uneventful and the patient was discharged in seven days.
How to cite this article:
Wani B, Upadhey R, Rathod V, Bhole A. Forgotten long-term indwelling double "J" stent. Saudi J Kidney Dis Transpl 2012;23:1043-5 |
| Introduction | |  |
The first double-"J" (DJ) stent was first manufactured in 1978. [1] It provides a convenient means of drainage to the upper urinary tract and its J-shaped tips at both the ends efficiently prevents migration from the kidneys and/or the urinary bladder. These days, DJ stents are in common use because they provide efficient and relatively safe urinary diversion between the kidney and the urinary bladder. [2] We report this case to highlight the possible serious complications with long-term indwelling stents that frequently result in complications and pose a management and legal dilemma.
| Case Report | | |
A poor, uneducated 38-year-old male patient from a rural background presented to us with burning micturition and colicky pain on the right side. He gave a history of surgery for pelvi-ureteric junction (PUJ) obstruction on the same side four years earlier. During the post-operative period, he was irregular in attending follow-up for removal of the DJ stent, which was placed at the time of surgery. Examination revealed a well-healed scar in the right flank. A plain X-ray of the abdomen showed a coil of the DJ stent in situ in the right kidney [Figure 1]. Ultrasonography revealed mild hydronephrosis of the right kidney with a tiny calculus in the urinary balder. Intravenous urography revealed mild hydroneph nephrosis with the DJ stent in situ in the right kidney. After the diagnosis, cystoscopic removal of the stent was attempted but without success as it was too deeply impacted. Thus, a decision was taken to open the bladder. During the course of the operation, the impacted DJ stent was removed from the urinary bladder by suprapubic cystostomy. On examination, the vesicle end of the DJ stent was coated with encrustations causing cystitis [Figure 2]. The post-operative course was uneventful and the patient was discharged in seven days with improvement of his symptoms. | Figure 1: Plain X-ray of the abdomen showing the double-J stent in situ in the right kidney.
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 | Figure 2: Intra-operative photograph showing (A) encrustations at the vesical end of the stent (B) extracted double-J stent from the bladder (C) complete removal of the double-J stent with its double-J loops.
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| Discussion | | |
The DJ ureteral stent has become an integral part of the urological armamentarium. It allows good urinary drainage from the kidney to the bladder and is generally safe and well-tolerated. However, different complications may occur with short-term placement for three to nine weeks, including flank pain and irritative voiding symptoms, hematuria, dysuria, frequency, flank and suprapubic pain, referred to as the "stent syndrome." [1] Complications occur in patients with long-term placement of stents who do not come for follow-up; the forgotten stent. These delayed complications include hydronephrosis, encrustation and blockage, stuck stents, stent migration, stent knotting and fracture, spontaneous fragmentation and stenturia. [1],[2],[3],[4]
During insertion of a ureteric stent, one should not only ensure its accurate placement but also ensure that the length chosen is appropriate for the patient. Migration of a stent is a known complication. [1],[4] In our patient, the vesicle end had developed tiny encrustations causing pain and source of infection leading to cystitis. The proximal end of the stent remained in the renal pelvis and was patent.
Endourologic management of a forgotten DJ stent is well established and there is an algorithm available for the same. However, it should be managed endoscopically only by urologists who are well trained and sufficiently experienced in endourology. Open surgery has a role when multimodal endourology fails or when such a facility is not available, as in our case. [2]
Certain precautions and guidelines must be observed whenever a DJ stent is used. The stent is a double-edged sword and its routine use is not justified, at least where endourological facilities are not available in institutions or nursing homes or when a general surgeon operates. [4] Instead, temporary ureteric catheters can be used, which the patients notice and which are removed prior to discharge. When the use of a DJ stent is mandatory, the patient should be educated about the need for its timely removal. The patient's name, address and telephone number should be recorded in a stent register. The treating surgeon should regularly update his stent register so as to track overdue stents and ensure their removal at the earliest. This will avoid unnecessary morbidity for the patient and legal problems for the doctor. [5]
There are usually no complications with short-term DJ stent urinary drainage. However, indwelling DJ stents can cause serious complications, such as migration, encrustation, perforation and fragmentation. The duration of an indwelling DJ stent should be as short as possible, and, if a longer duration of stenting is required, the DJ stent should be replaced with a new one. Careful monitoring of patients could exclude any possibility of a stent being forgotten and left in situ.
| Acknowledgment | | |
The authors would like to thank all the personnel of the Department of Surgery, JNMC, Sawangi (Meghe), Wardha.
| References | | |
| 1. | Singh I. Indwelling JJ ureteral stents - a current perspective and review of literature. Indian J Surg 2003;65:405-12. 
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| 2. | Somers W. Management of forgotten retained indwelling ureteral stents. Urology 1996;47: 431-5.
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| 3. | Ivica S, Dragan S. Long-term indwelling double-J stents: Bulky kidney and urinary bladder calculosis, spontaneous intraperitoneal perforation of the kidney and peritonitis as a result of "forgotten" double-J stent. Vojnosanit Pregl 2009;66:242-4.
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| 4. | Ringel A, Richter S, Shalev M, Nissenkorn I. Late complications of ureteral stents. Eur Urol 2000;38:41-4.
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| 5. | Singh V, Srinivastava A, Kapoor R, Kumar A. Can the complicated forgotten indwelling ureteric stents be lethal? Int Urol Nephrol 2005; 37:541-6.
[PUBMED] |
Correspondence Address:
Bhushan Wani
Department of Surgery, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha 442004, Maharashtra
India
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DOI: 10.4103/1319-2442.100946 
[Figure 1], [Figure 2] |
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