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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 1043-1045
Forgotten long-term indwelling double "J" stent


Department of Surgery, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India

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Date of Web Publication13-Sep-2012
 

   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

How to cite this URL:
Wani B, Upadhey R, Rathod V, Bhole A. Forgotten long-term indwelling double "J" stent. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Oct 29];23:1043-5. Available from: https://www.sjkdt.org/text.asp?2012/23/5/1043/100946

   Introduction Top


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 Top


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 Top


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 Top


The authors would like to thank all the per­sonnel of the Department of Surgery, JNMC, Sawangi (Meghe), Wardha.

 
   References Top

1.Singh I. Indwelling JJ ureteral stents - a current perspective and review of literature. Indian J Surg 2003;65:405-12.  Back to cited text no. 1
    
2.Somers W. Management of forgotten retained indwelling ureteral stents. Urology 1996;47: 431-5.  Back to cited text no. 2
    
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.  Back to cited text no. 3
[PUBMED]    
4.Ringel A, Richter S, Shalev M, Nissenkorn I. Late complications of ureteral stents. Eur Urol 2000;38:41-4.  Back to cited text no. 4
[PUBMED]    
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.  Back to cited text no. 5
[PUBMED]    

Top
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

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    Abstract
   Introduction
   Case Report
   Discussion
   Acknowledgment
    References
    Article Figures
 

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