Methods
This is a retrospective study which was conducted at King Hussein
Medical Center
during the period between January 2005- April 2009, 15 patients (10 males and 5
females) aged 25-60 years were treated for severely encrusted JJ ureteral
stent, two of them with transplanted kidney, and one with single functioning
native kidney. All patients were evaluated clinically and were assessed by
investigations including KUB, and renal function profile. The duration of JJ
stents left in situe range from 6 months – 12 years. Three patients had severe
encrustation on the whole ureteral stent, one with single functioning kidney
and fragmented stent as shown in Fig. 1 and 2, and one of them with
transplanted kidney as presented in Fig. 3, 4 and 5. Five had severe
encrustation at both bladder and renal ends. Five had severe encrustation at
ureteric part and bladder end and 2 had severe encrustation at bladder end
only. All patients presented with loin pain, haematurea, and irretative urinary
symptoms. Multimodal therapies were used for management of the encrusted JJ
stents. Two patients with bladder end encrustation were treated successfully
endoscpically with cystolitholapaxy by stone crushing forceps and optical
lithotrite using the usual nephroscope and pneumatic lithoclast for
fragmentation of the stone.
Three cases with encrustation of the whole stent were
treated in sessions, two required cystolitholapaxy by the optical lithotrite,
ureteroscopy and percutaneous nephrolithotomy (PCNL) and one required
cystolitholapaxy by the optical lithotrite, percutaneous nephrolithotomy, but failed
ureteroscopy twice for ureteral part, and then were managed by ureterolithotomy.
The 5 patients with both end encrustations were treated by cystolitholapaxy
using stone crushing forceps and optical lithotrite, then percutaneous
nephrolithotomy. Those 5 patients with ureteric part and bladder end were treated
by cystolitholapaxy, and ureteroscopy in the same session. All our patients
were given prophylactic antibiotics on induction and for 5 days after treatment.
Result
The average duration of stent remain in the urinary
system was 30 months (range 6 months – 12 years). All patients
were stents and stone free
after 1-4 approach (ureteroscopy, percutaneous
nephrolithotomy, cystoliholapaxy and open surgery) in multi sessions. Those 2
patients with bladder end encrustation required one session of
cystolitholapaxy. Three patients with whole stent encrustation, two of them
required one session for cystolitholapaxy and ureteroscopy then one session for
PCNL, the other patient required 2 sessions for cystolitholapaxy and failed
trial of ureteroscopy, session for PCNL, and then one session for
ureterolithotomy. Five patients with both end encrustations required two
sessions, one for cystolitholapaxy and one PCNL. In those 5 patients with
ureteric part and bladder end encrustation, 3 of them were treated by one
session cystolitholapaxy and ureteroscopy, the other two patients required two
sessions one for cystolitholapaxy and one for ureteroscopy.
One major complication was encountered, which is small
bowel loop injury through and through by PCNL tract in one of the transplanted
kidney patient, because the approach was abdominal through the upper pole of
the kidney and managed by immediate laparotomy and repair of bowel injury.
Residual small stone in lower group calyx in one patient, persistent urine leak
from PCNL tract in 2 patients managed by JJ stent placement for 4 weeks. No
impairment of renal function was recorded. All patients were stone and stents
free at the end of treatment.
Discussion
JJ stents has become an important armamentarium and
valuable tools in the hands of urosurgeons. It prevents ureteral obstruction
and provides direct drainage of upper urinary tract without the need for
external drainage.(15,16) However, its placement is not
without any complications, stent migration, blockage, fragmentation,
encrustation, knotting, renal failure and stone formation.(17-21)
The stents encrustation etiology is multifactorial,
resulting from recurrent urinary tract infections, alkaline urine, calcium
phosphate and struvite accumulation.(23-27) chronic stone
formers.(27,28) duration of the stents and pregnancy.(29,30)
The rate of encrustation is significantly related to the duration of stenting
or dwelling time.
El-Faqih and colleagues(31) noted a
9.6% encrustation rate for stents remain in less than 6 weeks duration, which
increased to 47.5% for those remain for 6 to 12 weeks and 76.3% for those remain
more than 12 weeks of duration; therefore, many authors recommended early
removal of the stents.(7,30,31)
Successful management means achieving a stent and
stone free status, with preservation of normal renal function
Encrustation of forgotten stents is the most serious
complication; its management represents a challenge for urologist, and
necessitates a multimodal approach.(21,22) Few studies have
introduced algorithms for management of retained indwelling ureteral stents.(24,32,33)
Recently, endourological surgery has become the first
choice in the management of severely encrusted ureteral stent. However, it
should be managed only by those well trained and sufficiently advanced in
endourology. Open surgery has a role when multimodal endourology fails or when
such facility is not available.(34-37) Also in the last 4
years one sitting laparoscopic and percutaneous management of a heavily encrusted
DJ stent has been reported with minimal morbidity and short hospitalization.(37,38)
In our study our plan is to use endourological
procedure for extraction of the whole stents and encrustation around it, which
is the case in all our patients except one whose ureteric part of the stent and
encrustation around it is filling the whole ureter, so, we were unable to
advance ureteroscope up in the ureter, that is why ureterolithotomy done for
him. Although surgical intervention can provide all necessary solution to deal
with forgotten indwelling stents, the best treatment remains prevention. It has
been reported that a period between 2 and 4 months can be considered optimal.(10,32,39)
In our study we reported one major complication which
is small bowel injury by PCNL tract in a lady with transplanted kidney,
abdominal approach have been used, urgent laparatomy and simple bowel repair were
done immediately.(40,41)
In our study, diagnosis of encrustation of ureteral
stents has been based only on unenhanced radiograph of the abdomen.
Ultrasonography is indicated in situation where radiograph is contraindicated
or fails to visualize the stents.(8, 41-43)
Conclusion
Severe encrustation of the JJ stents requires
multimodal therapy for managing this complex problem; the choice of
endourological treatment depends on the location of the encrustation and burden
of the encrustation. Each patient may need multiple approaches in one or
multiple sessions. Open surgery may be indicated when minimally invasive
procedures fail.
References
1.Gaffer
A.
DJ-Stenting; Efficacy in the management of obstructive uropathy. Professional
Med J Mar 2007; 14(1): 56-59.
2.Iqbal S. Indwelling JJ ureteral stents-A current prospective
and review of literature. Indian Journal of Surgery 2003; 65(5): 405-412
3.Beiko BT, Knudsen BE, Denstedt
JD. Advances in ureteral stent design. J Endourol
2003; 17:195-199.
4. George
H, Kittinut K, Jean D, et al. Ureteral Stenting and Urinary Stone
Management: A Systematic Review. The Journal of Urology 2008; 179: 424-430.
5. Furio
C, Valentina C, Cristian F, et al. Heparin Coating on Ureteral Double J
Stents Prevents Encrustations: An in Vivo Case Study. J Endourol2008;22: 1-8.
6.Arvantinos E, Gravas S,
Karatzas, AD, et al. Forgotten, encrusted ureteral stents: A challenging
problem with endourologic solution. J Endourol 2006; 20:1045-1049.
7. Aron M, Ansari MS, Singh I, et
al. Forgotten Ureteral Stents Causing Renal Failure: Multimodal Endourologic Treatment. J Endourol 2006; 20:423-428.
8.Richter S, Ringel A, Shalev M,
et al. The indwelling ureteric
stent: a `friendly' procedure with unfriendly high morbidity. BJU
International 2000; 85: 408-411.
9.Rahul G, Pranjal Mi, Jamal R. Vanishing Shaft of a Double-J Stent . Urol J 2008; 5:277-279.
10. Hervé T, Jean-Louis P,
Abdelhack R, et al. Detection
of Encrusted Indwelling Ureteral Stents Using a Twinkling Artifact Revealed on
Color Doppler Sonography. AJR 2001; 176:1446–1448.
11. Bannakij L. Endourologic Management of Severely Encrusted
Ureteral Stents. J Med Assoc Thai 2005; 88 (9): 1203-1206
12. Riccardo, Antonio M, Umberto
P, et al. The Forgotten Stent:
Late Complication in a Patient with Neobladder. The Scientific World Journal
2006; 6: 410–412.
13. Sang WL, Jeong HK. Renocolic Fistula
Secondary to a Perinephric Abscess: A Late Complication of a Forgotten Double J
Stent .J Korean Med Sci 2009; 24: 960-962.
14. Raja
G, Vijay R, Thomas G. A case of pyonephrosis secondary to ureteral stent calculus. International
Urology and Nephrology 2005; 37:467–470
15. Thorsten H E, Steffen, Jürgen
R.
Multimodal stone therapy for two
forgotten and encrusted ureteral stents: a case report. Cases Journal 2009,
2:106-107.
16. Nazar
AM, Altaf AT, Jan MM. indication and
complication of indwelling ureteral stent . Pakistan Journal of
Surgery 2007; 23(3):187-191
17. Brian E, Howard K, Dianne R. Knot formation in a patient with an indwelling
ureteral stent international. Braz J Urol 2006; 32 (3): 308-309.
18. Bhanot
A. Stones formation at both
ends of forgotten ureteral DJ stent. Hinese Clinical Medicne 2009; (8):480-482.
19. Vishwajeet S, Ankush G. Stenturia: A Rare Complication of Indwelling
Ureteral Stent. Urol J 2009; 6: 226-227.
20.Arshad
M, Shahzad S S, Muhammad H A. Applications and complications of
polyurethanestenting in urology. J
Ayub Med Coll Abbottabad 2006; 18(2):69-72.
21.Singh
V, Srinivastava S, Kapoor R, et al. Can the complicated forgotten
indwelling ureteric stents be lethal?. International Urology and Nephrology
2005; 37:541–546.
22. Perera ND, Wijewardena M. Removal of severely encrusted forgotten ureteral
stents by minimal access techniques Ceylon Med J 2002; 47(1):27-28.
23.Jiang J, Zhu F, Jiang Q, et
al. Extraction of a long 2
forgotten ureteral stent by ureteroscopic pneumatic Lithotripsy. Chinese
Medical Journal 2004; 117 ( 9) : 1435-1436
24. Singh I, Gupta NP, Hemal AK, et
al. Severely encrusted polyurethane ureteral stents: management
analysis of potential risk factors. Urol 2001;
58:526-531.
25. Somers W. Management of forgotten retained indwelling ureteral
stents. Urol 1996; 47:431-435.
26. Singh I. Indwelling JJ ureteral stents: a current perspective
and review of literature. Indian J Surgery 2003; 65:405-412.
27. Raymond B, Michael Y, Ronald J. et al. Complications
of Ureteral Stent Placement. RadioGraphics 2002; 22:1005–1022.
28. Gotwald TF, Peschel R,
Frauscher F, et al. Indwelling ureteral stent fragmentation with severe
encrustation and stone formation. J Urol 1999; 162: 788-789.
29.González-Ramírez MA,
Méndez-Probst CE, Feria-Bernal G. Double-J
catheter calcification risk factors and management, Rev Mex Urol 2009; 69(1):7-12
30.Schulze KA, Wettlaufer JN,
Oldani G. Encrustation and stone
formation: complication of indwelling ureteral stents. Urol 1985; 25:
616-619.
31.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: 1487-1491.
32.Lam J, Gupta M. Tips and tricks for the management
of retained ureteral stents. J
Endourol 2002; 16:733-741.
33. Iqbal
S, Nain S. Missed
fractured ‘trapped JJ stent’ in a solitary functioning renal unit
–Implications of management. International Urology and Nephrology 2003;
35: 247–249.
34. Harshad SP, Rahul CH, Dharmendra K. A
partially prolapsed, encrusted Double J (D/J) stent: A Case Report. The Internet Journal of Surgery 2007; 13:2.
35.Ivan
I, Ivica S. Trapping of the double-J stent in the urinary tract eight years after
extracorporeal shock wave lithotripsy. International Urology and Nephrology 2000;
32: 29–31.
36.Manish B, Suresh
P, Satyend D. Laparoscopic management of a retained heavily
encrusted ureteral stent. International Journal of Urology 2006; 13 (8): 1141 – 1143.
37.Curtis C, Jason B,
Matthew P, et al. Noval approach for removal heavely encrusted urinary
stent. The Canadian journal of urology 2009; 16(5):4831-4835.
38.Anderew J L, Hugh J W,
Joseph W S, et al. Indwelling ureteral stenting: percutaneous managements of
complications. Radiology 1986; 158:219 -222.
39.Ors AO, Zor M, Bedir S, et
al. Percutaneous approach for extraction of renal
fragmented double-j stent: case report. Balkan Military Medical Review
2007; 10,184-186.
40.Shaheel B, Steven J, Tze M. Forgotten indwelling stent in a transplanted kidney:
a case report. Cases Journal 2009, 2: 27.
41. Ben CH, Prokar DA, Richard TI,
et al. Multimodal management
of urolithiasis in renal transplantation. BJU International 2005;
96:385-389.
42.Tze W. Percutaneous
nephrostomy and antegrade ureteral stenting: technique, indication and
complications. Eur Radiol 2006; 6(9): 2016-2030.