Challenges in treatment and diagnosis of forgotten/encrusted double-J ureteral stents: the largest single-center experience

Urological Challenges during Pregnancy: Current Status and Future Perspective on Ureteric Stent Encrustation

The management of ureter hydronephrosis and urolithiasis during pregnancy has been changed by the adoption of ureteric stents. Despite their broad use for several other conditions, from emergency to elective settings, their complications cannot be ignored. Being most prevalent during pregnancy, urinary tract infections and stent encrustations are particularly common and can affect either fetal growth or maternal-fetal homeostasis, leading to obstetric complications. The main concern associated with ureteric stents is the indwelling time, which could represent the potential trigger of those complications. However, to ensure the optimal management of a ureteric stent during pregnancy, factors such as the grading of encrustations and the presence, size, and location of stones should be evaluated in pre-operative planning. As a consequence, a multimodal approach, including obstetrics, gynecologists, urologists, and nurses, is essential to ensure a complication-free procedure and successful ureteric stent removal. Finally, future research should focus on utilizing biodegradable and biocompatible materials to reduce and even eliminate the complications related to forgotten stents in order to reduce the financial burden associated with stent replacement and the management of stent-encrustation-related complications.

A case report on the management of neglected and forgotten DJ stent for 18 years with severe encrustation and giant bladder stone

Ureteral stents play a vital role in urologic surgeries, aiding in urinary flow maintenance, obstruction alleviation and facilitating healing. However, when stents are forgotten, they can lead to encrustation, resulting in significant patient morbidity and posing challenges for urologists Stent-related complications have been shown to increase with the duration of time the stent is left in place. This report details the clinical presentation, diagnostic process, and treatment of a 68-year-old male patient had a neglected stent placed 18 years ago after extracorporeal shockwave lithotripsy. He presented with severe stent encrustation, a solitary giant bladder stone, and renal stones. The patient underwent a cystolithotomy to remove the bladder stone followed by an ultrasound-guided percutaneous nephrolithotomy with pneumatic lithotripsy in a separate procedure. Preventive strategies such as implementing a stent registry, enhancing patient education, and encouraging follow-up appointments are crucial to avoid such complications.

Combined Percutaneous and Endoscopic Ureterolithotripsy of Calcified Double J Stent

In urological practice, the routine procedure of placing a double J stent aims to facilitate drainage of the upper urinary system. Despite its temporary nature and the necessity for timely removal, approximately 12% of these stents are retained in patients for extended durations due to various reasons. Forgotten ureteral stents can lead to complications that increase the morbidity and mortality of patients. This report discusses a case of the double J stent that became calcified due to prolonged use and needed to be removed in a combined procedure.

Management of neglected and fragmented DJ stent with severe encrustation and stone: A case report

INTRODUCTION AND IMPORTANCE

DJ stents are widely used in urological procedures and interventions. One of the main problems associated with DJ stent is encrustation and stone formation. The main risk factor for Forgotten, encrusted and calcified (FECal) stent is duration of the stent placement. In addition to high index of suspicion, Imaging like U/S and CT scan are important diagnostic modality. Multiple endourologic and open procedure may be needed for management of fecal stent.

CASE PRESENTATION

This case report is to discuss a 23 years old female patient with a neglected stent after right pyelolithotomy was done 6 years back. The presence of the stent was identified incidentally after she visited local health facility for recurrent LUTS. The CT scan shows fragmented and encrusted stent with in the bladder and pelvis, stones in stent coils and isolated lower pole stone. She was managed by a procedure of cystolithotomy and right PCNL in separate sessions.

CLINICAL DISCUSSION

Common complication of DJ stent placement especially if left for long duration is encrustation, stent migration, fragmentation and stone formation. Patient or relatives unawareness about the stent placement is the most important cause for neglecting stent. Multiple Endourologic procedures may be needed for the management of FECal stent. However some resource limited settings do combination of endourologic and open surgery.

CONCLUSION

Minimizing the duration of the stent especially for patient with risk factors is advised to decrease encrustation. Since management of FECal stent is challenging both for patient and urologists, prevention is the way to tackle it. Multiple procedures may be required to manage FECal stent.

Forgotten ureteral stents: a systematic review of literature

BACKGROUND

The forgotten ureteral stents (FUS) is one of the late complications of stent placement. This systematic review summarized different aspects of FUS and focused on the problems and solutions related to FUS.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. PubMed® and Embase® were searched from inception until October 1st, 2022. Eligible studies were those defining FUS as a stent unintentionally left in situ longer than at least 2 months.

RESULTS

Total 147 studies with 1292 patients were finally included. The mean indwelling time of FUS was 33.5 months (range from 3 months to 32 years). The most common initial cause for stent placement was adjunct treatment to urolithiasis (79.2%). The major forgetting reasons were patient-related (83.9%), which included poor compliance, lapse in memory, and misconceptions about the necessity of timely removal. Primary presenting complaints were flank pain (37.3%), lower urinary tract symptoms (33.3%), and hematuria (22.8%). Encrustation (80.8%) and urinary tract infections (40.2%) were the most common complications detected in patients with FUS. Computed tomography evolving as a preferred imaging test (76.1%) was indispensable for evaluating encrustation, migration, fracture and other complicated situations in patients with FUS. Besides, evaluation of kidney function and infection status was also of great importance. Multiple and multimodal procedures (59.0%) were often necessitated to achieve the stent-free status, and were mostly endoscopic procedures. Cystoscope was most commonly used (64.8%). Retrograde ureteroscopy (43.4%) and antegrade stent removal (31.6%) were often used when dealing with more complicated situations. Extracorporeal shockwave lithotripsy (30.4%) was often used as adjunctive to other endoscopic procedures, but it sometimes failed. The decision regarding the choice of treatment is based on the volume and site of encrustation, the direction of migration, the site of fracture, kidney function and other urinary comorbidities.

CONCLUSIONS

FUS not only pose hazard to patients' health, but also impose a huge economic burden on medical care. Thorough preoperative evaluation is fundamental to developing the treatment strategy. The management of FUS should be individualized using different treatment modalities with their advantages to minimize patients' morbidities. Prevention is better than cure. Strengthening health education and setting a tracking program are of great importance to the prevention of FUS.

Can we predict the incidence of high-grade Clavien-Dindo complications in patients with forgotten encrusted stents undergoing endourologic management?

Objective

Ureteral stents are customarily inserted to facilitate urinary drainage, but they come with their own glitches of being forgotten and/or encrusted leading to serious consequences. The present study aimed to report the complications in patients with forgotten and encrusted stents according to the Clavien-Dindo system specific to urological procedures and identify the factors leading to high-grade (Clavien-Dindo Grade 4A or above) complications.

Methods

The hospital records of patients with forgotten encrusted double-J stents over a period of 8 years were reviewed. The parameters recorded included patient demographics, indwelling time, need for percutaneous nephrostomy, hemodialysis, urine culture, blood culture, total blood counts, serum creatinine, radiologic findings, management techniques, number of surgical interventions, modified Clavien-Dindo complications, follow-up, and mortality, if any.

Results

Forty patients were included in the study. The median age was 52 (range 6-85) years. Of the total, 25 (62.5%) patients had a "significant" stent load; 31 (77.5%) had renal failure or acute kidney injury on presentation; 19 (47.5%) patients had sepsis at presentation. Among the patients presented with sepsis, 11 (57.9%) patients demonstrated a positive urine culture; and 7/11 (63.6%) patients exhibited pan-resistant organisms. Twelve out of 40 (30.0%) patients in our series developed high-grade Clavien-Dindo complications. On univariate analysis, sepsis at presentation (p=0.007), stent load (p=0.031), diabetes (p=0.023), positive urine culture (p=0.007), and stent indwelling time of more than 1 year (p=0.031) were found to be significant. On multivariate logistic regression analysis, sepsis at presentation (p=0.017) and positive urine culture (p=0.016) were significant predictors for high-grade complications.

Conclusion

It is prudent to identify specific risk factors, namely sepsis at presentation and positive urine culture to triage and optimize these patients before surgical management.

Outcomes Associated with the Endourological Management of Stent Encrustation: Findings from a Literature Review on Behalf of the EAU YAU Urolithiasis Group

PURPOSE OF REVIEW

Double J ureteric stents (DJs) are useful aids for urinary drainage in case of stones or tumour causing ureteric obstruction. Prolonged dwelling time such as when forgotten can lead to encrustation. Our aim was to perform a literature review to evaluate outcomes associated with endourological management of encrusted stents (ES).

RECENT FINDINGS

There now exist validated tools which can aid in grading the severity of encrustation and aid operative planning such as the total number of surgeries that may be required. Evaluation of different treatment strategies remains under reported. Removal of encrusted stent is a challenging problem, and it typically requires a multimodal endourological approach.

The “Tri-Glide” Technique: A Case Report on a Novel Intraoperative Approach for Removal of Retained and Encrusted Ureteral Stents

Background

Retained ureteral stents can result in significant morbidity and can be surgically challenging to urologists. A multimodal approach is often necessary for removal, potentially including retrograde and antegrade procedures performed over multiple anesthetic sessions. We describe the novel “Tri-Glide” technique for treating retained stents, particularly those with stent shaft encrustation prohibiting safe removal. Case Presentation. Two patients with nephrolithiasis and retained, encrusted ureteral stents were managed with the “Tri-Glide” technique. Patient #1 was a 58-year-old man with a severely calcified ureteral stent, retained for 14 years. After undergoing simultaneous cystolitholapaxy and percutaneous nephrolithotomy to treat proximal and distal encrustations, the stent shaft remained trapped in the ureter due to heavy calcifications. Three hydrophilic guidewires were passed alongside the stent, allowing it to easily slide out of the ureter intact. Patient #2 was a 74-year-old man who after only 3-months of stent dwell time developed severe stent shaft encrustation preventing removal. After multiple maneuvers failed, the “Tri-Glide” technique was used to create a smooth track for stent to slide out intact with gentle traction. Both patients did well postoperatively with no complications.

Conclusion

The “Tri-Glide” technique can aid in the management of complex encrusted stent extractions, especially when there is significant shaft encrustation.

Endourological management of encrusted ureteral stents: an up-to-date guide and treatment algorithm on behalf of the European Association of Urology Young Academic Urology Urolithiasis Group

Encrustation of ureteral stents can represent a complex challenge. Patients can require multiple intervention types as well as several operative sessions. Our aim was to establish a practical guide for managing such cases as well as an accompanying treatment algorithm. Nearly all cases can now be successfully managed with minimally invasive methods such as ureteroscopy and/or percutaneous nephrolithotomy. Use of a validated tool for grading burden of encrustation is recommended. Careful patient counselling as well as operative planning are of paramount importance. Identifying high risk patient groups such as pregnancy and implementing prevention strategies are also crucial.

In vivo urinary compatibility of Mg-Sr-Ag alloy in swine model

A biodegradable metallic ureteral stent with suitable mechanical properties and antibacterial activity remains a challenge. Here we reveal the scientific significance of a biodegradable Mg-Sr-Ag alloy with a favorable combination of balanced mechanical properties, adjustable indwelling time in urinary tract and evident antibacterial activity via in vivo experiments in a swine model. Attributed to the rheo-solidification process, equiaxial microstructure and significantly refined grains (average grain size: 27.1 μm) were achieved. Mg₁₇Sr₂ and Mg₄Ag were found as the primary precipitates in the matrix, due to which the alloy obtained ca. 111% increase in ultimate tensile strength in comparison to pure magnesium. Both the in vitro and in vivo results demonstrated the satisfactory biocompatibility of the alloy. Histological evaluation and bioindicators analysis suggested that there was no tissue damage, inflammation and lesions in the urinary system caused by the degradation process. The stent also improved the post-operative bladder functions viewed from the urodynamic results. Our findings highlight the potential of this alloy as antibacterial biodegradable urinary implant material.

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Innovative biodegradable antibacterial Mg-Sr-Ag alloy.

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In vivo study in pig ureter models.

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Enhanced mechanical properties and adjustable indwelling time.

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Outstanding urinary compatibility and evident antibacterial activity.

A Novel Visual Grading for Ureteral Encrusted Stent Classification to Help Decide the Endourologic Treatment

Objective: The aim of the study is to propose a visual classification for encrusted stents (ESs) to help choose the appropriate endourologic treatment. Materials and Methods: A multicenter, retrospective, and descriptive study was performed. A total of 140 patients with encrusted Double-J stents were enrolled from 5 different institutions. The novel visual grading for ureteral encrusted stent (V-GUES) classification system ranges from A to D, increasing with severity of encrustation. Results: ESs could be removed with a single intervention in 112 patients (86.8%). Type A and B ESs could be removed in all patients (100% success). Type D stents had minor retrieval and stone-free rates (p = 0.006 and p < 0.0001, respectively). Flexible ureteroscopy had a low success rate (77.7%) for type C stents (odds ratio [OR]: 0.21). Combined access had a 100% success rate for retrieval of type C ESs and a 92.9% success rate for type D ESs (OR: 9.18). Type D stents were associated with patients requiring more than one session to retrieve the stent (OR: 0.11) and stones (OR: 0.21). Conclusions: The V-GUES system is associated with treatment success rates of ES retrieval and stone-free status. It is also associated with the complication rate and the number of sessions needed for patients to be stent and stone free. The V-GUES classification could help counsel patients about the best treatment options and their outcomes. Further prospective studies will be needed to provide external validation.

Submucosal impaction of a forgotten DJ stent: addressing the unexpected

A 16-year-old man with horseshoe kidney presented with a right-sided forgotten double J stent (DJS), 1 year after bilateral percutaneous nephrolithotomy. X-ray of the kidney, ureter and bladder showed bilateral residual stones with no encrustations or stone formation on the DJS. Initial attempt of DJS removal using 22 French (Fr) cystoscope and 6/7.5 Fr semirigid ureteroscope failed due to resistance while pulling the DJS and inability to uncoil the upper end of DJS. Finally, percutaneous antegrade scopy was done suggestive of submucosal impaction of the forgotten DJS in upper ureter. The overlying mucosal bridge was cut using holmium: Yttrium Aluminum Garnet (YAG) laser and the DJS was retrieved. The index case highlights an unusual cause of entrapment of the DJS and whenever resistance is encountered, the use of force should be avoided and the cause of resistance should be troubleshooted, thereby preventing serious injuries like ureteral avulsion.

Huge encrusted ureteral stent forgotten for over 25 years: A case report

BACKGROUND

Ureteral stent insertion is a relatively non-invasive procedure commonly used in the field of urology to resolve urinary obstruction. However, they are sometimes forgotten and the risk of complications increases with time.

CASE SUMMARY

A 43-year-old woman with a history of recurrent urinary tract infections visited our hospital for evaluation of persistent left flank pain, and lower urinary tract symptoms despite anti-biotic treatment. She had received urological surgery in her teens but did not know the details of her surgery. Kidney, ureter, and bladder X-ray and abdominopelvic computed tomography revealed a forgotten left ureteral stent with huge encrustation at both ends and a severely dilated left kidney with parenchymal thinning. In order to remove the ureteral stent, a laparoscopic nephroureterectomy was planned. The ureteral stent was successfully removed, and she was discharged after recovery. The patient was followed up for two years after surgery and did not show any signs of long-term complications.

CONCLUSION

Long indwelling stents can cause dire complications requiring radical interventions. Stent registry systems, novel stent material development, and proper patient education is important for complication prevention.

Risks of forgotten double-J ureteric stents after ureterorenoscopic lithotripsy in Taiwan: a nationwide population-based study

Delayed double-J ureteric stent (DJ) removal may cause severe morbidity. We aimed to identify high-risk patients for forgotten DJs to prevent iatrogenic injury and improve safety. Data of patients with DJs placed after ureterorenoscopic lithotripsy (URSL) between 2000 and 2013 from the National Health Insurance Database in Taiwan were included. Forgotten DJs were defined as indwelling DJs for > 6 months after URSL, which is approximately two times longer than the expiratory duration. Age at stenting, sex, socioeconomic status, specialty of stenting physician, comorbidities, postoperative emergency room visiting and abdominal plain x-ray filming frequencies, and alpha blocker use for > 7 days after stenting were analysed. Of 13,058 patients, 12,969 (99.31%) had timely removed DJs while 89 (0.68%) had forgotten DJs. Per a univariate analysis, patients with forgotten DJs were older, female, and of low socioeconomic status, and the use of more than one DJ for one URSL, placement by non-urologists, and less frequent postoperative abdominal plain x-ray filming and postoperative alpha blocker use were risk factors. Per a multivariate analysis, elderly patients (Odds ratio [OR] = 3.37, 95% confidence interval (CI) 1.36-8.32, p = 0.0085), DJ placement by non-urologists (OR = 9.63, 95% CI 6.09-15.24, p < 0.0001), more than two DJs for one URSL (OR = 2.93, 95% CI 1.58-5.42, p = 0.0006), and less frequent postoperative abdominal plain x-ray filming (OR = 0.66, 95% CI 0.51-0.86, p = 0.0016) were significantly associated with forgotten DJs. Forgotten URSL-related DJs are infrequent in Taiwan. Old age, complicated DJ insertion requiring more than two stents for one URSL, and stent placement by non-urologists are risk factors. Physicians should be aware of these high-risk patients.

Where do urologists stand in the era of novel coronavirus-2019 disease

PURPOSE OF REVIEW

The novel coronavirus-2019 disease (COVID-19) pandemic has had devastating consequences on healthcare systems globally. The effect this has on urologists and the patients they care for is not fully understood and presents the challenge of prioritizing the most urgent cases. We aim to review the impact on urology services and evaluate strategies to minimize disruption.

RECENT FINDINGS

Various healthcare systems have been forced to postpone treatment for many urological conditions as resources are dedicated to the treatment of COVID-19. Training has been postponed as staff are reallocated to areas of need. Face-to-face contact is largely minimized and innovative, virtual communication methods are used in the outpatient setting and multidisciplinary team meetings. Surgical practice is changing because of the risks posed by COVID-19 and procedures can be prioritized in a nonurgent, low priority, high priority or emergency category.

SUMMARY

Although the COVID-19 pandemic will inevitably affect urological services, steps can be taken to mitigate the impact and prioritize the patients most in need of urgent care. Similarly, in future; simulation, e-learning and webinars will allow interaction to share, discuss and debate focused training and education.

The risk factors and complications of forgotten double-J stents: A single-center experience

BACKGROUND

Postoperative urology patients may require the insertion of a ureteral stent. However, the delayed removal or change of the ureteral stent may lead to serious consequences for some patients. This study primarily aimed to examine the risk factors and complications associated with forgotten double-J stents (DJSs).

METHODS

In this retrospective study, postoperative patients who underwent DJS insertion were recruited. Based on the brand of DJS, the maximal stent life (MSL) was classified into 3-month, 6-month, and 12-month groups, and a forgotten DJS was defined as the one that had yet to be removed 2 weeks past its MSL. A total of 479 patients were analyzed. The reasons for the use of DJSs use and the time and method of their insertion were recorded, and the risk factors and possible complications associated with forgotten DJSs were analyzed.

RESULTS

The primary reason for DJS insertion was urolithiasis (69.7%), and insertions performed using ureterorenoscopy were the most common (413/479, 86.2%). Eighteen patients (3.8%) had forgotten DJSs, with an average overdue period of 63.17 days (18-189 days). Multivariate analysis revealed that patients older than 60 years (odds ratio [OR] = 3.626, 95% confidence interval [CI] = 1.070-12.289; p = 0.039) and DJSs exchanged using fibrocystoscopy (OR = 5.437, 95% CI = 1.060-28.256; p = 0.042) were significantly associated with forgotten DJSs. Out of the 18 patients with forgotten DJS, three (16.67%) experienced symptomatic complications, with one developing acute pyelonephritis, and the remaining two experiencing stone encrustation.

CONCLUSION

Patients older than 60 years were 3.6 times more likely to have forgotten DJSs than patients aged 60 and below, and DJSs exchanged using fibrocystoscopy were 5.4 times more likely to be forgotten than those inserted using ureterorenoscopy. Greater attention with regards to tracking and recalling DJSs should be paid in high-risk patients to prevent forgotten DJSs and associated complications.

Novel Use of the Epic Electronic Medical Record Platform to Identify Lost Ureteral Stents

Introduction and Objective: Ureteral stents are utilized in the management of many urologic conditions including nephrolithiasis, ureteral strictures, ureteral injuries, and malignant obstruction. Prolonged placement has a risk of stent failure with obstruction, infection, and encrustation. We describe the novel use of the Epic electronic medical record (EMR) platform to identify patients lost to follow-up after ureteral stent placement. We additionally identified risk factors for lost stents. Methods: A methodology was created in Epic to log ureteral stent insertion and removal, with automated reporting of stents implanted for >90 days. Starting in January 2015, a nurse reviewed the reports monthly and contacted lost patients to arrange follow-up. We retrospectively reviewed patient charts for clinical characteristics including age, gender, race, surgical urgency (elective vs emergent), and insurance status to identify risk of failure to follow-up. Results: We identified 1788 patients who underwent ureteral stent placement over the study period. Sixteen patients (0.9%) failed to follow-up for ureteral stent explantation. Using multivariate logistic regression, stents placed in an emergent setting (odds ratio [OR] 3.5, p = 0.018) and black race (OR 4.03, p = 0.018) were independent predictors of failure to follow-up. Age, gender, and insurance status were not predictors of follow-up. On average, explanted stents were in place for 15 days vs 165 days among those patients lost to follow-up. Conclusions: Lost ureteral stents are rare, however, potentially high impact events. Automated data collected through an EMR such as Epic facilitates easy identification of these events before potential complications. Stents placed in an emergent setting are at a higher risk of poor follow-up as they may not be readily connected in the health care system or misunderstand discharge instructions, creating barriers to follow-up. Black race is an independent predictor of a stent being retained and is of uncertain etiology, which will require further investigation to clarify.

It is efficient to monitor the status of implanted ureteral stent using a mobile social networking service application

Forgotten ureteral stents (FUS) is a great threat to both patients and doctors. Applications on smartphones can significantly reduce the incidence of FUS. But existing applications do not have instant notification and consultation functions. To implement those function, we developed a ureteral stent tracking system embedded in a social networking service application, WeChat. "Ureteral Stent Tracking System" was developed on WeChat, a social media application using by 1.4 million active users. The study consecutively enrolled patients who underwent ureteral stent installation from April 2018 to July 2018. Each patient's information was recorded on the smartphone by the urologists to create a document immediately after the surgery. The system sends notifications twice a week to both patients and clinicians via the message function of WeChat. A total of 183 patients were enrolled. The most senior patient enrolled was 73 years old. 156 (85.2%) patients underwent stent extraction before the scheduled time. 22 did not undergo stent extraction before the scheduled time because of urinary tract infection or stone residue. They underwent stent extraction within 1 month after the scheduled time. Two patients did not come to the hospital until we had made a phone call to them, though they had received notification from the online system. During the study, no patient was lost-to-follow up. In bilateral stents cases, no stent was forgotten after extraction surgery. A total of 85 (46.4%) patients consulted 132 issues in the system. 52 (39.4%) patients complained about hematuria. 36 (27.3%) patients reported lower urinary tract symptoms. All the consultations were answered within 24 h. "Ureteral Stent Tracking System" implement instant notification and consultation functions via WeChat. It helps urologists to manage indwelling ureteral stents and to reduce the incidence of FUS efficiently.

Fluoroscopy-free double-J stent placement through ureteroscope working channel postuncomplicated ureteroscopic laser lithotripsy: A novel technique

Objectives:

To report a technique for ureteroscopic laser lithotripsy (URSL) and retrograde placement of a double-J (DJ) stenting through the ureteroscope working channel without the use of a fluoroscope compared to the conventional technique.

Patients and Methods:

Between June 2015 and December 2017, 170 patients selected for URSL for treatment of ureteral stones and DJ insertion was evaluated. Patients are divided into two groups according to the use of fluoroscopy. In Group A (100 patients), fluoroscope is used and group B (70 patients) without fluoroscopy guidance. In group B, URSL is performed first and followed by DJ insertion by the semi-rigid ureteroscope 8.5-11 Fr under vision without fluoroscopy.

Results:

Stone free rate in 96% versus 94.3% for groups A and B respectively. This technique was successful in all the included patients: 166 retrograde DJ stenting post URSL for ureteric calculi and 4 cases for anuria. Group A are exposed to radiation with mean 26.6 seconds in URSL procedure and 4.8 seconds for DJ stenting. Group B was exposed to zero dose. For group A, the stents size was 6 Fr for 70% of patients and 15 % for 4.7 Fr and 15% for 7 Fr stenting. In Group B, stents of 4.7 Fr and length 24-26 cm were used in all patients. Failure of DJ insertion is reported in 9% for group A and 13 (18.5%) patients for group B.

Conclusions:

This study report the feasibility and efficacy of the completely fluoroscopy free URSL and DJ stenting to treat ureteric stones.

Treatment of fragmented and severely encrusted ureteral double-J stent forgotten for 11 years through multimodal endourological methods

Ureteral catheters are frequently used in urology clinics for intrinsic or extrinsic pathologies which cause ureteral obstruction to provide urinary drainage from the kidney to the bladder. With the increase in stent use, an increase is observed in complications occurring due to ureteral stents in direct proportion with this increase, and ureteral double-J (DJ) stents forgotten in the urinary system are observed commonly in urological cases when the patients do not refer to a health institution in this condition and may cause severe problems, such as infection, stent fragmentation, migration, kidney failure, encrustation, and hydronephrosis conditions. A 30-year-old male patient referred to our clinic with right-side pain, dysuria, and incontinence complaints. It was learned that the patient had endoscopic stone surgery due to right ureteral stone and kidney stone 11 years before the presentation. In the imaging methods of the patient, it was observed that the DJ stent forgotten had separated into three parts, and stones were observed in the right ureter. Cystoscopy was made under general anesthesia. The torn distal end of DJ stent was observed in distal urethra. The foreign object was removed with forceps. Then with ureterorenoscope, the stones integrated with the stent at the end of the piece of DJ stent in the ureter were fragmented with pneumolithotriptor. Stone pieces and the second removed part of the stent were extracted with foreign object forceps. Then using nephroscope through percutaneous intervention, the stones at the end of the third torn piece of DJ stent were fragmented with pneumolithotriptor. They were extracted with forceps. After DJ stent installation, each patient should be checked by giving required information and told that the stent must be removed. In cases with forgotten stents and complications, the stents should be removed with suitable medical, endourological, or minimally invasive surgical methods taking care to protect kidney functions.