ABSTRACT

CORRESPONDING AUTHOR:
Dr. Anil Darokar,
15/32, Samnati Colony,
Shegaon Road, VMV Post,
Amravati – 444604, Maharashtra.
E-mail: anildarokar@yahoo.co.in

ABSTRACT: Double J stent provide good urinary drainage from kidney to the urinary bladder. It is an important tool in the armamentarium in the hands of an urosurgeon. The prevalence of all consequences and complications increase the longer a stent remains in place. We present a rare case of 25 years old male with forgotten fragmented D/J stent. Endourological / open removal of multiple stent fragments is a challenging problem. Comprehensive method of follow up after D/J stent placement is needed to avoid late complications.

KEYWORDS: Double J stent, Fragmentation.

INTRODUCTION: Ureteral stenting is a routine procedure in daily urological practice and is commonly indicated to relieve and prevent upper urinary obstruction and to manage ureteric injuries to minimize urinary extravasation and to expedite the ureteral healing, which otherwise could be prolonged and hazardous to the patient.¹ It provides good urinary drainage from kidney to the urinary bladder. D/J stents constitute an important tool in the hands of an urosurgeon. The use of ureteric catheters was first reported by Peck in 1967.

Neither the urinary environment nor the stent placed within it is stable for long periods of time. The prevalence of all consequences and complications increases the longer a stent remains in place. Common complications have been lower abdominal pain, dysuria, hematuria, fever, urinary frequency and nocturia.^2,3 Long term indwelling ureteral stents have led to stent migration, encrustation, calculus formation and spontaneous fragmentation.⁴ Forgotten stent refers to an overlooked stent^{5, 6} that is generally associated with significant complications such as sepsis, renal decompensation, massive encrustation and stent fragmentation.

CASE REPORT: A 25 years old male presented with dribbling of urine and hematuria. On abdominal examination bladder was palpable. Posterior urethra was hard on palpation. History revealed that he had undergone open right pyelolithotomy 4 years ago. Patient forgot about the stent which was put at that time. His hematological and biochemical parameters were normal. Urine showed plenty of RBC’s and Pus cells. X ray KUB revealed 3 fragments of double J stents. One stent fragment was lying in right upper ureter whereas other two were in the bladder. One of the bladder stent fragments had entered in the posterior urethra. The stent fragments were removed by open surgery as endosurgical intervention was likely to be hazardous. Upper ureter was explored by right subcostal kidney incision. There were firm adhesions between posterior abdominal wall muscles and posterior peritoneum. Accidentally peritoneum got opened at 2 places which was sutured. Right ureter itself was firmly adherent to posterior abdominal wall. Ureter separated. Stent fragment palpated. Stent fragment was removed by doing ureterostomy over the stent. Ureterostomy was closed with 3/0 polyglactin. Abdominal wound was closed by keeping retroperitoneal drain. Bladder stent fragments were removed by separate suprapubic incision. Post-operative period was uneventful. Patient was discharged on 7^th day after removal of stitches.

DISCUSSION: Despite tremendous advances in stent biomaterials and design, D/J stents are not free of complications and problems and the search for an ideal D/J stent may remain utopian.⁷ Complications occur in patients with long term placement of stents who do not come for follow-up, the forgotten stent. Stent breakage is thought to be due to the hostility of the urine solution and prolonged indwelling time (more than 1 year). All ureteral stents may develop encrustation and lose tensile strength which results in stent fracture and even stenturia.⁸

Ringel A et al⁹ reported 11 of 110 cases (10%) there were stent fragmentation and in 9 (8.2%) stent migration. Of the 110 ureteral stents, 32.7% had to be removed because of late complications. Hao et al¹⁰ evaluated 2685 cases of D/J stent for different nephroureteric conditions and concluded that these stents are a safe and useful adjunct for both endoscopic and open procedures, if it was kept in situ for less than 28 days.

N. A. Memon et al¹¹ in a series of 120 patients reported incidence of gross hematuria in 2.5% and stent fracture in 8.3% cases.

Broken stent fragments in the kidney can be safely removed by PCNL, while ureteric fragments can be managed by minimally invasive techniques^{12, 13} such as ureteroscopy and intracorporeal lithotripsy. Forgotten stents should be managed endoscopically only by those well trained and sufficiently experienced in advanced endourology^{14, 15} Open surgery has a role where multimodal endourology fails, but one must remember that this is also not easy and is fraught with its own attendant risks of causing further renal impairment and sepsis. In case prolonged stenting is mandatory, change the stent at least once every 3 months and earlier in stone formers and chronic renal failure patients.

CONCLUSION: A rare case of a 25 years old male patient with a forgotten fragmented D/ J stent is presented. Fracture and fragmentation are late complications of a D/ J stent especially when patient does not come for follow up. Endourological / Open removal of multiple fragments is a challenging problem for a surgeon fraught with dangers especially if patient has a compromised renal function. This calls for a comprehensive method of follow up for patients after D/ J stent placement to avoid late complications.

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-RAY KUB showing fragmented stent in right upper ureter, urinary bladder and posterior urethra