Management of forgotten double J stent and its complications: a single center experience

INTRODUCTION

Double J (Dj) stent has been introduce in 1967 by zimskind, since then it has been a indispensible pillar in endourological armamentarium.¹ In general Dj stent facilitate the unobstructed drainage, maintain uretral patency, protects the upper tract and act as scaffold over which healing can occure.Therefore it mainly used following any endourological or open urinary tract surgery as well as to overcome the extrinsic or intrinsic obstruction in ureter. DJ stent is made of various materials like, silicone, polyurethane, silitek, C-Flex, Percuflex. Most commonly used stent is polyurethane, while silitek and C-Flex are silicon based co-polymer stent, and percuflex is quite biodurable as well as biocompatible stent with impressive tensile and coil strength.² Overall the Dj stent is safe and well-tolerable. Mild stent related symptoms can be managed effectively with anticholinergic medications. Although despite many improvisation in stent material and design problems related to long term indwelling ureteral stents such as encrustation, occlusion, migration, spontaneous fragmentation, stone formation, and renal impairment still persist. It has been reported that the stent encrustation rates are 9.2%, 47.5% and 76.3% if stent remains indwelling for 6 weeks, 6-12 weeks and more than 12 weeks, respectively.³ The DJ stent generally needs to be replaced or removed within 6 weeks to 6 months depends upon which material of stent used and for what purpose.⁴ The management of complicated stents is one of the most difficult endourological procedures as the loss of tensile strength due to neglected Dj stent and it may lead to its breakage as well as fragmentation. The various methods of treatment such as shock wave lithotripsy (SWL), cystolithotripsy (CLT), ureterorenoscopic lithotripsy (URSL), percutaneous nephrolithotomy (PCNL), and open surgical methods can be employed to manage it.⁵ So we have conducted this study to share our institutional experience in management of complicated forgotten Dj stent.

METHODS

A retrospective study was conducted at our department of urology and renal transplant, S. C. B. medical College and hospital, from January 2018 to December 2022. Patients who were admitted or referred to our department with double J stent indwelling time more than 6 months without indication of prolonged stenting have been included in this study. We excluded the patients with symptoms related to indwelling Dj stent less than 6 months. Total 30 patients were enrolled who met the inclusion criteria. Data from the institutional records were analysed retrospectively. Institutional ethical committee clearance has been obtained. The demography, educational/socioeconomic status, the indication of stenting, duration of stenting, presenting complaints were recorded. Renal function tests, urine routine microscopy with culture & sensitivity were done in all patients. Degree of stent encrustation evaluated by plain film radiography and non-contrast computed tomography of kidney ureter and bladder (NCCT KUB) as well as CT Urography to assess the renal function. In patients with non-visualized kidneys on CT Urography, Tc99m diethylene triamine penta acetic-acid (DTPA) renogram was done to estimate the renal function. Treatment decision was made based on clinical and radiological findings. As per institutional protocol the patients with minimal or no encrustation were planned for cystoscopy and gentle traction with stent removal forceps under C arm guidance. The procedure was abandoned if resistance was found during extraction and then procedure planned under anaesthesia. Initial treatment for encrustation involving the stent body was retrograde ureteroscopy using a 8Fr semirigid ureteroscope and intra-corporeal lithotripsy with a pneumatic lithotripter or with holmium laser lithotripsy and then URS biprong or triprong forcep was used to remove the stent. if this technique failed, if encrustations involved the upper coil of the stent, percutaneous nephrolithotomy (PCNL) using a rigid 24Fr nephroscope was performed. If encrustations involved the lower coil of the stent, transurethral cystolithotrity or cystolithotripsy was performed. Post operatively resenting was done in selective cases based on intraoperative findings. In one patient with a history of indwelling Dj stent since last 11 yrs, suffered from formation of severly calcified encrustation throughout the length of Dj stent leads to ipsilateral hydroureteronephrosis with non-functioning kidney underwent open nephroureterectomy with cystolithotomy. Postoperatively, plain-film radiography was obtained to confirm the stent-free status and for proper counseling in patients who were restented for timely removal of it.

Statistical analysis

Descriptive analysis was done for various clinical parameters. All data were expressed as a percentage, mean± standard deviation. To test the correlation of stent duration with moderate to severe encrustation, the independent t test was used. A p<0.05 was considered significant. For statistical analysis conducted using IBM SPSS v29.

RESULTS

Demographic data and base line characteristics described in (Table 1). Out of 30 patients 25 (83.33%) patients were from our institution and the remaining 5(16.67%) were from other. In all cases, polyurethane stent was used. The mean age of the patients was 42.97±12.4 years, and the age ranged from 18 to 70 years. There were 20 (66.67%) men and 10 (33.33%) were women. The mean indwelling duration of stent in situ was 41±12 months and the duration ranged from 9 months to 11 years. 4 (13.33%) patients had higher secondary education, while 9 (30%) patients had education below higher secondary and 17 (56.67%) patients were illiterate. All belongs to rural and distant area with the poor socioeconomic background. Poor compliance was noted in 23 (76.67%) patients as they forgot or neglected their stent, and in 7 (23.33%) patients had a history of inadequate counselling by treating doctor was reported. The (Table 1) summarizes chief complaints for which patients visited hospital with forgotten DJ stent. Most common presenting complaint was flank pain with storage lower urinary tract symptoms (LUTS) in 18 (60%) patients. The indications of indwelling stents following intervention are shown in (Table 1). Most common intervention following which stent placed was URSL in 10 (33.33%) patients and 8 (26.67%) patients had PCNL. In 3 (10%) patients had history of bilateral (B/L) URS + Dj stenting for obstructive uropathy with B/L obstructing ureteric calculus, also 1 (3.33%) patient had history of Grade IV renal injury with urinary extravasation for which Dj stent was given, while 8(26.67%) patients had a history of open surgeries. Regarding the late complications 6 (20%) patients had fragmented stent (Figure 1). There were 8 (26.67%) patients who had mild encrustation, whereas 22 (73.33%) patients had moderate to severe encrustations. One patient had severe encrustation with obstruction leads to ipsilateral sever hydrouretronephrosis (HDUN) and non-functioning kidney (Figure 1).

Abbreviations: Dj: Double J, PCNL: Percutaneous nephrolithotomy, URSL: Ureterorenoscopic lithotripsy, CLT: Cysctolithotrity, B/L: Bilateral URS: Ureterorenoscopy, LUTS: Lower urinary tract symptoms.

Stent migration was also noted in 1(3.33%) patient (Figure 1). Management modalities of forgotten Dj stent are shown in (Table 2).

In 4 (13.3%) patients managed with cystolithotrity (Figure 2), 15 (50%) patients PCNL was suffice (Figure 2) while 3(10%) patient was managed with PCNL + CLT. Whereas 3 (10%) patients were managed alone with URSL using holmium laser lithotripsy and 4 (13.3%) patients have undergone URSL+ CLT. In one case open nephrourterectomy with open cystolithotomy for forgotten Dj stent with non-functioning kidney (Figure 1). No patient had clavindindo class II or higher complications in post-operative period. The (Table 3) showed the relationship between the indwelling time and moderate to severe encrustation showed positive strong correlation with parson correlation coefficient 0.973 which was statistically significant (p value 0.014).

DISCUSSION

DJ stenting is a routine urological practice in endourology. To define Forgotten DJ stent there is no strict criteria but various studies has considered > 6 months of duration of stent in situ. While retained DJ stent is the one that is irretrievable endoscopically requiring further auxiliary intervention.⁶ For forgotten stent low education status and low socioeconomic back ground may be one of the patient related factors. In present study 17 (56.67%) patients were illiterate. Ali et al in their study reported illiteracy rate was 68.75%.⁷ Another factors that can be responsible for forgotten Dj stent are lack of adequate counselling to the patient or patient’s attendant and poor compliance of the patients. In our study 23 (73.67%) patients have found with poor compliance whereas 7 (23.33%) patients had history of inadequate counselling. The forgotten DJ stent has a variable presentation, which includes storage LUTS, dysuria, flank pain, hematuria & UTI. In our study flank pain with storage LUTS (60%) was most common complaints at the time of presentation. Damiano et al also observed flank pain in 25.3%, storage LUTS in 18.8%, hematuria in 18.1%, and fever in 12.3%, of the patients.⁸ Whereas Patil et al found dysuria was most common presenting symptoms in 80%, while flank pain in 30% patients in their study.⁹

Urine culture was done in all patients in our study and 76.7% (23/30) patients had positive urine culture with most common organism was E. Coli 53.3% followed by Pseudomonas (13.3%), Klebsiella (3.3%), Enterococcus (3.3%), Acinetobacter (3.3%). Rahul et al also found 85.7% had urine culture positive and also most common organism was E. coli.¹⁰ During the management of forgotten DJ stent with prolonged indwelling time one should be planned considering the late complications of forgotten Dj stent like degree of stent encrustation, integrity of stent or fragmentation, migration of stent or not, obstruction in form of obstructive uropathy, as well as function of ipsilateral kidney.¹¹

There is multifactorial etiology for encrustation like indwelling time, bacterial colonisation and formation of biofilm on the stent, pregnancy, metabolic and congenital disorders etc.¹² The degree of encrustation is directly proportional to the indwelling time.¹³ The maximum duration of indwelling stent till recorded is 23 years.¹⁴ In our study mean dwelling time was 41±12 months and maximum was 11yrs. The most common indication for stenting in our study was post-URSL in 10(33.3%) patients. The exact mechanism of the encrustation is still debatable although various in vitro studies have shown that hydrophilic - coated polyurethane stents encrust faster and to a larger extent compared to the silicone or non-hydrophilic counterpart. The encrustation is the product of the crystallization of organic compounds of the urine produced by the bacterial biofilm. The urease formed by the adhered bacteria in biofilm hydrolyses the urea and generate ammonia. This raises urinary pH and encourages magnesium and calcium accumulation as struvite and hydroxyl apatite on the stent.^15,16 so in our study there were 8 patients who had post operatively stone analysis available has shown that 6 (20%) patients had combination of calcium and magnesium phosphate deposits and 2 (6.67%) patients had calcium oxalate deposits. In present study out of 22 (73.33%) patients 12 (40%) patients had encrustation throughout the stent, while 2 (6.66%) patients distal end was encrusted and 8 (26.67%) patients had proximal end moderate to severe encrustation. Takashi et al observed that the proximal end was involved in 41.8% compared to 22.1% at the distal end.¹⁷ This phenomenon has been reported by others too.¹⁸ This was attributed to a more effective peristalsis at the lower part, and because the intravesical portion of the stent is at an angle, which decreasing the deposits and minimizing the encrustation at the lower end. Another major problem is stent fragmentation as in harsh environment of urine stent material losses its flexibility and becomes brittle. In present study we found 6 (20%) patients had fragmented Dj stent, among those 2(6.67%) were diagnosed pre operatively on imagine and 4 (13.33%) intraoperatively. Kumar et al found that stents had fragmented into multiple pieces over a mean indwelling time of only 14 weeks.¹⁹ Fragmentation of polyurethane stent is 4 times as frequent as silicone stent, caused by repeated mechanical stress, especially along the side holes which are the most common sites of fragmentation.²⁰ If no encrustation is visible on plain radiography, removal of the stent can be attempted gently via cystoscopy under C-arm and if there is any resistance, one should stop immediately to prevent stent fragmentation and ureteric injury in form of the ureteric avulsion or perforation. Patients with severe encrustations, high stone burden, fragmentation as well as failed gentle attempt of stent retrieval can be managed via different treatment modalities like CLT, URSL, PCNL, and open surgical intervention depending upon the location, the stone burden and ipsilateral renal function.

The encrustation along the ureter can be managed with URSL. If ureteroscope is not easily negotiable either due to sever encrustations or extensive ureteric wall edema, better to adopt the other approaches. In such scenario PCNL is the preferred approach. Another approach is a two-stage bailout technique which has been described by Mistry et al In their experience, they observed that a placement of a new stent adjacent to the encrusted stent for 2-4 weeks facilitates the removal of primary stent by simple pull.²¹ In proximal moderate to severe encrustation PCNL is preferred approach. ESWL can be an option in cases where proximal mild encrustation, but as monotherapy may not be appropriate or recommended. In our study, we have not used ESWL as in our cases degree of encrustation was severe. It was reported in literature that more the indwelling time there is more possibilities to have complications in form of encrustation or stone formation. We also found a strong positive correlation between the stent indwelling time and moderate to severe encrustations or stone formation and it was statistically significant (p=0.014). Combination of multiple procedures for complete clearance is also required in such cases. In our study 8(26.67%) patients required the multimodal approaches like URSL + CLT in 4 (13.3%), PCNL + CLT in 3(10%), open nephroureterectomy + cystolithotomy in 1 (3.33%) patient. All the patients were discharged within due course of time with no mortality and satisfactory outcome. Management of forgotten DJS require proper thorough evaluation and selection of possible minimally invasive and less morbid treatment modality that can yield complete clearance is crucial. Although it’s quite cumbersome and costly.²² Therefore it increases the financial burden and causes impaired quality of life specially to the people with low education and belonging to low socioeconomic status as they were most commonly involved. So, to prevent or decrease the incidence of forgotten stents it is responsibility of the treating doctor to adequately counsel the patient or the patient party. Also, to overcome this problem there are options available like maintaining a web-based registry use of biodegradable stents, use of heparin coating with the aim to reduce encrustation.²³ We are now concentrating more on patient and their relative’s counselling as well as taking patient’s and relative’s signature on discharge cards and showing them post-surgery X-ray KUB explaining them the presence of stent in situ which required to be removed on provided date in discharge. When patient is lost to follow-up, we communicate with them via telephone or mail to bring down incidence of forgotten DJ stent. The only limitation of the study was small sample size.

CONCLUSION

In conclusion forgotten DJ stents with complications can be a potential source of added morbidity to the patients, should be manage with the best possible minimally invasive single or multimodal approach to yield complete clearance. Patient and patient’s relative’s education as well as proper counselling regarding timely Dj stent removal is essential in reducing stent-related complications.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Zimskind PD, Fetter TR, Wilkerson JL. Clinical use of long- term indwelling silicone rubber ureteral splints inserted cystoscopically. J Urol. 1967;97:840-4.
2. 2. Singh I, Gupta NP, Hemal AK, Aron M, Seth A, Dogra PN. Severely encrusted polyurethane ureteral stents: management and analysis of potential risk factors. Urology. 2001;58(4):526-31.
3. 3. El-Faqih SR, Shamsuddin AB, Chakrabarti A, Atassi R, Kardar AH, Osman MK, et al Polyurethane internal ureteral stents in treatment of stone patients: morbidity related to indwelling times. J Urol. 1991;146:1487-91.
4. 4. Bultitude MF, Tiptaft RC, Glass JM, Dasgupta P. Management of encrusted ureteral stents impacted in upper tract. Urology. 2003;62:622-6.
5. 5. Monga M, Klein E, Castañeda-Zúñiga WR, Thomas R. The forgotten indwelling ureteral stent: A urological dilemma. J Urol. 1995;153:1817-9.
6. 6. Pal R, Kalra Y, Biswas M. Forgotten DJ. Stent: a retrospective study. International J Res Rev. 2019; 6(12):476-80.
7. 7. Ali N, Somarendra K, Ali A. Forgotten Double-J Stent: Evaluation and Management in a Tertiary Hospital in the North East India. Int J Sci Stud. 2021;9(9):103-8.
8. 8. Damiano R, Oliva A, Esposito C, DeSio M, Autorino R, Armiento M. Early and late complications of double pigtail ureteral stent. Urol Int. 2002;69:136-40.
9. 9. Patil S, Raghuvanshi K, Jain DK, Raval A. Forgotten ureteral double - J stents and related complications : a real - world experience. Afr J Urol. 2020;4:8.
10. 10. Gupta R, Gupta A, Anand A, Azad T. Stent a Nagging Problem Management and Long Term Follow. JK Sci. 2019;19(2):110-4.
11. 11. Leibovici D, CooperA, LindnerA, Ostrowsky R, Kleinmann J, Velikanov S, et al. Ureteral stents: Morbidity and impact on quality of life. Isr Med Assoc J. 2005;7:491-4.
12. 12. Ahallal Y, Khallouk A, El Fassi MJ, Farih MH. Risk factor analysis and management of ureteral double-J stent complications. Rev Urol. 2010;12:e147-51.
13. 13. Vanderbrink BA, Ardeshir R. Rastinehad. Encrusted Urinary Stents: Evaluation and Endourologic Management. J Enourol. 2008;22:5-7.
14. 14. SohrabA,Aneesh S, Sureka SK,Varun M, Nitesh P, Manoj K, et al. Forgotten reminders: An experience with managing 28 forgotten double-J stents and management of related complications. Indian J Surg. 2015;77:1165-71.
15. 15. Wollin TA, Tieszer C, Riddell JV. Bacterial biofilm formation, encrustation and antibiotic adsorption to ureteral stents in dwelling in humans. J Endourol. 1998;12:101-11.
16. 16. Robert M, Boularan AM, El Sandid M. DoubleJ ureteric stent encrustations: Clinical study on crystal formation on polyurethane stents. Urol Int. 1997;58: 100-3.
17. 17. Takashi K., Hiroki Ito, Hideyuki Terao. Ureteral Stent Encrustation, Incrustation, and Coloring: Morbidity Related to Indwelling Times. J Endourol. 2012:26:213-4.
18. 18. Shandera KC. Minimally invasive management of the calcified ureteral stent. Tech Urol. 1997;3(1):54-7.
19. 19. Kumar M, Aron M, Aggarwal AK. Stenturia: An unusual manifestation of spontaneous ureteral stent fragmentation. Urol Int. 1999;62(1):114-6.
20. 20. El-Sherif A. Fracture of polyurethrane double pigtail stents: an in vivo retrospective and prospective fluoroscopic study. Br J Urol. 2008;76:108-14.
21. 21. Mistry K, Pal P, Chitale S. A simple two stage 'BailOut' technique for the removal of an unyielding ureteric stent. Urology. 2013;82:242-4.
22. 22. Sancaktutar AA, Söylemez H, Bozkurt Y, Penbegül N, Atar M. Treatment of forgotten ureteral stents: How much does it really cost? A cost-effectiveness study in 27 patients? Urol Res. 2012;40:317-25.
23. 23. Lynch MF, Ghani KR, Frost I, Anson KM. Preventing the forgotten ureteral stent: Implementation of a web-based stent registry with automatic recall application. Urology. 2007;70:423-6.