Management of forgotten ureteral double J stents : Report of two cases and review of the literature

J Clin Exp Invest www.jceionline.org Vol 3, No 2, June 2012 Correspondence: Dr. Ahmet Ali Sancaktutar Dicle University Medical School, Department of Urology, Diyarbakır, Turkey Email: aasancaktutar@gmail.com Received: 10.02.2012, Accepted: 30.04.2012 Copyright © JCEI / Journal of Clinical and Experimental Investigations 2012, All rights reserved JCEI / 2012; 3 (2): 2636 Journal of Clinical and Experimental Investigations doi: 10.5799/ahinjs.01.2012.02.0156

Anahtar kelimeler: Unutulmuş üreter stenti, endoskopik tedavi ABSTRACT Double J (DJ) ureteral stents are frequently used as a natural consequence of common use of endoscopic procedures.Even though use of these stents is practical and safe, undesired problems such as urinary tract infection, kidney dysfunction may develop in case of their long stay in the body.DJ stents staying for a long time in the body due to forgotten by urologist and frequently by the patients or due to carelessness of the patients which may cause serious medical and legal problems.
Herein, we reported two cases with DJ stent placed 4 and 2 years ago after open kidney stone operation and encrusted as they were forgotten.These 2 cases were treated by application of ESWL, endoscopic laser cystolithotripsy, suprapubic percutaneous cystolithotripsy, ureteroscopic lithotripsy and percutaneous nephrolithotomy methods consecutively.In conclusion, cases with DJ stents should be informed and warned strictly to avoid rare but serious problems due to delay or forget of these stents.We think that with an algorithm including the consecutive treatment alternatives management of encrusted DJ stents might be more successful.J Clin Exp Invest 2012; 3(2): 263-266

INTRODUCTION
Indications of double J stents (DJ stents) usage have been widely increased.DJ stent placement became a standard protocol in various endourologic procedures. 1 A matter of what purpose it is used, long stay of DJ stents in the body causes undesired side effects such as encrustation, infection, migration, hydronephrosis and fragmentation. 2 Displacement and treatment of forgotten stents depend on the severity encrustation and the stone formation at the stent.In such situations, changes in a wide range from (Extra Corporeal Shock Wave lithotripsy) ESWL to open surgery or laparoscopy. 3,4 this report, evaluation and making stone free of two cases, one with 4 years and the other with 2 years forgotten DJ stent, and applied treatment algorithm of forgotten DJ stent were discussed in the light of literature.

CASE REPORTS Case 1
Twenty years old male patient was presented to our clinic with right lumber pain.In his past history it was learned that he underwent open renal operation in another center 4 years ago.In direct urinary system X-ray (KUB), it was observed that DJ stent was encrusted along the entire length and 5x5 cm stone formation was present at the lower part of it in the bladder (Figure 1a).Also, stones with a size of 1x1 cm at lower and upper pole of the kidney were observed at urinary system USG.In intravenous pyelography (IVP) analysis, both kidneys were functional.In TcDTPA scintigraphic study, right kidney uptake was calculated as 48% and left kidney uptake was 52%.
Firstly, 3 sessions of ESWL was applied along the entire length of the encrusted DJ stent.The bladder and encrusted part of the DJ stent up to middle section of the ureteral were cleared from the stone by endoscopic approach (Figure 1b).In another session, percutaneous nephrolithotomy (PCNL) was applied for the residual middle-upper ureter part and renal part of the encrusted stent (Figure 1c).Stent was cut from upper part and removed out as two parts (Figure 1d).ESWL was applied to the stone in the right kidney and to entire length of DJ stent for three days.In another session, after entering with ureterorenoscopy (URS), the stone in the ureter was divided into small pieces by laser lithotripsy.By entering with nephroscope through suprapubic route lithotripsy was applied to encrusted part of the DJ stent in the bladder.DJ stent was displaced.

DISCUSSION
Owing to technological advances allowing endoluminal evaluation of urinary organs, ureteral stents are used more widely. 1While the reason of DJ stent application was open kidney stone operation that was done 4 years ago in our first case, it was right ureteral endoscopic stone surgery in the second case.
McCahy et al. 5 recommended that a computer record should be composed recording the patients that stent was placed in urology clinics and warning the urology physicians about the time of removal of stents.In our first case the patient and his parents declared that they were warned about the stent by their clinicians, however they forgot it.In our second case he told that he was not informed and warned by his clinician.
Cases with encrusted DJ stent should undergo a full urological evaluation. 6We examined both patients with ultrasound, IVP and renal scintigraphy.
There is not only one method to manage the forgotten and encrusted DJ stents.While ESWL, URS and traction was preferred for mild to moderate encrusted cases, the approach is more complex in severe forms of encrustation.Some authors used one or more of methods such as ESWL, URS, laser lithotripsy, PCNL, chemolysis with various agents by inserting PCNL tube and open surgical methods. 3,7,8,9In our first case, we primarily applied ESWL, URS and laser lithotripsy and treatment PCNL was performed in another session.In the second case; first we performed ESWL.In another session endoscopic laser lithotripsy and URS was applied.
In conclusion, the treatment of all cases with ureteral stent should be accepted as incomplete unless the DJ stent is removed.DJ stents should be removed at the shortest time without exceeding the time of their insertion purpose.Both patient and their parents should be informed about the medical problems that may develop in case of forgetting these stents.In cases that developed serious encrustation and/or stone load due to long stay or forgotten of ureteral stent, successful outcome could be get with low morbidity by starting with minimal invasive methods.Despite these treatments, PCNL may be an appropriate alternative in case of failure of other methods.