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ORIGINAL ARTICLE

Forgotten DJ Stent a Nagging Problem -Managementand Long Term Follow Up

Rahul Gupta, Arti Gupta, Ajay Anand, Tariq Azad

Since Zimskind et.al (1) first reported an endoscopicplacement of silicon ureteral splint in 1967 for the reliefof ureteral obstruction, ureteric stents have becomefundamental to many endoscopic and open urologicalprocedures. Ureteral stents have come a long way interms of design and material. This was done to facilitatestent manipulation, prevent spontaneous stent migration,and lower patient discomfort (2). However, despite manyinnovations and improvements in stent material and design,problem relating to long term indwelling ureteral stentssuch as stent encrustation, occlusion, migration,spontaneous fragmentation, stone formation, and renalimpairment persist. This stent encrustation can be a causeof significant morbidity. Rarely the forceful removal ofthe encrusted stent can result into stent fragmentation,ureteral tears, and ureteral avulsion (3,4,5). We shareour experience of patients with forgotten indwelling stents.

The indwelling time, cause behind forgotten stent,morbidity, and management is discussed. Also, thesepatients were followed up for up to one year to look forany adverse effects or delayed complications followingretained stents.Material and Methods

We removed 35 forgotten DJ stents from patients whopresented to us, from July 2008 until June 2014. Thepatients with forgotten stent included those who did notfollow-up for the stent removal within the stipulated period(< 12 weeks). These patients usually presented once theywere symptomatic or had urinary sepsis (fever with flankpain with positive urine culture and raised total bloodcounts). Evaluation and treatment protocol include adetailed history, indication for stenting. Biochemistry(RFT's), haemogram, urine routine and culture sensitivitywas done in all the patients. Radiological investigations

Introduction

AbstractWe, review our experience and algorithm of tackling such stents safely, with one year follow up of thesepatients. Between July 2008 until June 2014, 35 forgotten DJ stents were tackled at our unit. Patient withforgotten stent was defined as one who did not follow-up for the stent removal within the stipulated period.Prior to the definitive management, all patients were subjected to biochemistry, radiological investigationsand a urine culture sensitivity so as to assess degree of encrustations and active infection and renalfunction. These patients were followed for one year post management of the forgotten stents.Averageage of presentation was 39.8 + 4.3 years. 85% of the patients were male and average indwelling time was11+ 5.5 months. Stents were retrieved endourologically in 33/35 patients. 17 patients required only CPE,seven patients required PCNL (for proximal renal calculus). Ureteroscopy with pneumatic lithotripsy wasdone for six patients and three patients required cystolithotrity. Two patient required nephrectomy as thererenal unit had become non functional. DJ stent should be used judiciously as forgotten stents are a realityeven today. Detailed preoperative assessment and prompt management goes a long way in reducing themorbidity of forgotten stent. Moreover, once managed effectively there were no long term adverse effectsobserved.

Key WordsForgotten DJ Stent, Encrusted Stent, DJ Stent

From the Deptt. of G. Surgery & Anesthesiology* , Govt. Medical College, Jammu- J&K IndiaCorrespondence to :Dr. Rahul Gupta, Astt. Prof., Deptt. of Surgery Govt. Medical College, Jammu (J&K), India

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included an ultrasonography, X-ray KUB (to look forencrustations&/or stone formation, hydronephrosis).Intravenous urography for functional evaluation was donein all. In case of nonvisualized kidney the patient wassubjected to a DTPA renal scan. CECT was reservedfor those with renal abscess or perinephric collection onultrasonography. Depending on the evaluation thetreatment algorithm was planned as shown in Fig.1

Of all the patients, 30 had a positive urine culture andof these 15 had fever with flank tenderness (urosepsis)and raised total blood counts. All patients were startedon sensitive antibiotics at least 48 hrs prior to intervention.Those with urosepsis were treated with culture specificantibiotics until they were afebrile (>24hrs) and hadattained baseline total counts before subjecting them toany endourological intervention. If required, urinarydiversion was carried out (PCN) to control urosepsis priorto intervention. All stents removed were subjected to infrared spectroscopy for crystal deposition.Patient follow upprotocol involved first follow-up at one month, second atsix months and third follow-up at one year. At each followup the patients were subjected to urine routine, ultrasoundof the Kidney ureter and bladder region (KUB). Thesewere done to rule out any long term effects of theseforgotten stents.Results

Between July 2008 till June 2013, 35 forgotten stentswere retrieved in our endourological unit. Demographicprofile, side and avg. duration is provided in table no.1

Indications of stenting were, 21 following open surgery(open pyelolithotomy-13, open ureterolithotomy-7, openpyeloplasty-1), 11 stents were placed after anendourological intervention (Post Ureteroscopy in 8 andpost PCNL in 3) and remaining three stents were placedfor obstructive uropathy (calculus obstruction -2, CAcervix-1). Of these, 11stents had been placed in ourinstitution and rest at peripheral hospital. Clinicalpresentation was storage LUTS (lower urinary tractsymptoms) in 23 and urinary sepsis in 15 patients.Average indwelling time was 11+ 5.5 months. In twopatients, stent had a stent indwelling time of 24 months.

All patients were subjected to urine culture andsensitivity prior to stent extraction. Urine culture waspositive in 30/35cases (85.7%). Commonest organismwas E.coli (24/30) followed by Proteus and Klebseilla in

three patients each. Plain KUB revealed calculi eitherproximal or distal in 11/35(31.4%) stents(Fig.2a,b,).However minor calcifications were not pickedup on KUB(Fig.3a,b).

All stent could be retrieved endourologically, Table no.2depicts the various endourological procedures carried outto remove the stents. Two patient who requirednephrectomy required percutaneous diversion in view ofthe pyonephrosis. These patients were subjected to aDTPA renal scan and had GFR of <10ml/min.

Since we strictly followed the principal of non-forcefulextraction we did not encounter stent breakage. Any stentextraction which required force was abandoned. Patientwas posted again under anaesthesia and stent extractionwas facilitated by adding suitable endourologicalprocedure.Stent analysis (infra red spectroscopy)revealed combination of calcium and magnesiumphosphate deposits in majority (28/35). Remaining sevenhad calcium oxalate as the predominant component.

More than 80% (28/35) of forgotten stents were dueto the poor compliance. While remaining seven patientsgave the history of not being aware of the stent placementi.e communication gap between the operating surgeonand the patient was responsible in 20% of our patients.All the patients were rendered stent free and stone freeat the end of the treatment, with two patient requiringnephrectomy. Those patients requiring intervention(PCNL /URS/Cystolitholapaxy) for stent removal werenot re-stented, however an retrograde catheter of 6 frwas kept to attain the renal drainage in the post operativeperiod for 48hrs. All procedures were performed safelywithout intraoperative complications, and there were nopostoperative complications reported. These patientswere kept on one week of antibiotic in the post op period.

Once discharged these patients were called back firstafter one month , then six months and final follow-upwas at one year .they were advised to follow up early incase of fever or flank pain. On each follow-up they weresubjected to urine routine and an ultrasonography of theKUB region. All these patients had normal investigationson follow-up.Discussion

Forgotten DJ stents can be a challenging problem. Theyare often associated with significant morbidity and rarelymortality if not managed carefully (5,6). One of the most

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common complications of forgotten DJ stent is theencrustations which makes the management of thesestents difficult (2,5).Rate of encrustation is directlyproportional to the indwelling time of the stent as wasreported by El-Faqih in their series of 290 patients. Theyobserved 9.2% of the stents of <6 weeks duration wereencrusted and the rate rose to 76.5% for stents of >12weeks duration (7). In a recent observation made byTakashi Kawahara et al the stent encrustation occurredin 26.8% in < 6 weeks, 56.9% at 6 to 12 weeks, and75.9% at more than 12 week (8). In our series, theindwelling time was 11+ 5.5 months with two patientshaving an indwelling time of 24 months. Encrustation wasevident on all stents removed (minor[24/35] or seen onKUB [11/35]). The exact cause of the encrustation isdebatable but in vitro studies have shown that hydrophilic- coated polyurethane stents encrust faster and to a largerextent compared to the silicone or non-hydrophiliccounterpart (9). All patients in our series had polyurethanehydrophilic stents .This encrustation is further enhancedin the patients with history of urolithiasis, who have threetimes increased risk of encrustation compared to non stoneformers (10). In our series 45.7% (16/35) stents hadencrustations significant enough (either in the form ofstone formation, or not amenable to retrieval by CPE) tobe tackled endourologically. Of these patients all had DJstent placed following surgery for urolithiasis. Other riskfactors involved in facilitating encrustation includebacterial colonisation, biofilm on the stent, pregnancy (11).

However, why some have only encrustation and othersform a stone needs more research. Probably urinarymetabolic evaluation in these patients would be of help.

Of the site of encrustation Takashi Kawahara et alobserved that the proximal end was involved in 41.8%compared to 22.1% at the distal end. This phenomenonhas been reported by others too (4) . This was attributed

Total number 35Age in years 39.8 + 4.3Male/female 30/5

Right /left side 23/12Average indwelling

time(Months)

11+ 5.5

Sr.No. Procedure Number1 Cystoscopy 172 Cystolithotrity

(for stone at lower end)03

3 Ueterorenoscopy wihpneumatic lithotripsy

06

4 Percutaneousnephrolithotripsy

07

5 Open nephrectomy 02

Table 1. Depicting, Demographic Profile, side and Average Stent Duration

Table 2. Depicting The Various Procedures Required For Removal of Forgotten Stents.

to a more effective peristalsis at the lower part, andbecause the intraluminal part of the stent is at an angle,thereby decreasing the formation of deposits and alsominimizing the encrustation at the lower end (12). In ourseries also significant encrustation (16/35), requiringPCNL accounted for 43.7% (7/16) of cases while 37.5%(6/16) required Ureteroscopy and 18.7% cystolithotrity(3/16). Thus, emphasizing on the fact that upper endencrustation is more common than that of lower end.

Forgotten stents may be asymptomatic or may presentas irritative lower tract symptoms, flank pain, hematuria,stenturia, urinary incontinence, and urosepsis even death(6,13,14). In our series 23/35 patients presented withirritative LUTS. (15) patients presented with urosepsis.85.7% (30/35) patients in our series had a positive urineculture. Fifteen patients presented with history of fever,flank pain and had raised total counts along with a positiveurine culture. Stone analysis (infra red spectroscopy) ofthe retrieved stent revealed encrustation of calcium andmagnesium phosphate in 28/35 and remaining seven hadcalcium oxalate crystals. This is attributed to the bacterialbiofilm formation on the stent surface. This bacterialbiofilm formation is a natural phenomenon, which occursonce the stents are exposed to the urine (15). Thisbacterial growth leads to urease production, which attacksurea and leads to an increase in the urinary pH. Theincreased pH attracts calcium and magnesium ions tothe biofilm matrix, resulting in crystal formation i.eencrustation (15) .This in-turn results in , stent blockade,obstruction to urinary flow and hence, urinary tractinfection.

All patients underwent KUB prior to the attemptedstent removal to identify stent encrustation. Since theprincipal chemical composition is, typically calcium andx-ray of the KUB region should facilitate identification

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of the encrustation (11). In our case though we couldrecognize 11/35 stents with calculus at the proximal ordistal end (i.e either renal or urinary bladder), five patientsin whom the KUB was normal did need retrogradeureteroscopy with lithotripsy for the stent removal. Thus,reinforcing the point that x-ray KUB though is a usefultool to recognize the significant encrustation but maymislead if the encrustation is minimal.

Many approaches have been described in the literaturewith good success for removal of forgotten encrustedstents (3,5,11,16) . In certain cases when a retained stentdoes not accommodate ureteroscope, a new ureteral stentalongside of retained stent is placed with the aim topassively dilate the ureter to facilitate intervalureteroscopy (17). Recently a two-stage bailout techniquehas been described by K.Mistry et al (18).In theirexperience, they observed that a placement of a newstent adjacent to the encrusted non yielding stent for 2-4weeks facilitated the removal of primary stent by simplepull. In our series we always followed the principle ofgentle traction under fluoroscopy and if there was anyresistance despite a normal KUB the procedure wasabandoned this was done avoid any disaster (ureteralavulsion) or stent breakage. These patients were thenplanned for stent removal under anaesthesia withdisintegration of the encrustations using pneumaticlithotripsy. This improved the safety as well as the successof the procedure. We did not use the 'Bail Out' techniquein any of our patients. Two patients with non functioningrenal unit and a retained stent required nephrectomy.

A lot of measures have been discussed in literature to

Functional renal evaluationif abnormal IVU

Renal Scan

If No encrustation on KUB In case of encrustations/Definitive stone

CPE# and gentle traction on the stentUnder f luoroscopy and Local anesthesia

Plan accordingly

If easy then stent was retrieved(No forceful retraction was attempted)

Cystolitholapaxy/Ureteroscopy/PCNL^

History takingUrine culture and sensitivity$

X-ray KUBUSG (KUB region)Sr.Creat*.

Fig.1 Showing Study Protocol

Fig 2a. & b. X-ray KUB Showing Right Broken DJ Stent & DJ Stent with Upper end Calculus

Fig.3a& B. X-Ray KUB with forgotten DJ missedEncrustation & Removed DJ Stent With Calcification atlower end

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1. Zimskind PD, Fetter TR, Wilkerson JL. Clinical use oflong-term indwelling silicone rubber ureteral splints insertedcystoscopically. J Urol 1967;97: 840-41.

2. Monga M, Klein E, Castaneda-Zuniga WR,Thomas R. Theforgotten indwelling ureteral stent: a urological dilemma.Urology 1995; 153: 1817-20.

3. Borboroglu PG, Kane CJ. Current management of severelyencrusted ureteral stents with a large associated stoneburden. J Urol 2000;164:648-50.

4. Singh I, Gupta NP, Hemal AK, et al. Severely encrustedpolyurethane ureteral stents: Management and analysis ofpotential risk factors. Urology 2001;58:526-31.

5. Mohan-Pillai K, Keeley FX Jr, Moosa SA, et al.Endourological management of severely encrusted ureteralstents. J Endourol 1999;13: 377-79.

6. Singh V, Srinivastava A, Kapoor R, Kumar A. Can thecomplicated forgotten indwelling ureteric stents be lethal?Int Urol Nephrol 2005;37:541-46.

References

7. el-Faqih SR, Shamsuddin AB, Chakrabarti A,et.al.Polyurethane internal ureteral stents in treatment of stonepatients: Morbidity related to indwelling times. J Urol1991;146:1487-91.

8. Takashi K., Hiroki Ito, Hideyuki Terao, et.al. Ureteral StentEncrustation, Incrustation, and Coloring: Morbidity Relatedto Indwelling Times. Jr Endourology 2012:26: 213-14.

9. Tunney MM, Keane PF, Jones DS, Gorman SP.Comparative assessment of ureteral stent biomaterialencrustation. Biomaterials 1996;17:1541-46.

10. Robert M, Boularan AM, El Sandid M, Grasset D. Double-J ureteric stent encrustations: Clinical study on crystalformation on polyurethane stents. Urol Int 1997;58:100-4.

11. Vanderbrink BA, Ardeshir R. Rastinehad, et.al. EncrustedUrinary Stents: Evaluation and Endourologic Management.J Enourol 2008; 22:5-7.

12. Bultitude MF, Tiptaft RC, Glass JM, Dasgupta P.Management of encrusted ureteral stents impacted in uppertract.Urology 2003;62:622-26.

13. Damiano R, Oliva A, Esposito C, De Sio M, Autorino R ,D'Armiento M. Early and late complications of doublepigtail ureteral stent. Urol Int 2002; 69: 136-8.

14. Rahul G, Pranjal M, Jamal R. Vanishing Shaft of a Double-J Stent. Urol J 2008;5:277-9.

15. Wollin TA, Tieszer C, Riddell JV, Denstedt JD, Reid G.Bacterial biofilm formation, encrustation, and antibioticadsorption to ureteral stents indwelling in humans. JEndourol 1998;12:101-111.

16. Murthy KV, Reddy SJ, Prasad DV. Endourologicalmanagement of forgotten encrusted ureteral stents. Int BrazJ Urol 2010;36:420-429.

17. Hubert KC, Palmer JS. Passive dilation by ureteral stentingbefore ureteroscopy: Eliminating the need for active dilation.J Urol 2005;174:1079-1080.

18. Mistry K, Pal.P and Chitale S. A simple two stage 'BailOut'technique for the removal of an unyielding uretericstent.Urology 2013;82:242-44.

19. Ather MH, Talati J, Biyabani R. Physician responsibilityfor removal of implants: The case for a computerizedprogram for tracking overdue double-J stents. Tech Urol2000;6:189-92.

20. Lynch MF. Ghani KR, Frost I, Anson KM. Preventing theforgotten ureteral stent: implementation of a web-basedstent registry with automatic recall application. Urology2007;70:423-26.

21. Auge BK, Ferraro RF, Madenjian AR, Preminger GM.Evaluation of a dissolvable ureteral drainage stent in a Swinemodel. J Urol 2002;168:808-12.

22. Cadieux PA, Chew BH, Knudsen BE, Dejong K, Rowe E,Reid G, Denstedt JD . Triclosan loaded ureteral stentsdecrease Proteus mirabilis 296 infection in a rabbit urinarytract infection model. J Urol 2006;175:2331-35.

23. Cauda F, Cauda V, Fiori C. Heparin coating on ureteraldouble J stents prevents encrustation: an in vivo case study.J Endourol 2008;22:465-72.

prevent or decrease the incidence of forgotten stentsthese include patient education, physician education (19),maintaining a web based registry (20),use ofbiodegradable stents, use of heparin coating with the aimto reduce encrustation (21,22,23). In our series 24/35(68.5%) stents had been placed in the peripheral hospitalsfollowing various procedures. We strongly believe that inaddition to the patient education, physician education interms of morbidity and mortality associated with retainedstents shall go a long way in preventing such situations.Specially, so in our scenario where >50% of the populationlives in hilly areas, in areas with difficult terrains and, areoften uneducated .They usually depend on the localmedics for initial help, and these people can guide themto take timely and appropriate help to avoid unwantedmorbidity. In addition, the use of indwelling stents shouldbe rationalized specially so, by the general surgeons whodo not have the ways and means to retrieve the stent.Wefollowed all our patients' upto one year with urine routineand ultrasound KUB region. None of them had any longterm sequel.Conclusion

Though DJ stent is a fundamental part of urology, stentuse should be judicious as forgotten stents are a realityeven today. Also, patients and physicians need to besensitized towards this menace and there awareness shallgoes a long way in reducing the morbidity associatedwith the forgotten stent. Moreover, once managedeffectively there were no long term sequel observed.