Reporting 5 Cases of Forgotten Ureteral Stent Treated by Endourological Approaches and Citrate Alkaline Therapy


Dr. Yasinidweini, Ph.D., MD, FEBU*

Citation: Reporting 5 Cases of Forgotten Ureteral Stent Treated by Endourological Approaches and Citrate Alkaline Therapy. American Research Journal of Urology; 2(1): 1-9

Copyright This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract:

Purpose: This research it intended to present our experience in various endourological approaches and citrate alkaline therapy for treating forgotten encrusted ureteral stents.

Material and Methods: During the term starting from January 2010 till December 2013, five patients; 2 males and 3 females; with encrusted urethral stents, were studied. The average indwelling time of the stent was 5 years (range is 2 to 13 years). Mean ages were 37 years old. Kidney function test, urine culture, coronal computerized tomography (C/T) scan without contrast, plain- film radiography, intravenous urogram and renal isotopes scan were used for renal function assessment.

Results: The entire stent of all patients sample was encrusted. An Extracorporeal shock waves lithotripsy (ESWL) was performed for all, in addition to citrate alkaline medication in order to trying stopping the progress of encrustation and the growth of stones. Cystolithotripsy was used to manage the distal coil of the encrusted stents and in some cases we used cystolitholapaxy to crush bladder stones in addition to heavily encrusted stents. All patients rendered stone and stent free. One patient remained in the follow up symptomatic with loin pain, and thus he needed open surgery of nephrectomy due to impaired non-function kidney, with the histopathology report of malakoplakia of the kidney; which is rare inflammatory disease that is associated with Escherichia Coli infection.

Conclusion: Endourological management and alkaline medication of forgotten stents is highly successful and often there is no need for open surgery.

Keywords: Forgotten stents; urethral; lithotripsy; lithiasis; endourology; Citrate. 


Description:

INTRODUCTION

In 1967 Zimskind was the first to describe endoscopic stent placement to relieve urethral obstruction (1). Stents are hollow tubes with a coil at each end, which is inserted through the bladder; usually into the ureter and thence into the renal pelvis

Urethral stents are widely used in urological practice. They are designed to bypass a ureteric obstruction due to intrinsic or extrinsic causes (e.g. stone, malignancies, strictures etc.)or draining the kidney (e.g. post renal surgery) (1-5).They are also placed after iatrogenic injuries of the ureter and before any complex abdomen procedure to identifying and protecting ureters (6).Complications of wide spread usage of stents are stent encrustation, stent fragmentation, stone formation and recurrent urinary tract infection (7, 8). There are many methods of treatment combinations of extracorporeal shock wave lithotripsy, cystolithotripsy, retrograde ureteroscopy with intra-corporeal lithotripsy, percutaneous nephrolithotomy and open surgery has been used as to removal of these encrusted stents (9-14).

Forgotten Stent

rare, but potentially is very serious as the biofilm may become encrusted with stone, and further making, technically,the removal process very difficult.

We are reporting herein these cases to highlighting the possible serious complications, with long-term indwelling stents, in patients who do not attend to follow up the forgotten stent that frequently originates complications.

These delayed complications including hydronephrosis, encrustation, blockage, stuck stents, stent migration, stent knotting, fracture, spontaneous fragmentation and stenturia; pose a management and legal dilemma.

Certain precautions and guidelines must be observed whenever JJ stent is used .The stent is a double –edged sword and thus routine usage thereof is not justified; at least where endourological facilities are not available in institutions.

We are reporting 5 cases of forgotten JJ ureteral stent which had been placed long time ago; four patients who received urolithiasis therapy and one patient underwent pyeloplasty surgery in Al –BashirHospital.

Males to females’ ratio is 2:3. Clinical picture was symptomatic in 3 patients with flank pain and recurrent UTI, while two patients were asymptomatic. Forgotten stent duration between 2-13 years, is ranged at 5-years. Mean age was 37 years. Radiography of the kidneys, ureters, bladder and computed tomography demonstrated stone encrustation over the whole JJ stent. Kidney function test, renal isotopes scan and urine cultures were performed before the treatment. Alkaline citrate therapy with potassium sodium hydrogen citrate granules, as stone formation inhibitors was taken from the first beginning of treatment, ESWL,cystolithotripsy and ureteroscopic lithotripsy were performed to remove JJ performed.

FIRST CASE

A 38- year’s old, married female patient suffering from high fever up to 39º C and severe right flank pain; was admitted to the emergency room at Al –Bashir Hospital. The first impression of the case was right perinephretic abscess by ultrasound and CT scan. Right flank percutaneous drainage was done and yielded pus-like fluid.

Fever and flank pain subsided much after drainage, and after 3 days later, urine came out by drain, which means that spontaneous rupture of one calyx occurred and fistula formation between calyx and Para- renal space is performed.

JJ stent was inserted in right ureter and Foley’s catheter was also inserted to prevent reflux of the urine to the kidney and KUB showed right ureteric stone beside JJ in situ. Urine stopped to come out by drainage after two days. Then drain removed, patient was discharged in good condition to be seen, one month later, by ESWL for her ureteric stone . After ESWL therapy,the patient did not follow –up her case anymore, even though she should follow up after one week from her discharge to receive the result of therapy by KUB X-Rays.

Many communication trials were made with the patient to enable us dealing with the JJ stent but to no avail. After two years we received telephone call from her father who brought her to our outpatient clinic, which imposed on us to start the medical treatment from the first beginning.

We have tested her kidney function which was within normal value, and further her urine culture was free from bacterial growth.

The renal isotopes scan DMSA showed Right kidney scarred & Lt kidney normal.
Split function

Rt kidney function was 29% Lt kidney function was 71%. The CT scan showed encrusted stent and ureteric stone. Thus multiple modality of treatment was started. ESWL of the encrusted upper coil of the stent was performed. Alkaline therapy started from the first beginning, with citrate sodium and potassium medication to decrease encrustation and stone formation. Lithotripsy of the lower encrusted coil was performed. Ureteroscopy with lithotripsy of ureteric stone and removal of encrusted stent was also done. The duration of treatment was extended to six months. The patient was subject to many follow ups but she remained symptomatic with loin pain. Second renal isotopes’ scan DMSA was performed after completing the treatment; that displayed impaired non function of the Rt kidney, and thus it required nephrectomy to be done. Further the histopathology reported malakoplakia of the kidney; which is a rare inflammatory disease associated with Escherichia Coli infection (Granulomatous interstitial nephritis caused by kidney parenchymal malakoplakia). Fig.(1-2).


2nd CASE

A 33 years female patient underwent, on 9-October- 2009,RtPyeloplasty Andersen- Hynes due to pelvi-ureteric junction (PUJ) obstruction with JJ insertion. In November 2009 she was pregnant and Delivery was in August 2010.
She presented in June 2013 with forgotten stent (for 3.5-years duration),
4-episodes of ESWLs and Alkaline therapy (Uralyt U) were performed. The stent performed was removed after
4 months of treatment commencement. Fig. (3, 4, 5).