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Research Article | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 241 - 248
Complications, management and prevention of various morbidities associated with forgotten JJ stents: retrospective study in a tertiary care hospital
 ,
 ,
 ,
1
Associate professor and Head of the department, R G Kar Medical College, Kolkata, India
2
Senior resident, R G Kar Medical College, Kolkata, India
3
Post doctoral trainee, R G Kar Medical College, Kolkata, India
Under a Creative Commons license
Open Access
Received
Nov. 25, 2024
Revised
Dec. 5, 2024
Accepted
Dec. 23, 2024
Published
Jan. 19, 2025
Abstract

Objectives: The objectives of this study were to evaluate the clinical profile, the long -term complications, managements, prevention of various morbidity of forgotten double –J (DJ) stents. Materials and Methods: The study was conducted a retrospective analysis of patients with forgotten DJ stents from February 2020 to January 2025. The following parameters such as age, sex, literacy, socioeconomic status, indications for stent placement, indwelling time, presenting complaints, reason for non-removal, radiological investigations, managements given, complications and eventual outcome were recorded and analyzed. Results: A total of 48 patients were included in our study, of which 14 patients (29.2%) underwent previous procedures (for which DJ stent was inserted) in our institution and the remaining 34 patients (71.8%) were referred from other hospitals. The mean age of the patients was 37.28 years. Out of 48 patients, 35(72.9%) were male and 13(17.1%) patients were female. Most of the patients 31(64.6%) were illiterate and belongs to lower socioeconomic class group 25(52%). DJ stents were more commonly inserted on right side 29(60.4%) than left side 21(39.6%). The mean duration of indwelling stent in situ was 24.76 months ranging 6 months to 96 months. Most common indications for DJ stenting were URSL 18(37.5%), pre-stented ESWL 3(6.3%) cases, post PCNL 9((18.7%) cases, post open pyelolithotomy /ureterolithotomy 9(18.7%) cases, Pyeloplasty 5(10.4%) cases, ureteroneocystostomy and B/L DJ insertion 2(4.2%) cases in each. Presenting complaints were pain 38 (79.2%), dysuria 31(64.6%), storage LUTS 21(43.8%), recurrent UTI 19(39.6%) and hematuria 8(16.7%) cases. In our study who had DJ insertion, location of stones as follows ureteric stone 41(85.4%), bladder stone 38(63.3%), renal stone 24(50%) cases and combined stones are as follows renal stone +bladder stone +ureteric stone 17(35.4%), bladder stone + ureteric stone 14(29.2%), renal stone+ ureteric stone 7(14.6%), renal stone +bladder stone 6(12.5%) cases. The incidence of fragmented DJ stents was 5(10.4%) and migrated distally in 4(8.3%) cases. Reasons for forgotten DJ stent was known 27(56.3%) cases and did not know 21(43.7%) cases. DJ stents were removed in 48 patients. Single procedure was required in 33(68.8%) cases and multiple procedures were required in 15(31.2%) cases. 41(85.42%) patients were managed by endoscopic approaches with either single or multiple procedures (total 65 procedures) and 7 patients require open procedures. In our study thirteen 13(21.1%) patients were having mild encrustations and were removed through retrograde cystoscopic extraction, without any intraoperative complications. Five patients (10.4%) had spontaneous stent fragmentation, and four patients (8.3%) had migrated DJ stents. For proximal renal calculus, PCNL was done in 11(22.9%) patients while URSL was done in 17 (35.4%) cases. ESWL in 5 patients with encrusted stent followed by cystoscopic removal of those stent were done and in two patients ESWL along with cystolithotripsy were done. PCLT and TUCLT were done in 9(18.8%) and 8(16.7%) patients respectively. Open procedure like pyelolithotomy, ureterolithotomy, cystolithotomy and ureteric reimplantation were done in 7(14.6%) cases in those patients where endoscopic procedures failed, large bladder calculus or patients develop vesicoureteric reflux (VUR). Conclusions: Forgotten DJ stents may have severe consequences and morbidity which is not uncommon and usually seen after 6 months of indwelling. Management of forgotten DJ stents are judicious use of different endourological procedures like CPE, URSL, PCNL, PCLT, TUCLT or ESWL, open ureterolithotomy, pyelolithotomy or cystolithotomy. Patient should be informed about the complications of forgotten DJ stent. Proper education and counseling of patients and their relatives before and after procedure and strictly maintaining stent register is the cornerstone of preventing long standing indwelling of forgotten DJ stent and stent related complications and morbidity to the patients.

Keywords
INTRODUCTION

DJ stent is routinely and most widely used indwelling stent during performing various urosurgical procedures. It was first mentioned in 1967 by Zimskind et al.1 They are mainly used after any elective surgery of ureteric obstruction due to intrinsic or extrinsic causes such as stones, strictures, ureteropelvic junction obstruction, retroperitoneal fibrosis, malignancies, and congenital anomalies.2 These stents keep the ureter patent, ensure resolution of any oedema and allow to heal any injury. In patients with obstructive uropathy, DJ stent is generally accepted as method of choice. It is usually safe, well-tolerated and beneficial but not free of complications. The DJ stent has been known to have various short- term complications and long -term complications. DJ stent placement for longer duration has mild to severe complications such as hematuria, stent occlusion, encrustation, migration, fragmentation, stone formation, urinary tract obstruction, hydronephrosis, urinary tract infection, urosepsis, pyonephrosis, renal function impairment and /or nonfunctioning kidney. Encrustation are most commonly found in prolonged indwelled forgotten stents. El-Faqih et al. reported encrustation rate of 9.2% if DJ was kept for < 6 weeks; 47.5% in 6-12 weeks and it rose up to 76.3% if the DJ was left in place up to 12 weeks3. Therefore, DJ stent should not be kept for indefinite period and to be removed as early as possible after its purpose is served or changed frequently to reduce stent related complications and morbidities. Though, most of the times patients tend to forget the removal of DJ stent in spite of written and verbal instruction, sometimes there was lack of communication from health care providers. Managing complication itself has its own inherent complication and morbidity. Therefore, forgotten DJ stent has become a challenging issue for urologists. The objectives of this study were to evaluate the clinical profile, the long- term complications, etiologies, management options, role of endourological procedures, prevention of various morbidity of forgotten double –J (DJ) stents. It will help in understanding the importance of prevention of complications by judicious use of DJ stents. The various methods of treatment such as shock wave lithotripsy (ESWL), cystolithotripsy(CLT), ureteroscopic lithotripsy(URSL), percutaneous nephrolithotomy(PCNL), and open surgical procedures have been used for treatment of encrusted stents.4

MATERIALS AND METHODS

The study was conducted a retrospective analysis of patients with forgotten DJ stents from February 2020 to January 2025. All those patients with forgotten stent and were previously operated at our center as well as referred to our institution with more than 6 months of DJ stent placement without prolonged stenting indication were included in this study. Written informed consent was obtained from all the patients. This study was approved by the Institutional Ethics Committee and the study procedure was in accordance with the principles of the Declaration of Helsinki. The following parameters such as age, sex, literacy, socioeconomic status, indications for stent placement, indwelling time, presenting complaints, various treatment given, reason for non-removal, radiological investigations, managements given, complications and eventual outcome were recorded and analyzed. The education and socioeconomic status of the patients were calculated by the modified Kuppuswamy scale. The education status ranged from score 1 to score 7. The patients were classified under Class 1- upper, Class2-upper middle, Class 3-lower middle, Class4- upper lower, and Class 5- lower according to socioeconomic status. All patients were assessed by detailed history, clinical examination, all routine preoperative and relevant investigations. The demography, educational/socioeconomic status, the indication of stenting, duration of indwelling, presenting complaint, radiological investigation, and procedures required for complete DJ stent removal were recorded as per the Proforma of the study. In all patients, the initial diagnosis was done by the kidney, ureter, bladder X-ray (KUB X-ray) and ultrasound of whole abdomen. Initial evaluation included urinalysis, blood urea, creatinine, whole blood count, urine culture and sensitivity test. To evaluate anatomy, stone burdens, stent encrustation and status of stents (broken, migrated), non -contrast computerized tomography (NCCT) and/ or intravenous urography were performed. DTPA (diethylene triamine pentaacetic acid) renogram was performed if hydronephrosis or raised urea, creatinine was found. Treatment decision was taken accordingly from clinical, radiological and laboratories findings. The presence of encrustation and fragmentations was detected by kidney and urinary bladder (KUB) film and categorized on CT scan. Encrustation <5 mm in diameter on CT were considered mild, >5 mm and <10 mm in diameter were considered moderate, and >10 mm were considered severe.

 

The patients with minimal encrustation were planned for cystoscopy and gentle traction of stent under C arm guidance. It was abandoned if found more than expected resistance during retrograde extraction. The patients with severe encrustation and stone formation on lower coil only were managed by cystoscopic lithotripsy (CLT) using pneumatic lithotripter. The patients with failed retrograde extraction and large stones in the upper coil were managed by percutaneous nephrolithotripsy (PCNL). Sometimes pyelolithotomy, ureterilithotomy and cystolithotomy were required in some cases. Nephrectomy may be required in patients with nonfunctioning kidney to avoid the morbidity of numerous interventions. Finally, we also evaluated the correlation of stent duration with the complications and need for multiple procedures. Re-stenting was done in patients with complicated encrustation. Descriptive statistical analysis was performed and data was represented as percentage, mean ± standard deviation. To test the correlation of stent duration with complications and need for multiple procedures, the independent t-test was used. A P <0.05 was considered significant.

RESULTS

A total of 48 patients were included in our study, of which 14 patients (29.2%) underwent previous procedures (for which DJ stent was inserted) in our institution and the remaining 34 patients (71.8%) were referred from other hospitals. The mean age of the patients was 37.28 years. Out of 48 patients, 35(72.9%) were male and 13(17.1%) patients were female. Most of the patients 31(64.6%) were illiterate and belongs to lower socioeconomic class group 25(52%). DJ stents were more commonly inserted on right side 29(60.4%) than left side 21(39.6%). The mean duration of indwelling stent in situ was 24.76 months ranging 6 months to 96 months. The indications of indwelling DJ stents are given in Table 1. Most common indications for DJ stenting were URSL 18(37.5%), pre-stented ESWL 3(6.3%) cases, post PCNL 9((18.7%) cases, post open pyelolithotomy/ureterolithotomy 9(18.7%) cases, pyeloplasty 5(10.4%) cases, ureteroneocystostomy and B/L DJ insertion 2(4.2%) cases in each. Presenting complaints (table 1) were pain 38 (79.2%), dysuria 31(64.6%), storage LUTS 21(43.8%), recurrent UTI 19(39.6%) and hematuria 8(16.7%) cases. In our study who had DJ insertion, location of stones as follows ureteric stone 41(85.4%), bladder stone 38(63.3%) (figure 1a,1b,1c,2a), renal stone 24(50%) cases (figure 6a) and combined stones are as follows renal stone +bladder stone +ureteric stone 17(35.4%), bladder stone + ureteric stone 14(29.2%), renal stone+ ureteric stone 7(14.6%) (figure 6b), renal stone +bladder stone 6(12.5%) cases. The incidence of fragmented DJ stents were 5(10.4%) (figure 3a) and migrated distally in 4(8.3%) cases (figure 3b). Reasons for forgotten DJ stent was known 27(56.3%) cases and did not know 21(43.7%) cases. DJ stents were removed in 48 patients. Single procedure was required in 33(68.8%) cases and multiple procedures were required in 15(31.2%) cases.  Forty- one 41(85.42%) patients were managed by endoscopic approaches with either single or multiple procedures (total 65 procedures) and 7 patients require open procedures. In our study thirteen 13(21.1%) patients were having mild encrustations and were removed through retrograde cystoscopic extraction, without any intraoperative complications (Table 2). Five patients (10.4%) had spontaneous stent fragmentation, and four patients (8.3%) had migrated DJ stents. For proximal renal calculus, PCNL was done in 11(22.9%) patients (figure 2b,6a) while URSL was done in 17 (35.4%) (figure 5b) cases. ESWL in 5 patients with encrusted stent followed by cystoscopic removal of those stent were done and in two patients ESWL along with cystolithotripsy (figure 5b) were done. PCLT and TUCLT were done in 9(18.8%) and 8(16.7%) patients respectively. Open procedure like pyelolithotomy, ureterolithotomy, cystolithotomy (figure 4a,4b) and ureteric reimplantation were done in 7(14.6%) cases in those patients where endoscopic procedures failed or patients develops vesicoureteric reflux (VUR).

 

Table1:                                                                   Patient demographics

Patient demographics                                                    Number of patients (n= 48)

Age(years) (Mean age ± SD)                                       37.28(8.82)

Sex

     Male                                                                           35(72.9)

     Female                                                                       13(17.1)

Educational status

     Illiteracy                                                                    31(64.6)

     Educated                                                                   17(35.4)

Socioeconomic status

     Upper                                                                           0

     Upper middle                                                              6(12.5)

     Lower middle                                                              8(16.7)

     Upper lower                                                                9(18.8)

     Lower                                                                           25(52)  

Site of involvement

     Right                                                                           29(60.4)

     Left                                                                             21(39.6)

Indwelling time (months)                                       24.76(6-96)     

Indications for indwelling stenting

   B/L DJ stent insertion                                                  2 (4.2)                   

   PCNL                                                                               9((18.7)

   ESWL                                                                              3(6.3)                                                                      

   URSL                                                                              18(37.5)

   Pyelolithotomy/ ureterolithotomy                            9(18.7)

   Pyeloplasty                                                                     5(10.4)

   Ureteroneocystostomy                                                2(4.2)

                                                                            

Presenting complaints

   Pain                                                                               38 (79.2)                                                                    

   Dysuria                                                                          31(64.6)

   Hematuria                                                                      8(16.7)

   Recurrent UTI                                                               19(39.6)

   Storage LUTS                                                                21 (43.8)       

 Location of stones

   Renal stone                                                                   24(50)

   Bladder stone                                                               38(63.3)

   Ureteric stone                                                              41(85.4)

   Bladder stone+ ureteric stone                                  14(29.2)

   Renal stone +bladder stone                                        6(12.5)

   Renal stone+ ureteric stone                                        7(14.6)

   Renal stone +bladder stone +ureteric stone          17(35.4)

Fragmented                                                                       5(10.4)

Migration                                                                           4(8.3)

Reasons

   Forgot(sF)                                                                      27(56.3)

   Did not know                                                                21(43.7)

Procedures

   Single procedure                                                         33(68.8)

   Multiple procedure                                                     15(31.2)

 

Table 2: Managements of forgotten DJ stents

                           Treatments

                                       Total

 

                                        N(%)

Cystoscopy

                                      13(21.1)

Ureteroscopy

                                      17 (35.4)      

ESWL

                                        7(14.6)

PCNL

                                      11(22.9)

PCLT

                                        9(18.8)

TUCLT

                                        8(16.7)

OPEN PROCEDURE

                                        7(14.6)

 

 

 

 

 

Figure 2a: CT urography showing forgotten right DJ stent with large bladder calculus.

Figure 2b: Forgotten left DJ stent with retained proximal portion removed by PCNL.