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Submucosal impaction of a forgotten DJ stent: addressing the unexpected
  1. Shiraz Akif Mohammed Ziauddin,
  2. Sudheer Kumar Devana,
  3. Aditya Sharma and
  4. Kapil Chaudhary
  1. Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
  1. Correspondence to Dr Sudheer Kumar Devana; drsudheer1983{at}gmail.com

Abstract

A 16-year-old man with horseshoe kidney presented with a right-sided forgotten double J stent (DJS), 1 year after bilateral percutaneous nephrolithotomy. X-ray of the kidney, ureter and bladder showed bilateral residual stones with no encrustations or stone formation on the DJS. Initial attempt of DJS removal using 22 French (Fr) cystoscope and 6/7.5 Fr semirigid ureteroscope failed due to resistance while pulling the DJS and inability to uncoil the upper end of DJS. Finally, percutaneous antegrade scopy was done suggestive of submucosal impaction of the forgotten DJS in upper ureter. The overlying mucosal bridge was cut using holmium: Yttrium Aluminum Garnet (YAG) laser and the DJS was retrieved. The index case highlights an unusual cause of entrapment of the DJS and whenever resistance is encountered, the use of force should be avoided and the cause of resistance should be troubleshooted, thereby preventing serious injuries like ureteral avulsion.

  • urological surgery
  • urology

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Background

Double J stents (DJSs) are an indispensable part of modern urological armamentarium and are used frequently by urologists for a myriad of indications. Short-term indwelling DJSs are associated with morbidity in the form of stent-related symptoms. However, longstanding or forgotten DJS can be associated with simple to life-threatening complications like recurrent urinary tract infection, pyelonephritis, stent migration, stent fragmentation, encrustation, stone formation and urinary tract obstruction leading to urosepsis or renal failure.1–3 Management of removal of forgotten DJS can range from simple ureteroscopic to percutaneous or open surgical removal.4–6 Here we present a unique scenario faced by us where we failed to retrieve a forgotten DJS transurethrally due to submucosal impaction of DJS in the upper ureter.

Case presentation

A 16-year-old man with horseshoe kidney had right DJS placement following bilateral percutaneous nephrolithotomy (PCNL) for renal stones. He presented to us after 1 year with a forgotten right DJS. An X-ray of the kidney, ureter and bladder showed bilateral residual stones with no evidence of stent encrustation or stone formation on the forgotten DJS (figure 1). Hence, a plan for DJS removal and retrograde intrarenal surgery for residual stone was made. Serum creatinine was normal and urine culture was sterile.

Figure 1

X-ray of the kidney, ureter and bladder showing a forgotten double J stent on right side with bilateral residual renal stones.

The initial attempt at right DJS removal using 22 French (Fr) cystoscope failed as there was undue resistance felt while pulling the DJS. Using 6/7.5 Fr semirigid ureteroscope by the side of the forgotten DJS, ureteroscopy was done until the upper end of ureter. However, the ureteroscope could not be advanced beyond the upper ureter due to mucosal oedema. Using a 4 Fr foreign body forceps, another attempt to pull the DJS by grasping it in the upper ureter was attempted but it also failed as the upper coil of the DJS was not getting uncoiled and the same resistance was felt. With a suspicion of knotting of the upper coil of DJS in pelvis (figure 2), a decision for antegrade percutaneous removal of DJS was made. The patient was positioned in prone position and a percutaneous mid-posterior calyceal puncture was made and the tract was dilated until 24 Fr. On antegrade visualisation, no knotting or stone formation over the upper coil of DJS was noted. Another attempt to pull DJS by grasping its upper coil was done but on applying traction, there was a lot of resistance and along with the DJS the pelviureteric junction mucosa was also getting intussuscepted into the pelvis (figure 3).

Figure 2

Intraoperative fluoroscopy image showing a suspicion of knotting of upper coil of double J stent while pulling the stent from below along with residual stone in the kidney.

Figure 3

Intussusception of mucosa of the pelviureteric junction while pulling the double J stent by antegrade approach.

Antegrade scopy by the side of the DJS into the upper ureter was done. The stem of the DJS was grabbed and again it was pulled into the pelvis. With this manoeuvre, the lower end of the DJS with its lower coil got delivered into the pelvis. Now the DJS with both the upper and lower coils were delivered into the Amplatz sheath except a part of the stem of the DJS which was still stuck in the upper ureter (figure 4). On careful inspection with nephroscope, we noticed that the stem of the DJS was actually buried within the upper ureteric mucosa leading to impaction and resulting in failed attempts at its removal (figure 5). Finally, using 550-micron holmium: YAG laser fibre with a laser setting of 12 Hz frequency and 1 J energy, the mucosal overgrowth over the DJS was cut (figure 6). The DJS was actually impacted below the mucosa as after laser ablation the stent got delivered through the Amplatz sheath without causing grade 3 or grade 4 ureteric injury. Residual stone was also removed and a 4.8 Fr DJS was again placed which was subsequently removed after 4 weeks. The patient had an uneventful postoperative course and he is presently asymptomatic at a follow-up of 9 months.

Figure 4

Intraoperative fluoroscopy image showing both the ends of the double J stent in Amplatz sheath.

Figure 5

Submucosal impaction of the stem of the double J stent in the upper ureter.

Figure 6

Left image showing holmium laser fibre ablating the mucosal bridge over the double J stent. Right image showing the cut mucosal flap in the dilated upper ureter.

Discussion

DJSs are widely used in the contemporary urological practice and are quite well tolerated.7 Forgotten DJS is a complication seen in patients with poor compliance or due to patients being inadequately informed. Forgotten DJS is a source of significant morbidity to patients due to severe flank pain, fever secondary to ureteric obstruction and infection. They can also get severely encrusted and result in stone formation. In the worst scenario, the renal function can be severely deranged due to longstanding obstruction leading to loss of moiety as well.8 9

Adanur and Ozkaya found that forgotten DJSs can be safely and successfully removed by endourological techniques.10 They are generally managed with a combination of cystolithotripsy, ureteroscopy, PCNL and even open surgery.11 12 Polat et al observed significant relation between indwelling time and required treatment approaches.13 Cystoscopic retrieval under fluoroscopic guidance is mandatory while retrieving a forgotten DJS. During retrieval, while pulling the lower coil of DJS, the urologist should carefully assess the amount of resistance felt and also simultaneously look for the gradual uncoiling of the upper end of DJS. Encrustations and stone formation over the upper coil of forgotten DJS are the most common reasons for increased resistance and failure of uncoiling of upper end of DJS. Sometimes knotting of the upper end of DJS could also be the reason for the same.

In the index case, even though there were no encrustations or stone formation in the upper end of the forgotten DJS, still we had difficulty in retrieving it endoscopically due to submucosal impaction of the upper end of the DJS. After initial failed attempt of cystoscopic removal, ureteroscopic retrieval was attempted which also failed. The retrieval of the stent required a percutaneous antegrade approach and cutting the ureteral mucosal bridge with holmium laser. This was highly unusual that despite the absence of encrustations, the surgeon had to resort to percutaneous antegrade approach for the retrieval. The overgrowth of mucosa over the stent could be probably due to buttonholing of guidewire through the mucosa of the upper ureter during initial stent placement leading to submucosal impaction of DJS. Another plausible explanation could be passage of stent through any flap raised during the previous PCNL procedure and later on the mucosa has overgrown over the stent. This case also highlights the progressive step-by-step approach for the management of a forgotten DJS. It also re-emphasised never to exert undue force to pull a forgotten DJS, instead look for the reason for that resistance by doing scopy and then treat accordingly.

Learning points

  • Management of a forgotten double J stent involves a progressive step-by-step approach.

  • As the old dictum states that there is no scope of using force in endourology; whenever there is excessive resistance during an endoscopic manoeuvre, blind procedure should be aborted.

  • Direct visualisation of the cause of resistance should be troubleshooted for the safety of the patient and to avoid any dreaded complication of the procedure.

Ethics statements

References

Footnotes

  • Twitter @SudheerDevana

  • Contributors SAMZ—manuscript preparation and editing. SKD—central Idea generation and manuscript editing. AS—manuscript editing. KC—manuscript editing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.