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Combined Percutaneous and Transurethral Lithotripsy for Forgotten Ureteral Stents With Giant Encrustation

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Ibrahim Uygun at Kutahya Health Sciences University
Ibrahim Uygun
  • Kutahya Health Sciences University
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Abstract

Dear Editor, Forgotten ureteral stents (FUS) with encrustation can cause problems during treatment. Most FUS encrustations are small and are treated easily. However, if large, multiple, or long stones have formed, treatment is challenging to the surgeon. We congratulate Rabani, who reported successful treatment of a giant (> 35 mm stone formation) encrustation (1). As it is clearly known, patients with FUS refer to a doctor occasionally, but usually due to urosepsis or presepsis. Thus, their diagnosis should be sepsis, and their treatment should be carefully planned. Nevertheless, further evaluation and medical treatment should be conducted before the initial invasive procedure (2). After a physical examination, blood and urine analyses, plain X-rays, and ultrasonography should be performed. If the patient is in renal failure, it should be treated with urinary drainage by nephrostomy of the affected kidney and/or drainage of the contralateral kidney. A kidney evaluation (DMSA, DTPA, IVP, CT) and appropriate treatment should be performed. The management of encrusted FUS was reported in detail by Bostanci et al. (3). We agree with Rabani that the best treatment is to prevent this complication and design a recall system (1). Thus, Sancaktutar et al. at our university reported a reminder short message service (SMS) based on a computer system that tracks ureteral stents and automatically sends a reminder to the mobile phones of patients and urologists using an integrated stent register program and a stent extraction reminder program with an electronic patient record program located within our hospital’s computer network. This system has been used successfully on several patients (4). Treatment of encrusted FUS may require several combined endourological procedures (cystoscopic removal, ESWL, PCNL, URS, percutaneous or transurethral cystolithotripsy, open surgery, etc.). Rabani used percutaneous and transurethral cystolithotripsy with a bladder coil for a patient with a giant (> 35 mm) encrusted FUS and PCNL with a kidney coil using a pneumatic lithotripsy energy source. We recommend holmium laser lithotripsy in addition to pneumatic lithotripsy, which is effective and safe for treating urinary stones at all locations (5). However, laser energy can also break the ureteral stent.
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Combined Percutaneous and Transurethral Lithotripsy for Forgotten Ureteral Stents With Giant Encrustati
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Combined Percutaneous and Transurethral Lithotripsy for Forgotten Ure-
teral Stents With Giant Encrustation
Ibrahim Uygun
1, *
1
Department of Pediatric Surgery and Pediatric Urology, Dicle University Medical Faculty, Diyarbakir, Turkey
*Corresponding author: Ibrahim Uygun, Department of Pediatric Surgery and Pediatric Urology, Dicle University Medical Faculty, Diyarbakir, Turkey. Tel:
+90-4122488001, Fax: +90-4122488523, E-mail: iuygun@hotmail.com.
Keywords: Kidney Calculi; Ureteroscopy; Laser; Lithotripsy; Stents
Article type: Letter; Received: 08 Dec 2012; Accepted: 29 Dec 2012; Epub: 01 Jun 2013; Ppub: 01 Jul 2013
Please cite this paper as:
Uygun I. Combined Percutaneous and Transurethral Lithotripsy for Forgotten Ureteral Stents With Giant Encrustation. Nephro Urol
Mon.2013; 5(3): 847-8. DOI: 10.5812/numonthly.9533
Copyright © 2013, Nephrology and Urology Research Center; Published by Kowsar Corp.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which per-
mits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Dear Editor,
Forgotten ureteral stents (FUS) with encrustation can
cause problems during treatment. Most FUS encrusta-
tions are small and are treated easily. However, if large,
multiple, or long stones have formed, treatment is chal-
lenging to the surgeon. We congratulate Rabani, who
reported successful treatment of a giant (> 35 mm stone
formation) encrustation (1). As it is clearly known, pa-
tients with FUS refer to a doctor occasionally, but usu-
ally due to urosepsis or presepsis. Thus, their diagnosis
should be sepsis, and their treatment should be carefully
planned. Nevertheless, further evaluation and medical
treatment should be conducted before the initial inva-
sive procedure (2). After a physical examination, blood
and urine analyses, plain X-rays, and ultrasonography
should be performed. If the patient is in renal failure, it
should be treated with urinary drainage by nephrostomy
of the affected kidney and/or drainage of the contralat-
eral kidney. A kidney evaluation (DMSA, DTPA, IVP, CT)
and appropriate treatment should be performed. The
management of encrusted FUS was reported in detail by
Bostanci et al. (3).
We agree with Rabani that the best treatment is to pre-
vent this complication and design a recall system (1). Thus,
Sancaktutar et al. at our university reported a reminder
short message service (SMS) based on a computer system
that tracks ureteral stents and automatically sends a re-
minder to the mobile phones of patients and urologists
using an integrated stent register program and a stent
extraction reminder program with an electronic patient
record program located within our hospital’s computer
network. This system has been used successfully on sev-
eral patients (4).
Treatment of encrusted FUS may require several com-
bined endourological procedures (cystoscopic removal,
ESWL, PCNL, URS, percutaneous or transurethral cystoli-
thotripsy, open surgery, etc.). Rabani used percutaneous
and transurethral cystolithotripsy with a bladder coil for
a patient with a giant (> 35 mm) encrusted FUS and PCNL
with a kidney coil using a pneumatic lithotripsy energy
source. We recommend holmium laser lithotripsy in ad-
dition to pneumatic lithotripsy, which is effective and
safe for treating urinary stones at all locations (5). How-
ever, laser energy can also break the ureteral stent.
Authors’ Contribution
Ibrahim Uygun is the only author and 100% of the work
is done by him.
Forgotten Ureteral Stents
Uygun I
Nephro Urol Mon. 2013;5(3)848
Financial Disclosure
There is no financial disclosure.
References
1. Rabani SM. Combined percutaneous and transurethral lithotrip-
sy for forgotten ureteral stents with giant encrustation. Nephrou-
rol Mon. 2012;4(4):633-5.
2. Sancaktutar AA, Soylemez H, Bozkurt Y, Penbegul N, Atar M. Treat-
ment of forgotten ureteral stents: how much does it really cost? A
cost-effectiveness study in 27 patients. Urol Res. 2012;40(4):317-25.
3. Bostanci Y, Ozden E, Atac F, Yakupoglu YK, Yilmaz AF, Sarikaya S.
Single session removal of forgotten encrusted ureteral stents:
combined endourological approach. Urol Res. 2012;40(5):523-9.
4. Sancaktutar AA, Tepeler A, Soylemez H, Penbegul N, Atar M, Boz-
kurt Y, et al. A solution for medical and legal problems arising
from forgotten ureteral stents: initial results from a reminder
short message service (SMS). Urol Res. 2012;40(3):253-8.
5. Uygun I, Okur MH, Aydogdu B, Arayici Y, Isler B, Otcu S. Efficacy
and safety of endoscopic laser lithotripsy for urinary stone treat-
ment in children. Urol Res. 2012;40(6):751-5.
ResearchGate has not been able to resolve any citations for this publication.
Combined Percutaneous and Transurethral Lithotripsy for Forgotten Ureteral Stents With Giant Encrustation
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Ureteral stents are widely used in many urologic practices. However, stents can cause significant complications including migration, fragmentation, and encrustation and it may possibly be forgotten. Successful management of a retained, encrusted stent requires combined endourological approaches. To present our experience with the approaches for treating forgotten ureteral stents associated with giant stone formation. Seventy four patients with forgotten ureteral stents were managed by different open (nephrolithotomy and/or cystolithotomy), or endoscopic procedures in our center. Among these, 11 patients had severe encrustation (stones larger than 35 mm within the bladder or kidney) and seven patients of this group, presented at our department between July 2007 and December 2010. Combined endourological procedures percutaneous nephrolithotripsy (PCNL), cystolithotripsy (CLT), transurethral lithotripsy (TUL) were performed in one or 2 separate sessions. In these 7 patients the whole of the stents, especially both ends were encrusted. Initially, cystolithotripsy, retrograde ureteroscopy and TUL were performed in the dorsal lithotomy position. Following this, a gentle attempt was made to retrieve the stent with the help of an ureteroscopic grasper. In some cases the stent was grasped by a hemostat clamp out of the urethral meatus with a gentle traction to facilitate lithotripsy in the ureter and even in the kidney. Finally, a ureteric catheter was placed adjacent to the stent for injection of radio-contrast material to delineate the renal pelvis and the calyces. Then in the same session or later in another session the patient was placed in the prone position and PCNL of the upper coil of the encrusted stent along with calculus was done and the stent was removed. In 5 out of seven patients, the initial indication for stent placement was for urinary stone disease after open nephrolithotomy and pyeloplasty in other centers and in two patients after TUL. All patients underwent the procedure (s) under spinal anesthesia and all received antibiotics in preoperative period. The only available source of energy in our center was pneumatic lithotripsy. Multiple endourological approaches or even open surgery are needed because of encrustations and the associated stone burden that may involve bladder, ureter and kidney. This may require single or multiple endourological sessions or rarely open surgical removal of the encrusted stents. Although, endourological management of these stents achieves success in majority of the cases with minimal complications, the best treatment that remains is prevention of this complication and to achieve this important point designing a recall system is suggested.
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View
Single session removal of forgotten encrusted ureteral stents: Combined endourological approach
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Forgotten ureteral stents represent a difficult problem for urologists; the major complications are infection, migration, encrustation, stone formation, and multifractured stent, and a consensus on the best therapeutic approach is lacking. Here we present our experience with endoscopic management of this challenging problem and discuss the various endourological approaches for treating forgotten encrusted ureteral stents. From January 2005 to December 2010, 19 patients (11 women and 8 men) with encrusted ureteral stents were retrospectively analyzed. Combined endourologic therapies including extracorporeal shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), ureterorenoscopic lithotripsy (URSL), and cystolithotripsy (CLT) were used to achieve stent removal. A total of 19 patients with encrusted ureteral stents were treated at our center. The mean patient age was 46.2 ± 18.5 years (8-81), the average indwelling time of the stent was 24.7 ± 19.0 months (8-93), and the mean hospital stay was 3.4 ± 4.0 days (range 1-15 days). Using the described combination of techniques, all stents and the associated stones were eventually removed without any complications and patients were rendered stone- and stent-free. A main element of the treatment strategy was to keep the number of interventions as low as possible. The use of various combinations of endourological techniques can achieve effective stent and stone treatment after a single anesthesia session with minimal morbidity and short hospital stay.
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Treatment of forgotten ureteral stents: How much does it really cost? A cost-effectiveness study in 27 patients
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A solution for medical and legal problems arising from forgotten ureteral stents: Initial results from a reminder short message service (SMS)
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The objective of this study was to describe and present the initial results of a computer-based system that tracks ureteral stents and automatically sends a reminder through a short message service (SMS) to both the patient's and the urologist's mobile phones Using an integrated stent register program (SRP) and a stent extraction reminder program (SERP) with an electronic patient record program (EPRP) located within our hospital's computer network. In this system, the demographic data of all of the patients are recorded into the password-protected EPRP. After a stent is inserted, the surgeon enters the details of the operation into the EPRP. The SRP automatically asks the user to define the "optimal stent life (OSL)". The SERP checks the recorded patients daily and sends an SMS reminder to staff and patient when the OSL is reached. The SERP continues to send reminders via the SMS until stent is removed. We analyzed the success of the SMS recall system. A total of 186 patients received stents over an 11-month period. The patients in group-2 (n = 108) were recalled by the SERP, and the remainder of the patients (n = 78, group-1) were not included in the project. The mean delay from the designated OSL to the time of stent removal was 307 ± 118.6 (72-1,344) and 14.6 ± 2.06 (5-36) h in groups 1 and 2, respectively (p < 0.0001). Our initial results showed that the SRP and SERP prevent stent removal from being forgotten, thus preventing related medical and legal problems.
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