Removal of a Double J Stent: Not Always a Simple Procedure

Abstract

Double J stenting is a fundamental part of contemporary urologic practice for the prevention or management of obstruction within the upper urinary tract. Minimal and moderate side effects of double J stent indwelling are common. However significant morbidity can be seen especially in forgotten double J stent. We report our management of a patient with a forgotten double J stent complicated by severe encrustations, large stone formation at its bladder end, urinary tract infections and hematuria. Radiology was mandatory to provide accurate assessment of complications associated with the forgotten double J stent and to help determining the appropriate surgical management.

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Journal of Urology and Research
Cite this article: Jabbour Y, Saouli A, Karmouni T, El Khader K, Koutani A, et al. (2018) Removal of a Double J Stent: Not Always a Simple Procedure. J Urol
Res 5(3): 1104.
*Corresponding author
Youness Jabbour, Department of Urology, Ibn
Sina teaching hospital, Rabat, Morocco Postal
Adress: Hay El Menzeh N 800 C.Y.M, 10150, Rabat,
Morocco, Tel: 00212-0-660278360; Email:
Submitted: 25 June 2018
Accepted: 30 July 2018
Published: 01 August 2018
ISSN: 2379-951X
Copyright
© 2018 Jabbour et al.
OPEN ACCESS
Keywords
•Ureteric stent
•Encrustation
•Urinary tract infections
•Calculi
Case Report
Removal of a Double J Stent:
Not Always a Simple Procedure
Youness Jabbour1,2*, Amine Saouli1,2, Tarik Karmouni1,2, Khalid
El Khader1,2, Abdellatif Koutani1,2, and Ahmed Iben Attya
Andaloussi1,2
1Department of Urology, Ibn Sina teaching hospital, Morocco
2Faculty of Medicine and Pharmacy, Mohammed V University, Morocco
Abstract
Double J stenting is a fundamental part of contemporary urologic practice for the
prevention or management of obstruction within the upper urinary tract.
Minimal and moderate side effects of double J stent indwelling are common.
However signicant morbidity can be seen especially in forgotten double J stent.
We report our management of a patient with a forgotten double J stent
complicated by severe encrustations, large stone formation at its bladder end, urinary
tract infections and hematuria.
Radiology was mandatory to provide accurate assessment of complications
associated with the forgotten double J stent and to help determining the appropriate
surgical management.
INTRODUCTION
Double J stents are self-retaining hollow tubes which drain
the kidneys into the urinary bladder as first described by Finney
in 1978 with a main function of bypassing ureteral obstruction
[1].
With the development of endo-urology a variety of indications
have made the use of double J stents routine in urology.
This widespread clinical use of double J stent is not without
risk and is associated with a number of complications. Among
these complications, double J stent encrustation represents the
most frequent and challenging outcome.
CASE PRESENTATION
We report a case of a 64-years-old man with no particular
medical history. He presented to our department with a major
complaint of hematuria.
A double J stent was found to be indwelling for 2 years.
Initially the double J stent was inserted for management of a
painful and obstructive stone of the lumbar portion of the right
ureter with an intention to perform extracorporeal shockwave
lithotripsy thereafter. It seems that the patient tolerated his
double J stent so well that he was lost to follow-up for two years.
He returned two years later complaining about a growing right
lumbar pain and hematuria.
Overall, he was in good general health without any voiding
symptoms. X-ray showed the forgotten double J stent with
encrustation of its lower loop resulting in a large bladder stone
(Figure 1).
Computed tomography (CT) revealed a pelvicalyceal
dilatation of the right kidney probably related to double J stent
obstruction and the former ureteral stone. The double J stent
was encrusted in its ureteral portion with presence of two large
stones at its lower loop measuring respectively 2.9×1.7cm and
4.2×2.2cm in length and 1200UH in density (Figure 2).
Urine culture revealed klebsiella pneumoniae.
After antibiotherapy, Cystolithotomy and ureterolithototmy
were performed for removal of the encrusted double J stent, the
former ureteral stone and the bladder stones (Figure 3).
ucosa o the bladder as inflaed and bloody as ell as
that of the ureter. A large bladder incision was needed to extract
the large stones that developed within the lower loop of the
double J stent.
Post-operative recovery was uneventful and the patient was
discharged after 4 days stent free and stone free.
DISCUSSION
Forgotten double J stents continue to occur because of poor
patient compliance to the intent of stent use and instructions to
return for stent removal or failure of the physician to adequately
counsel the patient [2-7].

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to work [2,4].
Asymptomatic patients with a well-tolerated double J stent
are more prone to neglect or to forget their stent. After holding
them for many years they can develop serious complications
that are time-related ranging from hematuria, stent occlusion,
migration, fragmentation, encrustation, and stone formation
to serious complications like recurrent urinary tract infection,
urinary tract obstruction, and renal failure [2,3].
Clinical studies have shown that the prevalence of double J
stent complications increases with longer indwelling times [2-
4,6].
El Faqih et al discovered that encrustation occurred in 9.2%
of the stents retrieved before 6 weeks and rose to 76.3% when
stents were indwelling longer than 12 weeks [4].
Besides length of indwelling time a variety of factors
contribute to the high rate of double J stent encrustation.
Stent composition may play a role in its encrustation but
remains controversial despite the fact that in vitro studies shows
that silicone stents are less likely to encrust [6].
The presence of lithogenic urine in stone-former patient
clearly increases the risk of stent encrustation estimated to be
nearly three times higher compared to non-stone-former patients.
Thus, double J stent provides a matrix on which constituents of
the urine combine to form stones [2,3,6].
Adanur et al reported that previous existence of urolithiasis
Figure 1 KUB X-ray showing encrusted double J stent.
Figure 2 Coronal competed tomography scan showing encrusted
double J stent.
The oldest retained double J stent was seen in a patient after
23 years ( 276 months) as was mentioned in the study of Sohrab
et al, [7].
Double J stents are associated with some degree of morbidity.
Patients usually experience symptoms as suprapubic pain,
urinary frequency and urgency, dysuria, haematuria or inability
Figure 3 Encrusted double J stent with two big stones at its lower end
after surgical removal.

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was the prominent factor of encrustation of forgotten double J
stent [8].
Presence of urinary infection helps to accelerate the process
of encrustation [3].
As seen in our patient, and in most reported cases of double
J stent encrustation, severe encrustation tends to preferentially
occur at the renal or bladder end of the stent. This has been
explained by the peristaltic “wiping” of the ureteral portion of the
stent [5].
Encrustation of forgotten double J stents represents a serious
problem in urology practice, especially when a large stone burden
has developed. It makes removal of double J stents known to be
the easiest endourlogy procedure challenging, time consuming,
and costly due to necessity for ureteroscopy, nephroscopy or
even open surgery as in our case.
Radiology, especially CT scans, plays a major role not only
in monitoring patients with indwelling double J stents, but
also in evaluating the severity of associated complications and
in choosing the suitable way for removal of the encrusted and
retained stent [5,8].
Adanur et al. reported CT to estimate stent encrustation more
accurately when compared with X-ray [8].
Accurate radiological assessment and urine sterilization
are imperative prior to any attempt to remove the stent due to
complications related to operative intervention that can be lethal
as previously reported by some authors [7,9].
Most urologists tend to avoid open surgical interventions
when removing encrusted double J stents by using either one or
more endo-urological approaches.
To date, no guidelines on management of encrusted double
J stents are established. However, recommendations based on
authors experiences offer strategies for successful management
of such cases.
Sorhab et al. and Adanur et al. exposed two of the largest
and recent series in management of encrusted forgotten double
J stents with 28 and 54 patients respectively. They recommend
tailored management according to the site and size of stone
burden and a step-wise approach starting with minimally
invasive procedures [7,8].
Sorhab et al., reported a mean of 1.25 procedures per patient
including 17 cystoscopic, 10 percutaneous, and 2 ureteroscopic
interventions, one session of extracorporeal shock wave
lithotripsy, and one simple nephrectomy [7].
Adanur et al. proposed their algorithm for management
of encrusted double J stents starting with simple cystoscopic
stent reoal under a fluoroscoic control heled by rior
extracorporeal shock wave lithotripsy in a patient with
minimally or moderate encrusted stents with careful attention to
avoid ureteral injuries. If encrustation was only at the distal and
middle portion, the stent was removed following fragmentation
by laser lithotripsy. Encrustation of the upper end of the stent
was managed by retrograde intra renal surgery in case of
mild encrustation or percutaneous nephrolithotomy in severe
encrustation. Endoscopic cystolithotripsy or percutaneous
cystolithotripsy were used for management of distal stent
encrustation residing in the bladder. A combination of those
endouroloical aroaches ere suficient or the reoal o
forgotten double-J stents [8].
Singh et al. reserved open surgical interventions for removal
of double J stents to severe encrustation, greater than 4 cm2, after
failure of less invasive endoscopic procedures [10].
Talwar et al. reported, in their small series an-open approach
to provide successful stone-free as well as stent-free status with
a sinle oeratie interention in atients ith sinificant deree
of encrustation and stone burden [10].
In our case removal of the forgotten double J stent was
associated with a longer hospital stay, additional imaging and
laboratory elorations additional theraeutic reater dificulty
in surgery, and a much higher cost than usually charged for
simple cystoscopic stent removal. Computerized tracking system
for patients with indwelling double J stents may help to reduce
the incidence of forgotten stents thus avoiding associated cost,
morbidity and complications.
In this case, we opted for an open approach to remove
both the encrusted double J stent and associated stones in a
sinle oeratie interentional rocedure due to the sinificant
encrustation of the double J stent which was greater than 4 cm2,
and also to minimize the number of therapeutic sessions given
the poor compliance of the patient who was holding the double
J stent for 2 years and our fear of our patient’s lack of adherence
to care.
CONCLUSION
Prevention remains the best way to avoid complications
associated with forgotten double J stents by clearly communicating
to the patient the presence of any internal ureteric stents, the
temporary intent of their use, risks with prolonged indwelling
times and by respecting exchange intervals recommended by the
manufacturer.
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Jabbour Y, Saouli A, Karmouni T, El Khader K, Koutani A, et al. (2018) Removal of a Double J Stent: Not Always a Simple Procedure. J Urol Res 5(3): 1104.
Cite this article
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