Management of Forgotten Double J Ureteric Stent in a Young Male: A Case Report

Urologic devices called Double-J stents (DJSs) are frequently used to treat urinary tract blockage. Advancement in endourology in last few decades has led to an increase in use of ureteric stents and so its related complications. Herein, we report a case of a 17 years old male patient of poor socioeconomic background from a remote village of Afghanistan, presented to our out-patient department with abdominal pain at the right flank. He had history of double J stent placement during right open pyelolithotomy 6 year before. However, no further details were available.


In trodu ction
The double J stent offers a useful way of drainage for the upper urinary tract. It is a common surgical procedure in day to day urology. The indications of double J catheter placement include the relief of ureteral obstruction secondary to miscellaneous etiologies, maintaining satisfactory postoperative drainage, and after ureteral injuries during surgical procedures. In recent times significant advancements have been made in double J stent design and material in order to diminish complications. However, many serious complications like encrustation, stone formation, migration, and fragmentation, still occur, especially when stents are left in place for longer periods. Furthermore, a forgotten stent is very frequently complicated and poses a management and legal dilemma. Here in, we report a case of a forgotten double J ureteral stent complicated by fragmentation and stone formation at its renal pelvis and vesicle ends.

Case Rep ort
We report a case of a 17 years old male patient of poor socio-economic background from a remote village of Afghanistan, presented to our out-patient department with right loin pain and intermittent gross hematuria from one month. The pain was persistent, radiating to supra-pubic region, had a slow onset, moderate in intensity and was generally relieved by oral Diclofenac. An Abdomen & Pelvis ultrasonography was performed which revealed pelvi-calyceal fullness of the right kidney with a calculus measuring 7mm in the right renal lower pole major calyx, few echogenic foci and rounded loop of stent adjacent to right vesico-ureteric junction in urinary bladder.
On taking detailed history it was established that patient was not aware of Double J stent placement. During further exploration of past medical record it was revealed that he had gone through open vesicolithtomy fourteen years ago followed by an open pyelolithotomy and double J stent placement six years ago.
An ultrasonography was performed which showed pelvicalyceal fullness of the right kidney with a calculus measuring 7mm in the right renal lower pole. Echogenic foci and rounded loop of stent were seen in bladder adjacent to right vesico-ureteric junction. A renal scan revealed right kidney function 16.95% with GFR 13.1ml/min and left kidney function 83.05% with GFR 64.1ml/min. A cystolitholipexy was then performed and the lower end of the forgotten double J stent was removed along with the encrusted stone in bladder using stone punch. 1,2 This was followed by removal of ureteric and intra-renal fragments of double J stent using 8-Fr rigid Ureterorenoscope without any significant resistance. 3 Complete stone clearance was achieved and patient was Case Report discharged home. In light of this scenario we believe it is necessary to educate and maintain regular contact with the patient to ensure regular follow-up visits for patients with double J ureteric stent placements in order to avoid such complications in the future.  Consequently, the development of the illness and prognosis was described to the patient and legal guardian. Based on clinic presentation and imaging findings treatment decision was made followed by Anesthesiology Consultation. Patient didn't give consent for Nephrectomy as treatment option. In this case we decided to perform transurethral Cystolitholipexy with stone punch for removal of the intra-vesical part of Double J stent and Ureterorenoscopy using grasping forceps for removing ureteric and intra-renal part of Double J stent. A PCNL (percutaneous nephrolithotomy) was also planned in case stone fragment couldn't be accessed and removed.

Figure 2. CT KUB with 3D reconstruction: Double J stent with encrustation over both ends & fragmented into three parts, one inside kidney, second in ureter and third in urinary bladder.
After performing Cystoscopy, Cystolitholipexy was performed. Vesical part of the encrusted Double J stent was broken using stone punch and fragments removed using grasping forceps. 8-Fr Rigid Ureterorenoscope was passed into right ureter, stent fragment was identified and pull out using grasping forceps in a single go without any resistance. Then Ureterorenoscope was introduced into ureter again and taken up to pyeloureteric junction where renal part of stent fragment was identified and pulled out with grasping forceps smoothly.

Discussion
The double J stent has many advantages and disadvantages though it is used quite commonly placed. Not all stent placements have logical reasoning. Guidelines must be followed when deciding about placement of stent. When it is required, the patient and guardian must be informed about its complications and timely removal. A record of placed DJ stents must be maintained so that patients may be called for timely removal of stent. This way we can avoid stent related patient morbidity and legal issues. Endo-urologic management of a forgotten double J stent is well established and there is an algorithm available. However, it should be managed endoscopically only by those who are well-trained and expert in Endo-urology. In case of severe encrustations, management modalities are more complex. Many investigators have recommended Extracorporeal shock wave lithotripsy, Laser lithotripsy, Percutaneous Nephrolithotomy 10 , chemical-breakdown using various lytic agents administered via a percutaneous nephrostomy tube, and open surgery 11 either alone or in combination with other procedures. 5,6 With widespread usage of endoscopic instruments, a tendency to use relatively noninvasive interventions has been observed. However, in the literature, frequent usage of multimodal treatment principles is remarkable. 5,7,8 Especially in the presence of encrusted intrarenal part of Double J, the use of PCNL 9 and open procedures has been frequently reported.