Neglected double-J stent presenting as giant bladder and ureteral stone: A case report

Abstract

Implementing double-J (DJ) stents in urological practice helps to alleviate kidney and ureteral obstruction. The primary causes of neglecting a DJ stent typically involve inadequate counseling and poor patient compliance. Encrustations of neglected DJ stents present a significant challenge. This study aims to report on a neglected DJ stent that persisted for 3 years, presenting as giant bladder and ureteral stones. We report on a 35-year-old male with chief complaints of discomfort in the suprapubic and left flank, along with concurrent micturition leakage. He had a DJ stent implanted to treat his ureteral stone 3 years ago. Advanced imaging showed a left distal ureteral stone (0.7×0.8×1.9 cm), extensive hydronephrosis and hydroureter, and a bladder stone (4.7×3.9×3.2 cm). A left ureterorenoscopy (URS) was done to remove a stone from the end of the ureter, half of a DJ stent and a bladder calculus using cystolitholapaxy. However, the patient underwent a second surgery owing to a residual bladder stone. The patient was discharged from the hospital without any symptoms. A foreign object in the urinary tract, like a DJ stent, may create secondary calculi. Endoscopic treatment could improve the efficacy of treating large bladder stones simultaneously with ureteral stones. As a measure to prevent DJ stent-related complications, it is also essential for healthcare professionals to provide information and follow-up care to patients regarding the use of DJ stents.

Introduction

The Double J (DJ) stent is a widely used medical device in urology. The DJ stent has a limited duration of 3-6 months within the ureter, necessitating replacement or removal. A DJ stent can be considered neglected when it remains inside the ureter for more than 6 months [1]. DJ stents are typically inserted to aid in the outflow of urine from the blocked upper urinary tract. Nevertheless, the extensive utilization of DJ stents has resulted in diverse health complications.

The issue of neglected DJ stents, especially those that have become encrusted, is a significant challenge for both patients and medical professionals. Neglected DJ stents have the potential to cause medical complications such as stent rupture, stent encrustation, and recurrent urinary tract infections. The patient's condition might be greatly complicated by kidney dysfunction and complications associated with stones and encrustation [2,3].

During the last decade, significant improvements have been made in stent design and material in order to reduce complications. However, there is still many reported cases neglected DJ stent which leading to stone formation. Furthermore, endourological operations and open surgeries may encounter challenges and risks related to the stent, in addition to the difficulties involved with managing patients with neglected DJ stents [4]. Inadequate counseling and poor patient adherence to postplacement tests are the primary factors contributing to neglected DJ stents [5].

This case report presents a rare occurrence of a neglected DJ stent, resulting in the formation of large bladder and ureter stones. We present and reported this case section as recommended in the CARE Checklist.

Case presentation

A 35-year-old man came to Our Hospital's Emergency Department with symptoms of pain in the suprapubic area and the left side of his abdomen, as well as hematuria and involuntary leaking during urination. In 2019, he underwent a left URS (ureteroscopy) and had a left DJ stent inserted due to the presence of a left ureteral stone. Nevertheless, as a result of the COVID-19 pandemic and a demanding work schedule, the patient failed to attend any subsequent appointments related to the implanted DJ stent.

A comprehensive examination revealed a slightly elevated body temperature (37.5 C), although all other essential indicators were within the normal ranges. Upon physical examination, the patient showed discomfort on the left flank and suprapubic area, with a Visual Analog Scale (VAS) pain rating of 5. The laboratory tests showed a high white blood cell count of 18,900/µL, although kidney function was found to be within the normal range (blood urea nitrogen level of 10.5 mg/dL and serum creatinine level of 1.0 mg/dL). The urinalysis indicated the presence of a urinary tract infection, with a pH level of 7.0 and significant amounts of erythrocytes (3+) and leukocytes (3+).

Investigation

The Kidney Ureter Bladder (KUB) imaging showed the presence of a left DJ stent (Fig. 1). A stone was identified in the distal ureter using computed tomography (CT) sonography. The stone has a density of 1440 Hounsfield Units (HU) and measures 0.7×0.8×1.9 cm. Furthermore, a bladder stone was discovered, measuring 4.7×3.9×3.2 cm, with a density of 2726 HU. The distal tip of the DJ stent was found to be embedded within the stone. Furthermore, a significant instance of hydronephrosis was identified in the right kidney (Fig. 2).

Fig. 1.

Kidney Ureter Bladder (KUB) Photo (prior surgery, left DJ stent with distal tip embedded to bladder stone [red line]).

Fig. 2.

CT Stonography (prior surgery).

Treatment

The initial procedure involved URS lithotripsy and cystolitholapaxy. During the initial treatment, a substantial amount of the DJ stent was effectively removed, and the ureter stone was found to be completely clear of any particles. Nevertheless, the surgical procedure had to be discontinued as a result of extensive hemorrhaging and poor sight (Fig. 3). Postoperative imaging detected the presence of residual stones in the bladder (Fig. 4).

Fig. 3.

Intraoperative procedure. (A-C) Appearance of bladder stone on fluoroscopy, (D-E) Successfully extracted of stone fragments and DJ stent).

Fig. 4.

Abdominal plain film. (Post URS, showed residual bladder stone [red circle]).

One week after the initial treatment, a second cystolitholapaxy was performed to treat the remaining bladder stones. During the second surgery, we performed cystolitholapaxy until the bladder stone was completely free of any fragments, and postoperative imaging confirmed a visibly clear bladder stone. After the surgery, the patient's temperature dropped and on the third day after the procedure, the catheter was removed, allowing the patient to urinate easily with little discomfort. After being discharged from the hospital, the patient returned to the outpatient clinic after 2 weeks and reported no problems or issues.

Discussion

DJ stent placement is a critical medical intervention in urology. DJ stents serve as exogenous objects that provoke irritation in the trigone and ureter walls, resulting in symptoms such as urinary irritation, hematuria, and discomfort in the suprapubic region [6]. Immediate risks include increased frequency, painful urination, blood in urine (known as stent syndrome), discomfort, and urinary tract infections. Conversely, delayed complications, which manifest after 3-6 months, can include blockage, movement, fragmentation, infection, hydronephrosis, and the formation of crust-like deposits (encrustation) [7,8].

Encrustation is the process by which mineral crystals form on the surface of the stent, both inside and outside. This procedure can lead to substantial complications, particularly if the stent is retained for an extended period or inadvertently neglected [9]. Bacterial biofilm development and encrustation are caused by microorganisms such as E. coli, Streptococcus, and Pseudomonas [10]. The greatest risk factor for stent encrustation is the duration of stent installation, although there are other risk factors such as metabolic or congenital abnormalities, stone disease, bacterial colonization, chemotherapy, pregnancy, and chronic kidney failure [11]. Mineral crystals that can dissolve in urine primarily consist of calcium oxalate salts and are responsible for the formation of encrustation on DJ stents. When there is an infection, the breakdown of the stent happens faster due to the presence of oxalate. Residual urine in the bladder is a significant risk factor [12].

Complaints that result from the lack of attention given to DJ stents might appear in many clinical manifestations. Damiano et al. found that 25.3% of patients experienced pelvic pain, whereas 18.8% displayed signs of bladder irritation. In addition, 18.1% of the patients experienced hematuria, while 12.3% developed fever [2,13]. This is consistent with our patient, who had pain in the suprapubic region along with a temperature. There is a common understanding that patients who do not experience symptoms often forget or ignore their stent implantation, resulting in a greater amount of neglect compared to patients who have symptoms.

This is similar to a reported case by Jawad et al., who reported an exceptional case of a massive bladder stone that developed as a result of a neglected DJ stent over a period of 3 years. The patient experienced suprapubic pain and dysuria. Later, a KUB discovered a coiled DJ stent with a large bladder stone, and an open cystolithotomy was successfully performed for encrustation. Contrast between our case is only the treatment, which in this patient, we used the URS lithotripsy technique for the ureteral stone and cystolitholapaxy for the bladder stone [13].

Following the placement of a DJ stent, bladder stones can occur, typically measuring less than 1 cm. It might be spontaneously expelled from the body during urination [14]. In this case, we observed a significant bladder stone measuring 4.7 cm, with the distal end of the DJ stent entrenched within the stone. Additionally, there was a ureteral stone measuring 1.9 cm in the distal ureter, which occurred as a complication of extended DJ stent insertion.

The usual procedure for withdrawing DJ stents is a cystoscopy surgery, in which a small camera is introduced into the bladder via the urethra to precisely locate and extract the DJ stent [15]. An embedded stent in the bladder wall may be harder to remove. As a result, further treatments such as laser lithotripsy or open surgery may be necessary. The treatment chosen for bladder stones is dependent on the stone's location and dimensions. More extensive bladder stones may require more invasive procedures, such as cystolitholapaxy or open surgery. On the other hand, tiny stones can be dissolved with drugs or treated using noninvasive methods like Extracorporeal Shockwave Lithotripsy (ESWL) [16,17]. In this particular patient, we used the URS lithotripsy method to treat the ureteral stone and performed cystolitholapaxy to address the bladder stone. Despite undergoing cystolitholapaxy twice in response to decreased visualization and bleeding, postprocedure imaging showed no remaining stones. Furthermore, during the outpatient clinic follow-up 2 weeks after hospital release from the hospital, the patient did not report any problems.

Insufficient awareness of healthcare matters might result in diminished patient awareness and adherence rates. This has been recognized as a factor that contributes to the greater risk of DJ stent retention [11]. In our case, the patient failed to have the DJ stent removed for a duration of 4 years following stone surgery, mostly because of the COVID-19 epidemic and the patient's demanding work commitments. As a result, the DJ stent became encrusted, causing stones to form in the ureter and bladder.

Although successful management of these complications is done by endourological means in the majority of cases with minimal complications, the best treatment would be prevention from this complication. Effective counseling and strict adherence to treatment recommendations are essential for preventing the retention of DJ stents, underscoring the significance of regular meetings with healthcare providers. Surgeons have suggested implementing a hospital stent registration system to keep track of all DJ stent implantations. This system would also send reminders to service providers to contact patients who require DJ stent removal. The objective is to decrease the incidence of DJ stent retention, which can result in encrustation. Also, for long-term management, further imaging was necessary, both medically and legally, to exclude a retained stent or part of a stent [18,19].

This highlights the significance of enhancing patient awareness and adherence to treatment protocols by periodically seeking advice from healthcare experts and promptly removing DJ stents.

Conclusions

Failure to properly care for a DJ stent, which results in encrustation, poses a significant urological problem for both patients and healthcare providers. Furthermore, this problem can be prevented if the stent is rapidly removed. It is becoming important to provide thorough guidance on the utilization of DJ stents and the ability to identify urological stones that mimic ignored DJ stents by modern imaging. Additional study is required to develop specific recommendations for reducing problems caused by DJ stent neglect.

Patient consent

Informed consent for patient information to be published in this article was obtained. Appropriate informed consent was obtained for the publication of this case report and accompanying images. This report has been approved by the ethical committee of Dr. Soetomo General-Academic Hospital.