Optimal management of prolonged double-J stent indwelling

Dear Editor,

We present a case of neglected bilateral ureteral stents encrusted with extensive urinary tract stones and a review of the available literature on this condition. The patient had provided written informed consent for procedures and publication. A 63-year-old male patient was admitted due to “bilateral lumbar discomfort for 2 years and hematuria for 1 month”. He received no further treatment after bilateral double-J (DJ) stents were placed in our hospital for bilateral kidney stones 4 years ago. Upon admission and physical examination, bilateral costovertebral angle tenderness was noted. Thus, further imaging examinations and laboratory tests were performed. The abdominal CT revealed cast stones and hydronephrosis in both kidneys, encrusted ureteral DJ stents, and bladder stones (Supplementary Fig. 1). Urinalysis showed numerous white blood cells per high-power field and nitrate detection was also positive. Bacterial culture of midstream urine showed that the identified pathogens were Pseudomonas spp. (1×10⁵ colony-forming units [CFU]/mL) and Stenotrophomonas maltophilia (4×10⁴ CFU/mL). Serum creatinine was 2.40 mg/dL. Preoperative radionuclide glomerular filtration rate measurement was performed to evaluate renal function. Radionuclide examination results indicated a total glomerular filtration rate of 37.22 mL/min, with the left kidney contributing 15.94 mL/min and the right kidney 21.28 mL/min. The patient had no prior medical history of diabetes, hypertension, or coronary heart disease, and had never undergone any surgical procedures. Susceptible antibiotics were provided, and staged surgical treatment was performed after the urinary tract infection (UTI) was controlled.

The treatment process was split into four stages. In the first stage, the patient was placed in the lithotomy position, and then a 20.5 Fr nephroscope was inserted into the bladder through the urethra. The bladder stones were cleared using the EMS ultrasound lithotripsy system (Electro Medical Systems S.A., Nyon, Switzerland). The encrustations on the bladder DJ stents were ablated using the holmium laser. The surface stones of the encrusted DJ stent in the right ureter were removed with retrograde holmium laser lithotripsy through a 7.5 Fr ureteroscope with a 6 Fr access sheath. The right DJ stent was then successfully removed and a 5.0 Fr ureteral catheter for pyelography was passed. A 24 Fr standard access tract was established by using balloon dilation in the prone position. The staghorn stones in the right kidney were removed through percutaneous nephrolithotomy (PCNL) with the EMS ultrasound lithotripsy system, and then a right nephrostomy tube was inserted due to residual stones (Supplementary Fig. 2). In the second stage, the Galdakao-Modified Supine Valdivia (GMSV) position was established and a 24 Fr standard access tract was set up. The stones in the left kidney were cleared with the EMS ultrasound lithotripsy system via PCNL. The stones on the encrusted DJ stent in the left upper ureter were treated using antegrade semi-rigid ureteroscopy. Encrustations were peeled off and the stent was cut at the level of the upper ureter using the holmium laser, and then a new 5 Fr DJ stent (Cook Medical Ireland Ltd., Limerick, Ireland) was inserted into the left ureter due to the limited space (Supplementary Fig. 3). In the third stage, a 7.5 Fr ureteroscope with a 6 Fr access sheath was used to perform retrograde treatment for stones adherent to the left DJ stent (mid and distal ureteral portions) in the GMSV position through ureteroscopic lithotripsy. The left DJ stent was removed, and the residual stones in the kidney were treated with retrograde intrarenal surgery. The stones were cleared through the original access tract, and then a new 6 Fr left DJ stent (Cook Medical Ireland Ltd., Limerick, Ireland) was placed (Supplementary Fig. 4). In the fourth stage, the right kidney stones were removed through the original access tract using an EMS nephroscope in the GMSV position. Retrograde intrarenal surgery was performed to treat the residual stones in the right kidney. The postoperative course was uneventful. Kidney-Ureter-Bladder X-ray showed complete clearance of stones in the right ureter and kidney (Fig. 1).

Figure 1.

KUB X-ray of the residual stones in the right kidney treated by PCNL and flexible ureteroscopic lithotripsy. (A) Residual stones in the right kidney; (B) Right kidney stones removed by PCNL through the original access tract in the Galdakao-Modified Supine Valdivia position; (C) Residual stones cleared via ureteroscopic lithotripsy and insertion of a new ureteral stent. KUB, Kidney-Ureter-Bladder; PCNL, percutaneous nephrolithotomy; L, left.

Postoperative stone component analysis indicated a predominance of mixed stone composition, incorporating calcium carbonate-phosphate and struvite, along with the presence of carbonate apatite and calcium-magnesium-ammonium phosphate. We performed a midstream urine bacterial culture before every surgery and administered antibiotics based on the results. For the first surgery, the urine culture was positive, and intravenous antibiotics were administered for 1 week preoperatively. Other urine cultures were negative; oral antibiotics were administered for 1 week preoperatively, followed by intravenous antibiotics postoperatively. During the intervals between each surgery, antibiotics were not administered. The entire surgical process, from the first to the fourth stage, spanned 10 weeks. The first interval was 4 weeks, and the subsequent intervals were 3 weeks each. The first and third surgeries lasted approximately 2 h, while the others lasted about 1.5 h. The patient was then followed up for 3 months; his symptoms resolved completely with no evidence of stone recurrence. The serum creatinine level was 2.38 mg/dL, showing no significant change from the preoperative level.

Due to gaps in medical education and patient follow-up protocols, the timely removal of ureteral stents can be overlooked. Literature on retained ureteral stents reports cases where patients have had indwelling stents for periods as long as 17 years and even up to 23 years [1]. The major reasons for stent retention were patient-related (83.9%), which included poor compliance, lapses in memory, and misconceptions about the necessity of timely removal. The second most common reasons were physician-related (24.7%) and were attributed to inadequate counseling. Besides the above, objective factors (4.4%) such as individual financial problems, necessity to treat other diseases, low educational level, and social instability also led to the delay in stent removal [2]. To combat the problem of stent retention, treating physicians play an important role, including proper counseling of the patient regarding the indications for stent placement and its timely removal. Proper stent registry and documentation are maintained. Telephonic contact with the patient is arranged, once the due date of removal has passed. Strengthening patient education and awareness is necessary, and regular follow-up is needed during the entire stent indwelling period. Furthermore, there is a trend to establish universal monitoring programs and applications that are not institution-specific. Computerized monitoring programs, mobile applications, stent removal software, and text message reminders or e-mail services have been recommended to track patients with long-term indwelling stents [3]. Regarding the use of biodegradable ureteral stents, the evolution of stent materials and the exploration of different stent coatings would give these devices different roles tailored to different clinical needs. However, the safety, degradability, and functional efficacy of biodegradable ureteral stents still need to be confirmed by clinical trials with large sample sizes.

The protracted indwelling of DJ stents poses several significant risks, including persistent lower back pain, recurrent hematuria, stone formation, and potential impairment of renal function [4]. Concomitant UTIs are commonplace in the context of ureteral stents, which, if left untreated, may escalate to severe complications such as emphysematous pyelonephritis, carrying poor prognoses and life-threatening implications [5]. Vigilant management of UTIs in patients with prolonged ureteral stent indwelling to preempt infectious stone formation is important. It has been documented that 17.8% of the patients with ureteral stents exhibit positive urine cultures, while 20.4% demonstrate bacterial colonization directly on the stents themselves [6]. Escherichia coli (38.5%) and Enterococcus spp. (18.4%) are frequently identified pathogens in cultures derived from urine and stents [6]. Hence, the prophylactic use of antibiotics may be judicious to mitigate the incidence of biofilm formation and infectious stone development. Our case revealed a positive urinary culture, reflective of these observations. In addition, to reduce the complications associated with protracted DJ stent placement, optimal stent sizing and minimal indwelling intervals are advocated. When it is necessary to extend stent indwelling time, regular evaluations are recommended to monitor stent positioning and encrustation with expeditious stent replacement at any indication of adverse findings.

The encrustations forming on neglected DJ stents are capable of inducing a wide spectrum of urinary tract calculi, including bladder stones, ureteral stones, kidney stones, and in severe cases, concurrent bilateral urinary tract stones [7]. The development of staghorn calculi presents a particularly formidable challenge, as their intricate morphology complicates the surgical approach [8]. The majority of urinary tract stones attributable to prolonged stent indwelling can be managed through minimally invasive endourologic procedures [9]. Cystolithotripsy followed by ureteroscopy constitutes the prevalent mode of intervention, which is employed in 41.1% of such cases [10]; however, a minority of patients may necessitate more invasive measures, such as nephrectomy or open surgical procedures [11,12]. In the case at hand, extensive cast stones had formed within the bilateral urinary tracts. The preoperative renal function tests indicated that the right kidney functioned better than the left one. To benefit the patient's renal function, we opted to treat the right kidney first. Our sequential surgical strategy, which encompassed cystolithotripsy, ureteroscopic lithotripsy, semi-rigid ureteroscopic lithotripsy, and PCNL, was employed judiciously to reduce the stone burden in various anatomical locations. This multi-modal surgical approach was meticulously tailored not only to manage the substantial stone mass and stent encrustations, but also to preserve renal function as much as possible.

Our treatment team accrued substantial expertise in managing urinary tract stones through the complex surgical interventions undertaken for this particular patient. Infection prevention and management were of paramount importance throughout the treatment process. The judicious selection of combined armamentarium of endoscopic instruments played a critical role in minimizing patient trauma while ensuring satisfactory therapeutic outcomes. Furthermore, a segmented strategy for DJ stent removal was executed to deftly navigate this complex clinical situation. This tiered methodology entailed the placement of a new DJ stent to facilitate adequate urinary drainage and ureteral dilation, creating conducive conditions for the forthcoming surgical procedures.

In summary, our case highlights the challenges posed by prolonged DJ stent placement and the critical importance of vigilant management to prevent severe stone formation and ensure renal preservation. We demonstrate that a meticulously tailored, staged surgical approach can effectively treat complex stone disease with minimal adverse impact on renal function. This experience emphasizes the need for regular follow-up and individualized stent management to improve patient outcomes. Further research is required to establish best practices for timely stent management to optimize urinary tract health.

Author contributions

Study design: Liujian Duan.

Data acquisition: Chao Li.

Data analysis: Lin Zhang.

Drafting of the manuscript: Jianwei Cao.

Critical revision of the manuscript: Yunteng Huang.

Conflicts of interest

The authors declare no conflict of interest.

Appendix A. Supplementary data

The following is the Supplementary data to this article: